A systematic review and meta-analysis on pulmonary resections by robotic video-assisted thoracic surgery

Abstract

Background: Pulmonary resection by robotic video-assisted thoracic surgery (RVATS) has been performed for selected patients in specialized centers over the past decade. Despite encouraging results from case-series reports, there remains a lack of robust clinical evidence for this relatively novel surgical technique. The present systematic review aimed to assess the short- and long-term safety and efficacy of RVATS.

Methods: Nine relevant and updated studies were identified from 12 institutions using five electronic databases. Endpoints included perioperative morbidity and mortality, conversion rate, operative time, length of hospitalization, intraoperative blood loss, duration of chest drainage, recurrence rate and long-term survival. In addition, cost analyses and quality of life assessments were also systematically evaluated. Comparative outcomes were meta-analyzed when data were available.

Results: All institutions used the same master-slave robotic system (da Vinci, Intuitive Surgical, Sunnyvale, California) and most patients underwent lobectomies for early-stage non-small cell lung cancers. Perioperative mortality rates for patients who underwent pulmonary resection by RVATS ranged from 0-3.8%, whilst overall morbidity rates ranged from 10-39%. Two propensity-score analyses compared patients with malignant disease who underwent pulmonary resection by RVATS or thoracotomy, and a meta-analysis was performed to identify a trend towards fewer complications after RVATS. In addition, one cost analysis and one quality of life study reported improved outcomes for RVATS when compared to open thoracotomy.

Conclusions: Results of the present systematic review suggest that RVATS is feasible and can be performed safely for selected patients in specialized centers. Perioperative outcomes including postoperative complications were similar to historical accounts of conventional VATS. A steep learning curve for RVATS was identified in a number of institutional reports, which was most evident in the first 20 cases. Future studies should aim to present data with longer follow-up, clearly defined surgical outcomes, and through an intention-to-treat analysis.

Keywords: Robotics; meta-analysis; minimally invasive surgery; systematic review; video-assisted thoracic surgery.

Figure 1

Forest plot of the relative risk (RR) of postoperative morbidity after robotic video-assisted thoracic surgery (RVATS) versus open thoracotomy for patients with early-stage non-small cell lung cancer. The estimate of the RR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the numbers of events as a fraction of the total number randomized are shown for both treatment groups. For each subgroup, the sum of the statistics, along with the summary RR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics