Scoping review on long term oncologic outcomes in robotic-assisted lobectomy

Background: Open surgery was once the gold standard treatment for lobectomy, but in the 1990s, video-assisted thorascopic surgery (VATS) quickly became a popular surgical approach in pulmonary resections. However, adoption in many countries plateaued due to various reasons and starting in the early 2000s, robotic-assisted thorascopic surgery (RATS) began gaining ground. This scoping review aims to summarize contemporary data on the current state of robotic lobectomy as a maturing procedure, with a focus on oncologic outcomes and long-term survival as compared to traditional open and VATS techniques. Methods: We performed a systematic search in PubMed for Level I and II evidence, including studies from January 2000-February 2023. Our primary outcome of interest was overall survival (OS), disease-free survival (DFS), and recurrence rates for surgically-treated lung cancer. We also analyzed surrogate markers to assess oncologic quality and used objective variables such as lymph node harvest and upstaging rate as quality indicators. Results: Nineteen studies met inclusion criteria, including 7 comparative analyses, 10 meta-analyses, and 2 randomized controlled trials (RCTs). The PORTaL study demonstrated that robotic lobectomy was associated with a significantly better OS as compared to VATS [hazard ratio (HR) =0.79, P=0.007]. For DFS, 3 meta-analyses reported a significant advantage with a robotic approach, including the study by Leitao et al. [HR =0.74, 95% confidence interval (CI): 0.59-0.93, P=0.009], Wu et al. (HR =0.76, 95% CI: 0.59-0.97, P=0.03), and Zhang et al. [odds ratio (OR) =1.69, 95% CI: 1.11-2.57, P=0.01; I2=23%]. For recurrence, the PORTaL study found statistically lower recurrence rates in the robotic cohort than VATS (15.9% versus 19.2%, P=0.009). Similarly, Ma et al. found lower recurrence rates with robotic lobectomy versus VATS (OR =0.51, 95% CI: 0.36-0.72, P<0.001). Conclusions: The published data examined from high Level I-II evidence to date indicate some oncologic benefit, or at the least non-inferiority, of RATS compared to VATS.