Comparative outcomes of robotic- and video-assisted thoracoscopic surgery in thymectomy: a systematic review of implications for myasthenia gravis remission and long-term oncology

Introduction

Thymic epithelial tumors (including thymomas and thymic carcinomas) are the most common anterior mediastinal neoplasms, accounting for a large fraction of mediastinal masses (1). Complete resection of the thymus is the standard of care for early-stage thymic malignancies, as surgical excision yields the best chance for cure (1). In addition, thymectomy is an established therapy for patients with myasthenia gravis (MG); thymic removal has been shown to improve MG symptoms and achieve remission in a substantial proportion of cases (2,3). Historically, thymectomy was performed via median sternotomy (open transsternal approach), which provides excellent exposure of the anterior mediastinum (4). However, open sternotomy is associated with greater postoperative pain, longer hospitalization, and slower recovery. In recent decades, minimally invasive approaches to thymectomy have become popular in suitable patients, in part to reduce the morbidity of surgery (2,4).

Minimally invasive thymectomy was first introduced using video-assisted thoracoscopic surgery (VATS). VATS thymectomy enables complete removal of the thymus through small thoracic incisions, and it has been widely adopted for selected thymomas and non-thymomatous MG (1,4). Early series showed that VATS achieves comparable rates of complete resection (R0) to open surgery, while yielding shorter hospital stays and fewer complications (4,5). More recently, robotic-assisted thoracoscopic surgery (RATS) has emerged as an alternative minimally invasive technique for thymectomy. Robotic platforms (e.g., the da Vinci system) provide high-definition three-dimensional visualization and articulating “wristed” instruments, which allow more precise dissection in the confined anterior mediastinum (1,2). These technical advantages of RATS have translated into a safe and feasible procedure: several series report that RATS thymectomy yields excellent perioperative outcomes (low blood loss, low complication rates) and complete resection in virtually all cases (1,5). Systematic reviews and pooled analyses of available studies indicate that minimally invasive thymectomy (whether VATS or RATS) is associated with reduced intraoperative blood loss, fewer postoperative complications, and shorter recovery compared with open sternotomy (1,5). In comparative series, RATS and VATS approaches appear largely equivalent in clinical outcomes: both avoid the morbidity of sternotomy and achieve similar mortality and morbidity profiles (1,5). Notably, RATS may offer some perioperative advantages over VATS—such as even lower blood loss and lower conversion rates—at the cost of longer operative time and substantially higher equipment and maintenance costs (2,4).

Existing evidence suggests that RATS and VATS thymectomy achieve comparable long-term oncologic control. In a recent propensity-matched analysis (Zhu et al., 2024), RATS was associated with significantly shorter operative time, less blood loss, and far fewer conversions to open surgery compared to VATS, but the 5-year progression-free survival (PFS) and cancer-specific survival were equivalent (approximately 88–92% at 5 years in both groups) (4). Likewise, systematic reviews and meta-analyses have found no significant differences in long-term survival or recurrence between RATS and VATS, although the literature is limited. For example, O’Sullivan et al. (2019) reported that RATS thymectomy had advantages over open surgery (less blood loss, shorter hospital stay, fewer complications) and was comparable to VATS (5). They noted that the current data “suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach”, but emphasized that long-term follow-up data are scarce (5). In practice, most modern series report 5-year overall survival (OS) rates exceeding 85–90% for thymoma regardless of the surgical approach, reflecting the generally indolent nature of thymic tumors when completely resected (4). Importantly, long-term neurological outcomes in MG patients [such as rates of complete stable remission (CSR)] also appear similar between RATS and VATS (2). Taken together, the evidence indicates that RATS and VATS are similarly effective oncologically, while RATS may confer some perioperative benefits.

Despite these encouraging findings, important gaps and uncertainties remain. Thymic malignancies are rare and often slow-growing, so most published series are small, retrospective, and subject to selection bias. Very few studies have reported long-term (≥5 years) outcomes specifically for RATS versus VATS, as robotic thymectomy is a relatively recent innovation (4). No randomized trials have directly compared RATS and VATS in thymectomy, and thus definitive conclusions on long-term survival and recurrence are lacking (2,5). Furthermore, while RATS may reduce perioperative morbidity, its higher capital and per-case costs raise questions about cost-effectiveness that have not been fully addressed (2). Therefore, this systematic review aimed to comprehensively evaluate and synthesize the available evidence comparing RATS and VATS for thymectomy, focusing on long-term oncological outcomes, perioperative results, and economic considerations. It is important to note that thymectomy is performed for two primary indications—oncologic resection for thymic epithelial tumors and immunomodulation for MG—which have fundamentally different goals and outcome measures. This review encompasses both entities to provide a comprehensive evaluation of the surgical techniques, but will analyze and discuss the outcomes for oncologic and neurological indications separately to maintain conceptual clarity. By consolidating current data, this review seeks to clarify whether RATS provides equivalent or superior long-term outcomes to VATS and to guide evidence-based surgical decision-making. We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2011/rc) (6).

Methods

Literature search strategy

This systematic review was conducted according to a predefined protocol registered with PROSPERO (CRD420251126351) and adhered to the PRISMA guidelines (6,7). The study compared RATS and VATS for thymectomy in adult patients with thymic pathologies, including thymoma, thymic carcinoma, and MG.

Databases searched included PubMed/MEDLINE, Web of Science, and the Cochrane Library. The search strategy combined keywords and MeSH terms such as “thymectomy”, “thymoma”, “thymic tumors”, “myasthenia gravis”, “robotic-assisted surgery”, “da Vinci system”, “VATS”, and “video-assisted thoracoscopic surgery”. Only English-language studies were considered.

Inclusion and exclusion criteria

Included studies comprised randomized controlled trials (RCTs), prospective and retrospective cohort studies, and propensity score-matched analyses that directly compared RATS and VATS in adults (≥18 years) undergoing thymectomy. Eligible studies reported at least one long-term oncological outcome such as survival, recurrence, MG remission, or perioperative metrics, with a minimum follow-up of 12 months.

Excluded studies included case reports, editorials, conference abstracts, reviews, animal studies, pediatric studies, non-comparative designs, and those that reported only short-term outcomes or lacked sufficient data for analysis.

Selection of articles and data extraction

All search results were imported into Mendeley for deduplication, followed by title and abstract screening using Rayyan, a systematic review management platform (8). Two reviewers independently assessed full-text articles for eligibility. Disagreements were resolved through discussion or by a third reviewer.

Extracted data included publication details, study design, sample size, patient demographics, comorbidities, diagnosis, tumor stage, surgical technique, robotic platform, duration of follow-up, and primary and secondary outcomes. Primary outcomes included recurrence-free survival (RFS), PFS, and CSR. It is important to note that RFS and PFS are oncologic endpoints relevant to thymic tumors. Meanwhile, CSR is a neurological endpoint specific to MG, typically defined by standardized criteria such as those from the Myasthenia Gravis Foundation of America (MGFA), which require no symptoms or signs of MG and no MG medication for at least one year (9). These distinct outcome sets were analyzed separately according to the patient population of each study. Secondary outcomes encompassed operative time, complications, hospital stay, intensive care unit (ICU) stay, conversion rates, reoperations, readmissions, cost data, and survival analysis using Kaplan-Meier curves. Data were tabulated and synthesized for both qualitative and quantitative comparison.

For subgroup synthesis, each included study was categorized by its principal disease focus —Zhu et al. (thymic epithelial tumors), Imielski et al. (thymoma), and Kauppi et al. (MG)—and outcomes were synthesized narratively within these disease-specific strata to account for heterogeneity in case-mix, disease biology, and follow-up duration (4,10,11).

Risk of bias assessment

The Newcastle-Ottawa Scale (NOS) guidelines were used to evaluate this research, encompassing three perspectives: selection, comparability, and exposure (12). The assessment tool, including the star system, with a maximum of 9 stars, was used in this research. The specific evaluation system was 8–9 stars denote high quality (Table 1).

Data synthesis approach

Given the methodological heterogeneity in surgical techniques, patient populations (thymic tumors vs. MG), and outcome reporting, a narrative synthesis was performed rather than a meta-analysis. Outcomes were stratified by the primary disease indication (oncologic resection vs. immunomodulation for MG) and analyzed within these pre-specified subgroups. For MG outcomes, remission rates were analyzed according to the MGFA Post-Intervention Status definitions when available, with subgroup consideration for surgical approach (RATS vs. VATS). Given the limited number of included studies and their retrospective nature, formal sensitivity analyses were not feasible; however, the synthesis and conclusions were weighted towards findings from the study with propensity score matching (Zhu et al.) and those that reported multivariate analyses adjusting for confounders (Kauppi et al.) (4,11). The overall strength of evidence for each outcome domain was evaluated qualitatively, considering the study designs, risk of bias, and consistency of findings.

Results

Literature findings

The systematic search yielded 99 records from PubMed/MEDLINE, Web of Science, and Cochrane Library. After deduplication, 67 studies underwent title and abstract screening, of which 27 proceeded to full-text assessment. Ultimately, three retrospective cohort studies met the inclusion criteria and were included in this review (4,10,11). The PRISMA flow diagram is presented as Figure 1.

Figure 1 PRISMA flow chart.

Characteristics of included studies

The included studies encompassed a total of 434 patients who underwent minimally invasive thymectomy: 181 with RATS and 249 with VATS. These studies were conducted in diverse geographical settings (China, USA, Finland) and covered surgical cases from 1999 to 2019. All studies utilized the da Vinci Si robotic platform and conventional multiport VATS. Zhu et al. employed 1:1 propensity score matching to minimize confounding, a technique that creates balanced cohorts—pairing 66 RATS with 66 VATS patients on key baseline covariates—thereby approximating an RCT design for a more robust comparison of perioperative outcomes (4). The pathological indications across the studies: Zhu et al. analyzed a cohort of thymoma and thymic carcinoma patients; Imielski et al. investigated cases of thymoma with concomitant MG; while Kauppi et al. focused exclusively on a population with MG (4,10,11) (Table 2).

Long-term oncological outcomes

Thymic carcinoma and thymoma

Zhu et al. provided a propensity score-matched comparison of long-term outcomes in patients with thymic epithelial tumors, including thymoma and thymic carcinoma (4). At a median follow-up of 54–57 months, there were no significant differences between RATS and VATS. Five-year PFS was 87.7% for RATS compared with 90.6% for VATS, while 5-year OS was 87.7% vs. 92.2%, respectively. Recurrence and reoperation rates were minimal and comparable (RATS 2% vs. VATS 3%) (Table 3).

Imielski et al. conducted a comparative analysis of long-term oncological outcomes following minimally invasive thymectomy for thymoma (10). Their findings indicated no statistically significant difference in RFS between the RATS and VATS approaches, with 10-year RFS rates of 96.2% for RATS and 90.7% for VATS. Recurrence rates were not specifically reported for each cohort, and reoperations were required in 0% of RATS patients and 2% of VATS patients. OS was not separately reported for the thymoma subgroup (Table 3).

MG remission

Kauppi et al. analyzed patients with MG undergoing thymectomy and evaluated neurological remission, defined as CSR according to the MGFA criteria—meaning no symptoms or signs of MG and no MG medication for at least 12 months (9,11). A trend favored RATS for achieving CSR (26% vs. 18%, P=0.06). Importantly, multivariate Cox regression identified RATS as an independent predictor of MG remission (hazard ratio =0.472, 95% CI: 0.224–0.995, P=0.049). The study also reported no postoperative myasthenic crises. Recurrence rates of thymic disease were identical between groups (2% each) (Table 4).

Perioperative outcomes and postoperative complications

A comparative analysis of perioperative outcomes between RATS and VATS reveals several key distinctions. The conversion rate to an open procedure was lower for RATS in the study by Zhu et al. (3% vs. 15%), although a statistical P value was not provided for this metric. Conversely, Kauppi et al. reported no conversions in either group (4,11). Operative times presented a mixed picture. Zhu et al. found a statistically significant shorter median operative time for RATS (100 min) compared to VATS (120 min; P=0.039), while Imielski et al. reported a longer mean operative time for RATS (187.5 min) vs. VATS (161.1 min) that approached, but did not reach, statistical significance (P=0.06) (4,10) (Table 5).

Postoperative recovery, measured by hospital length of stay, consistently favored the RATS approach. Imielski et al. reported a significantly shorter mean stay for RATS patients (1.3 vs. 2.4 days; P=0.01), a finding supported by Kauppi et al., who noted a shorter median stay (2 vs. 3 days; P=0.013) (10,11). Zhu et al., however, observed no difference in median hospital stay (6 days for both groups) (4). Estimated blood loss was marginally lower in the RATS groups across the studies that reported it (40 vs. 50 mL; 20 mL vs. a range of 10–100 mL), though no statistically significant differences were detailed (Table 5).

The profile of perioperative complications was notably similar between the two techniques. Overall complication rates were low and comparable, as demonstrated by Zhu et al. (7.58% for RATS vs. 6.06% for VATS; P=0.987) (4). Individual complications—such as pneumonia, arrhythmia, and the need for re-operation—occurred at very low and similar frequencies in both groups across all studies. Imielski et al. did find a statistically significant advantage for RATS in 30-day readmission rates (1% vs. 13%; P<0.001) (10). Critically, mortality was reported as 0% across all included studies, and ICU stays, when reported, were brief and similar between groups (Table 5).

Economic outcomes

Zhu et al. found that RATS was associated with significantly higher costs than VATS (Chinese Yuan ¥68,122 vs. ¥37,886; P<0.001), primarily due to the cost of robotic equipment and instrumentation (4). Imielski et al. reported nearly equivalent average costs between the groups (~$14,000), though the data may have been affected by cost outliers (10). None of the studies conducted formal cost-effectiveness analyses (Table 6).

Follow-up duration

Follow-up periods varied among studies but were sufficient for assessing long-term outcomes. Zhu et al. reported a median follow-up of approximately 54 to 57 months (4). Imielski et al. reported a median follow-up of 6.7 years (IQR, 3.6–7.5 years) (10). Kauppi et al. had the longest follow-up, with a median of 12 years for the VATS group and 5 years for RATS (11). All studies met the minimum requirement of at least 12 months of follow-up (Table 6).

Discussion

Comparative analyses indicate that RATS and VATS thymectomy for thymic tumors achieve equivalent long-term oncologic efficacy. In propensity-matched cohorts, the 5-year OS was essentially identical (RATS 87.7% vs. VATS 92.2%), and early recurrence rates were the same, suggesting similar tumor clearance (13). For example, Ye et al. reported no early recurrences in either group, while finding significantly shorter chest-drain duration (1.1 vs. 3.6 days) and hospital stay (3.7 vs. 6.7 days) after RATS compared to VATS (14). A recent meta-analysis of 11 studies (1,418 patients) similarly showed that RATS was associated with lower intraoperative blood loss, reduced drainage volume and fewer drainage days, and shorter hospital stay than VATS, without differences in operative time or completeness of resection (15). These data imply that RATS may enhance perioperative recovery without compromising oncologic outcomes. Both approaches achieve comparable resection completeness and margin status in thymoma cases, reflecting that when performed by experienced surgeons, the robotic platform and standard thoracoscopy each allow adequate thymic clearance.

In patients with MG undergoing thymectomy, minimally invasive approaches via RATS or VATS have yielded similarly favorable neurologic outcomes with low morbidity. The findings from Kauppi et al. are particularly noteworthy; the RATS cohort demonstrated a higher rate of CSR (26% vs. 18%) (11). Likewise, Marcuse et al. (2023) reported that 82.4% of MG patients improved symptomatically after RATS thymectomy, with 8.4% achieving complete remission and 39.4% pharmacologic remission (16). The 5-year extension confirmed persistent benefit, with continued superior strength scores [mean Quantitative Myasthenia Gravis Score (QMG) ≈5.47 vs. ≈9.34, P=0.0007] and reduced steroid requirements (24 vs. 48 mg, P=0.0002) in the thymectomy arm (17). Collectively, these data confirm that minimally invasive thymectomy (via RATS or VATS) produces excellent clinical outcomes in MG patients and reinforce the well-established finding that surgical thymectomy provides superior disease control compared to medical management alone (17,18).

Large registry and multicenter studies corroborate these findings. Seo et al. found no differences in overall complication rates or length of stay between RATS and VATS, although RATS patients had fewer postoperative cardiac complications (19). Similarly, Papageorge and Antonoff note that mortality and major complications are equivalent between the two techniques (20). At the same time, several series report perioperative benefits favoring RATS. Chiba et al. found that RATS patients reached nursing-assessed recovery milestones faster than VATS patients (significantly shorter “B” and “CIII” dependency times), and other reports describe shorter chest-tube duration and earlier mobilization after RATS (14,15,21). Notably, recent innovations like subxiphoid RATS have shown additional benefits. For example, Ainiwaer et al. reported that subxiphoid RATS achieved significantly shorter operative time (80 vs. 110 min) and hospital stay (3 vs. 5 days; both P<0.001) than subxiphoid VATS (22). These advantages likely stem from the robotic system’s enhanced dexterity and visualization. Notably, Kamel et al. observed significantly fewer conversions to open surgery with RATS than with VATS, without any loss of oncologic efficacy (13). In summary, RATS tends to yield modest perioperative improvements (less blood loss, faster recovery) while VATS achieves similar complication rates and oncologic results. Surgeon experience and patient selection likely influence these outcomes.

Economically, the evidence is clear that RATS incurs higher costs. Multiple analyses report that RATS thymectomy is more expensive than VATS. In the national database study by Seo et al., VATS had the lowest total hospital cost, whereas RATS was associated with significantly higher expenditure (19). Papageorge et al. similarly remark that RATS patients generated higher hospitalization charges than VATS patients in large cohorts (20). Ye et al. explicitly state that robotic thymectomy is much more expensive than VATS (14). In one institutional study comparing transcervical and thoracoscopic cases, RATS cost only about 5% more than VATS; however, this small difference reflects a specialized practice environment and did not offset the overall higher cost of minimally invasive versus open approaches (23). In practice, RATS involves substantial capital investment (robotic system, maintenance) and disposable instrument costs, which tend to outweigh modest savings from shorter stays or fewer complications. No comprehensive cost-effectiveness analysis exists for RATS vs. VATS thymectomy; one decision-analysis suggested transcervical approaches might be most cost-effective in MG cases, but an analogous economic comparison of RATS and VATS is lacking (19). Overall, given its higher per-case expense, RATS must justify cost through either superior outcomes or patient-centered benefits, which have not yet been definitively demonstrated beyond small perioperative gains.

Notwithstanding the clear cost premium associated with RATS, its technical advantages provoke a critical hypothesis: could the superior dissection capability translate into sufficient long-term benefits to justify the initial investment? The enhanced precision of the robotic platform may facilitate a more complete thymic resection, including ectopic remnants, which is theorized to be a key factor in achieving higher rates of CSR in MG (11,24). If this technical superiority consistently results in better neurological outcomes—such as a reduced need for long-term immunosuppressive therapy, fewer hospitalizations for myasthenic crisis, and improved quality of life—the higher procedural cost could be partially or fully offset over the patient’s lifetime. Similarly, in oncology, a potentially more reliable achievement of R0 resection in complex cases might improve long-term survival, though this remains to be proven. Therefore, the current economic data, which captures only short-term procedural costs, presents an incomplete picture. Future research must integrate long-term neurological and oncological outcomes into formal cost-effectiveness models to determine if the initial investment in RATS is counterbalanced by superior long-term value.

To fully appreciate these outcomes, it is vital to contextualize them within the immunopathological framework of MG and its management. Thymectomy is believed to improve MG by removing the site of auto-sensitization against the acetylcholine receptor, thereby reducing the production of pathogenic autoantibodies and altering the population of autoreactive T-cells over time (25,26). This immunomodulatory mechanism explains the characteristically delayed and variable neurological response to thymectomy, with remission often occurring months or even years after surgery (26). This variability underscores why short-term follow-up may not fully capture the benefit of the procedure and highlights the importance of long-term neurological assessment. Furthermore, the postoperative journey almost always involves close collaboration between surgeons and neurologists. Thymectomy is not a standalone cure but a pivotal event within a continuum of care that includes optimized medical therapy. The primary surgical goal is to create the conditions for successful, often gradual, medication reduction or withdrawal under neurological guidance (17,18). Therefore, the superior remission rates associated with a technique like RATS should be interpreted as its contribution to facilitating this long-term, multidisciplinary treatment goal.

The decision to conduct this systematic review, despite the inherent limitations of the available retrospective data, is both timely and necessary. Thymic pathologies are rare, and conducting large-scale RCTs to compare RATS and VATS is challenging due to logistical constraints, surgeon preference, and the long follow-up required for oncological and neurological outcomes. In this context, prospective, single-institution studies provide invaluable deep phenotyping and detailed protocol standardization, but their generalizability can be limited. A systematic review serves a complementary yet distinct role: it rigorously synthesizes the collective evidence from multiple institutions and cohorts, thereby increasing the total sample size and statistical power to detect patterns that might be elusive in smaller studies. By transparently acknowledging the heterogeneity in outcomes and definitions across studies—as we have done in our methodology—a systematic review can provide the highest level of evidence currently achievable, map the consistency of findings across different settings, and most importantly, identify the specific gaps and methodological limitations (such as inconsistent reporting of MG therapy) that must be addressed in future prospective studies and registries. This synthesis thus provides a crucial, evidence-based foundation to guide surgical practice and future research directions in the absence of definitive RCTs.

Several important gaps and limitations qualify these conclusions. All current comparisons between RATS and VATS are retrospective or registry-based; no RCTs have directly addressed this question (20). As Papageorge et al. emphasize, the reliance on retrospective series introduces selection bias and limits causal inference (20). Furthermore, most published cohorts are relatively small or single-institution, so statistical power is limited, and results may reflect local expertise. Follow-up durations have typically been short, so late recurrences or survival differences could emerge. Furthermore, the more recent introduction of RATS led to asymmetrical follow-up, as seen in the Kauppi et al. study (11). While this is less concerning for assessing MG remission, it remains a potential confounder for interpreting long-term durability. Data on functional outcomes are also sparse: for example, the effect of surgical approach on MG remission is poorly characterized. A large multicenter analysis noted the shift to minimally invasive thymectomy but explicitly called for longer-term neurologic follow-up to determine whether perioperative benefits translate into improved MG outcomes (27). Additionally, for MG outcomes, the studies did not consistently account for confounding by concomitant immunosuppressive therapy, and the exclusion criteria for patients in pre-operative myasthenic crisis were not explicitly stated (28). Finally, it should also be noted that the combined analysis of oncologic and MG indications, despite separate outcome reporting, introduces heterogeneity. The definition of MG outcomes, such as CSR, varied, and oncologic endpoints (RFS/PFS) do not apply to MG disease control. In sum, while the evidence to date suggests equivalence of oncologic outcomes and some perioperative advantages of RATS, the literature is limited by its retrospective nature, potential confounders, and incomplete long-term data.

Conclusions

In conclusion, this review demonstrates that the comparative outcomes of RATS and VATS must be interpreted within the specific disease context. For thymic epithelial tumors, the techniques demonstrate equivalent long-term oncologic safety and efficacy. Conversely, for MG, where the goal is immunomodulation, RATS may offer a distinct neurological advantage as an independent predictor of higher CSR rates. Across both indications, RATS provides consistent perioperative benefits, including faster recovery and lower conversion rates, though at a significantly higher cost. These findings support an individualized approach to technique selection, guided by the primary disease, surgeon expertise, and economic considerations.

Acknowledgments

The authors would like to thank the Saudi Thoracic Society (STS) for their support.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2011/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2011/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2011/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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