Robotic-assisted thoracic surgery (RATS) lobectomy has diffused rapidly as an alternative to video-assisted thoracoscopic surgery (VATS) for resectable non-small cell lung cancer (NSCLC). A growing but heterogeneous evidence base—including prospective cohorts, meta-analyses, economic models, learning-curve studies and one large randomized trial—permits an updated synthesis to guide clinicians and policy makers. We conducted a focused, reproducible literature search of Cochrane CENTRAL, PubMed/MEDLINE and Embase through 15 August 2025 using terms that included “robotic lobectomy,” “RATS,” “VATS,” “non-small cell lung cancer,” “randomized,” “meta-analysis,” “cost” and “learning curve.” We prioritized randomized evidence, prospective comparative cohorts, high-quality meta-analyses, multicenter registries, and full economic evaluations published 2020–2025. Primary outcomes were perioperative (operative time, blood loss, conversion, complications, length of stay), nodal harvest and pathologic upstaging, disease-free and overall survival, quality of life (QOL), cost and learning-curve metrics. We present a transparent search strategy, selection criteria, and synthesized quantitative findings drawn from high-impact sources. The RVlob randomized controlled trial (n = 320) showed non-inferiority of robotic to VATS lobectomy for 3-year overall survival (RAL 3-yr OS 94.6% v VAL 91.5%; HR 0.65, 95% CI 0.33–1.28; noninferiority P = 0.0029). Observational multicenter cohorts (including a large JAMA Network Open study, n ≈ 1,088) found broadly comparable clinical outcomes but longer adjusted operative duration for RATS (median + 20.6 min). Pooled prospective data (Frontiers 2023; pooled n = 614) reported lower estimated blood loss with RATS (MD − 17.14 mL, 95% CI − 29.96 to − 4.33) and greater numbers of lymph-node stations sampled (MD + 1.07 stations, 95% CI 0.79–1.36). Learning-curve synthesis suggests technical proficiency at ≈ 25 cases (mean 25.3 ± 12.6) with convergence of operative times and outcomes thereafter. Cost-effectiveness analyses are heterogeneous: Heiden et al. (Ann Thorac Surg, 2022) reported modest per-case cost increases for RATS with ICERs that depend heavily on perspective and assumptions, while early RCT economic analyses (RAVAL early results / RPL-4 pathway) have reported ICERs in the range of ≈$15k per QALY under favorable assumptions. RATS lobectomy is oncologically non-inferior to VATS at mid-term follow-up and achieves perioperative safety comparable to VATS; it is associated with lower intraoperative blood loss, more extensive nodal station sampling in some series, and longer operative times early in adoption. Cost-effectiveness is context-sensitive and improves with higher case volumes, shorter OR times, and lower disposable instrument costs. Standardized lymphadenectomy, transparent learning-curve reporting, and longer randomized follow-up remain priorities.

State of the art of robotic lobectomy for non–small cell lung cancer: a systematic-style evidence synthesis

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发表日期：

2025年12月22日

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Danilo Coco,
Silvana Leanza

摘要

Robotic-assisted thoracic surgery (RATS) lobectomy has diffused rapidly as an alternative to video-assisted thoracoscopic surgery (VATS) for resectable non-small cell lung cancer (NSCLC). A growing but heterogeneous evidence base—including prospective cohorts, meta-analyses, economic models, learning-curve studies and one large randomized trial—permits an updated synthesis to guide clinicians and policy makers. We conducted a focused, reproducible literature search of Cochrane CENTRAL, PubMed/MEDLINE and Embase through 15 August 2025 using terms that included “robotic lobectomy,” “RATS,” “VATS,” “non-small cell lung cancer,” “randomized,” “meta-analysis,” “cost” and “learning curve.” We prioritized randomized evidence, prospective comparative cohorts, high-quality meta-analyses, multicenter registries, and full economic evaluations published 2020–2025. Primary outcomes were perioperative (operative time, blood loss, conversion, complications, length of stay), nodal harvest and pathologic upstaging, disease-free and overall survival, quality of life (QOL), cost and learning-curve metrics. We present a transparent search strategy, selection criteria, and synthesized quantitative findings drawn from high-impact sources. The RVlob randomized controlled trial (n = 320) showed non-inferiority of robotic to VATS lobectomy for 3-year overall survival (RAL 3-yr OS 94.6% v VAL 91.5%; HR 0.65, 95% CI 0.33–1.28; noninferiority P = 0.0029). Observational multicenter cohorts (including a large JAMA Network Open study, n ≈ 1,088) found broadly comparable clinical outcomes but longer adjusted operative duration for RATS (median + 20.6 min). Pooled prospective data (Frontiers 2023; pooled n = 614) reported lower estimated blood loss with RATS (MD − 17.14 mL, 95% CI − 29.96 to − 4.33) and greater numbers of lymph-node stations sampled (MD + 1.07 stations, 95% CI 0.79–1.36). Learning-curve synthesis suggests technical proficiency at ≈ 25 cases (mean 25.3 ± 12.6) with convergence of operative times and outcomes thereafter. Cost-effectiveness analyses are heterogeneous: Heiden et al. (Ann Thorac Surg, 2022) reported modest per-case cost increases for RATS with ICERs that depend heavily on perspective and assumptions, while early RCT economic analyses (RAVAL early results / RPL-4 pathway) have reported ICERs in the range of ≈$15k per QALY under favorable assumptions. RATS lobectomy is oncologically non-inferior to VATS at mid-term follow-up and achieves perioperative safety comparable to VATS; it is associated with lower intraoperative blood loss, more extensive nodal station sampling in some series, and longer operative times early in adoption. Cost-effectiveness is context-sensitive and improves with higher case volumes, shorter OR times, and lower disposable instrument costs. Standardized lymphadenectomy, transparent learning-curve reporting, and longer randomized follow-up remain priorities.