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De Iaco et al. Mini-invasive Surg 2020;4:63  I  http://dx.doi.org/10.20517/2574-1225.2020.37                                    Page 9 of 16

               Table 2. Best evidence papers about minimally invasive thymectomy
                Ref.            No. of   Surgical approach  Thymectomy/  5-year survival   RR (%)  Mean follow up
                               patients               thymomectomy     rate (%)                 (months)
                Roviaro et al. [59]  22  uVATS      Thymectomy          95           1.3          51.7
                Cheng et al. [21]  44   uVATS       Thymectomy          100          0            36.4
                Agasthian and Lin [60]  119  uVATS  Thymectomy          100          3.4          58.8
                Pennathur et al. [61]  18  bVATS    Thymectomy          100          0            27
                Takeo et al. [51]  35   bVATS       Thymectomy          100          2.8          65
                Mussi et al. [62]  14   Robotic     Thymectomy          100          0            14.5
                Marulli et al. [22]    79  Robotic  Thymectomy          97           1.3          51.7
                Kimura et al. [23]  45  uVATS       Thymectomy          100          6.7          -
                Marulli et al. [54]  100  Robotic   Thymectomy          100          0            67
                Tseng et al. [83]  95   VATS (22)   Thymectomy (42)     100          4.5          57
                                                    Thymomectomy (53)                1,5
                Schneiter et al. [63]  20  Robotic  Thymectomy          100          11.1         26
                Liu et al. [64]  76     uVATS       Thymectomy          100          2.6          61.9
                Ye et al. [65]    125   uVATS       Thymectomy          100          0            16.9
                Keijzers et al. [66]    37  Robotic  Thymectomy         100          2.7          36
                Bae et al. [82]  342    VATS (119)  Thymectomy (239)    99           12.1         94.5
                                        Transervical (1)  Thymomectomy (103)  100    9.7          85.6
                                        RATS (1)
                Gu et al. [80]    1,047  VATS (277)  Thymectomy (220)   93           3.1          38
                                                    Thymomectomy (57)   96           5.4
                Nakagawa et al. [81]  1,286  VATS (169)  Thymectomy (276)  97.3      4            53
                                                    Thymomectomy (276)  96.9         1.8
                Narm et al. [79]  762   VATS (297)  Thymectomy (76)     97           4.1          49
                                                    Thymomectomy (72)   96.3         3.7
                Marulli et al. [11]  134  Robotic   Thymectomy          100          0.7          48
                Rusidanmu et al. [77]  118  VATS    Thymectomy (43)     88.4*        6.98         -
                                        (unspecified)  Thymomectomy (75)  98.7*      2.67
                Weng et al. [67]  358   VATS        Thymectomy          94.5         8            60.5

               *10-year survival rate. RR: recurrence rate; RATS: robotic-assisted thoracoscopic surgery; VATS: video-assisted thoracic surgery; uVATS:
               uniportal VATS; bVATS: biportal VATS

                                                                                                       [69]
               were more favorable than those of sternotomy. Similar findings were reported by Şehitogullari et al. .
               In a recent analysis, they compared 21 vs. 24 patients who underwent RATS or VATS thymectomy. They
               found significant differences in terms of mean operative time, length of hospital-stay, and duration of
               pleural drainage, while mean operative time, operative pain, and remission rates were superimposable.
                           [70]
               Rückert et al.  performed a retrospective analysis on 74 vs. 79 patients with MG who underwent robotic
               or thoracoscopic thymectomy. With a follow-up of 42 months, they found a significant difference in
               cumulative complete remission rate of MG between the two groups in favor of the robotic one (39.25% vs.
               20.3%, P = 0.01); no differences were found in terms of conversion rate, operative time, and postoperative
               complications.

                        [71]
               Burt et al.  recently performed a retrospective multicenter analysis on 943 patients who underwent MIT
               or open thymectomy by focusing on R0 status as the primary outcome. By comparison, they found a non-
               significant difference in the R0 resection rate for patients treated with minimally invasive or open approach
               (83.4% vs. 79.4%), stating that the probability of achieving R0 resection for early-stage thymoma is not
                                                                                                        [72]
               influenced by a minimally invasive approach, and MIT is equivalent to OT in this regard. Kamel et al.
               published a recent multi-institutional analysis on 2,558 performed thymectomies using an open, VATS, or
               RATS approach. They found that patients who underwent thymectomy via an open approach were younger,
               had more advanced tumors, had more incomplete resections (32% vs. 30%, and 23%; P = 0.013), less
               frequently underwent regional lymph node dissection, and had longer hospital stays compared to the VATS
               and robotic groups. When they performed a matched analysis, all those differences became not statistically
               significant and the three approaches resulted superimposable.
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