Uniportal video-assisted lung resection versus robotic-assisted lung resection, is there a difference?
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Key findings
• Both uniportal video-assisted thoracic surgery (uVATS) and robotic-assisted thoracic surgery (RATS) had similar post-operative adverse event rates.
• RATS was associated with a shorter hospital stay and improved lymph node dissection.
• UVATS was associated with better pain control and lower morphine requirements post-operatively.
• Oncological outcomes, including recurrence rates and overall survival, were similar between the two approaches.
What is known and what is new?
• RATS and uVATS are minimally invasive techniques for lung resection, each with unique advantages. This study provides a direct comparison of RATS and uVATS, highlighting the shorter hospital stay and better lymph node dissection with RATS, and superior pain control with uVATS.
What is the implication, and what should change now?
• Both uVATS and RATS are effective for lung resection, with each method offering specific benefits.
• Either approach is reasonable, and can be based on surgeon preference and comfort level with that approach.
• Further prospective studies are needed to better understand the differences and refine selection criteria for these techniques to optimize patient outcomes.
Introduction
Lung resection is a common surgical procedure performed for both benign and malignant conditions of the lungs. Over the years, advancements in minimally invasive techniques have revolutionized thoracic surgery, offering patients the benefits of reduced post-operative pain, shorter hospital stays, and faster recovery (1). Among these techniques, robot-assisted thoracic surgery (RATS) and uniportal video-assisted thoracic surgery (uVATS) have gained increasing popularity and have become widely adopted in many institutions.
RATS involves the use of robotic systems that provide enhanced visualization, precise instrument control, and improved dexterity, enabling surgeons to perform complex thoracic procedures with greater precision (2). On the other hand, uVATS is a single-incision approach that utilizes a single small port, reducing the number of incisions and potentially minimizing surgical trauma (3). Both techniques aim to achieve comparable oncological outcomes to traditional open thoracotomy while minimizing surgical invasiveness and improving patient outcomes.
Several studies have investigated the outcomes and feasibility of RATS and uVATS for lung resection. However, there remains a need for further comparative analyses to elucidate the differences between these approaches and guide clinical decision-making. Understanding the potential advantages and limitations of each technique will help thoracic surgeons select the optimal approach for their patients, considering factors such as patient characteristics, tumor characteristics, and surgeon expertise. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-919/rc).
Methods
Study design and patient selection
This was a single-institution retrospective analysis that involved patients who underwent lung resection using either a uVATS or RATS approach. Operations were performed between July 1, 2020 and July 1, 2021. The study included patients with known or suspected lung cancer or metastases. Two experienced surgeons, one with expertise in RATS and the other with proficiency in multi-portal VATS (mVATS) and recent adoption of uVATS, performed all the operations. The uVATS surgeon had performed multiport VATS for over 15 years. In preparation for adopting uVATS he took a sabbatical at Shanghai Pulmonary Hospital. This was very helpful in understanding instrument positioning through the uniport incision, and the differences in camera view compared to an mVATS approach. The initial cases in the study were performed by the attending surgeon, but later on were increasingly performed by residents. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The institutional review board (IRB) at Allegheny General Hospital reviewed and approved this study (No. 2024-004). An informed consent waiver was obtained from the IRB due to the retrospective nature of this study.
Data collection
Data collection was performed by reviewing electronic medical records and surgical databases. Baseline characteristics including age, sex, comorbidities, and pulmonary function test results were collected for all patients. Additional data collected for analysis included adverse events, subjective pain scores, and morphine equivalent dose (MED) requirement for post-operative days (POD) 1 to 4. Adverse events were defined based on the Society of Thoracic Surgeons (STS) General Thoracic Database criteria.
Outcome measures
The primary outcomes assessed in this study were 30-day adverse events, inpatient subjective pain scores, and MED requirements. Subjective pain scores were recorded on a numeric rating scale ranging from 1 to 10, with higher scores indicating greater pain intensity. MED requirement was calculated to assess analgesic usage and compare opioid consumption between the two surgical approaches. Secondary outcomes included hospital stay, lymph node harvest, recurrence rates, overall survival, and time to recurrence.
Statistical analysis
Baseline characteristics, adverse events, subjective pain scores, MED requirement, hospital stay, lymph node dissection, and recurrence rates were compared between the uVATS and RATS groups. Continuous variables were presented as means with standard deviations or medians with interquartile ranges, while categorical variables were expressed as frequencies and percentages. Statistical significance was assessed using appropriate tests such as t-tests for numerical data and Chi-squared tests for categorical data. In-patient pain scores and MED requirement were compared by univariate and multivariate analysis using linear regression. Regression models incorporated a natural log transformation of the MED variable to correct for skewness. For the multivariate analysis we adjusted for the following potential confounding factors; age, sex, body mass index, chest tube duration, discharge with a chest tube, and history of opioid use.
Survival outcomes (overall survival and recurrence-free survival) were analyzed using Kaplan-Meier survival curves and compared between the two groups using log-rank tests. Statistical significance was set at a P value less than 0.05.
Results
A total of 128 patients underwent lung resection, with 50 patients in the uVATS group and 78 patients in the RATS group. The uVATS patients were found to be older than the RATS patients, with a mean age of 70.3 years compared to 65 years (P=0.01). However, there were no significant differences between the two groups in terms of baseline lung function as measured by forced expiratory volume in the first second (FEV1)% and diffusing capacity for carbon monoxide (DLCO)%, body mass index, and American Society of Anesthesiologists (ASA) scores. The mean procedure times were similar between the uVATS and RATS groups, indicating comparable surgical efficiency (Table 1). We found that RATS was associated with a significantly shorter hospital stay compared to uVATS, with a mean duration of 2.6 versus 4 days, respectively (P=0.02).
Table 1
| Variables | RATS (N=78) | uVATS (N=50) | P value |
|---|---|---|---|
| Demographics | |||
| Age (years) | 65±12 | 70.3±10 | 0.01 |
| BMI (kg/m2) | 28.7±6.4 | 26.9±6.2 | 0.13 |
| DLCO % | 70.6±29.0 | 72.2±33.1 | 0.78 |
| FEV1 % | 76.1±30.2 | 78.1±22.7 | 0.69 |
| Operative times | |||
| Procedure time (min) | 163±84 | 170±69 | 0.98 |
| Time in the operating room (min) | 211±67 | 242±74 | 0.21 |
Data are presented as mean ± standard deviation. RATS, robotic-assisted thoracoscopic surgery; uVATS, uniportal video-assisted thoracoscopic surgery; BMI, body mass index; DLCO, diffusing capacity for carbon monoxide; FEV1, forced expiratory volume in the first minute.
The most common adverse events are summarized in Table 2. Four major complications occurred, and all required an unanticipated return to the operating room. These included one uVATS patient with prolonged air leak requiring endobronchial valve placement, one uVATS patient with diaphragm disruption after en-bloc diaphragm resection and primary reconstruction, who required mesh on re-operation, and two patients who required re-exploration for bleeding (uVATS =1, RATS =1). There were no significant differences in the overall rates of adverse events between the uVATS and RATS groups. The 30- and 90-day mortality rates were zero in both groups.
Table 2
| Outcomes | RATS (N=78) | uVATS (N=50) | P value |
|---|---|---|---|
| Conversion to thoracotomy | 1 (1.3) | 0 | 0.61 |
| ICU admission | 1 (1.3) | 0 | 0.61 |
| Return to operating room | 1 (1.3) | 3 (6.0) | 0.17 |
| Atrial fibrillation | 1 (1.3) | 4 (8.0) | 0.08 |
| Prolonged air leak | 14 (17.9) | 9 (18.0) | 0.59 |
| Discharged with chest tube | 13 (16.7) | 6 (12.0) | 0.32 |
| Length of hospital stay (days) | 2.6±1.6 | 4.0±4.8 | 0.02 |
| Readmission within 30 days | 8 (10.3) | 3 (6.0) | 0.31 |
Data are presented as n (%) or mean ± standard deviation. RATS, robotic-assisted thoracoscopic surgery; uVATS, uniportal video-assisted thoracoscopic surgery; ICU, intensive care unit.
With respect to pain control, uVATS showed advantages on POD 3 and 4 on univariate analysis. On multivariate analysis the differences were not significant (Table 3). Regarding MED requirement, there was a trend for lower opioid use on POD 1, that was significantly better for uVATS on POD 2–4. We completed a multivariate analysis to adjust for potential confounding factors on our pain data, including age, sex, body mass index, chest tube duration, being discharged with chest tube, and history of opioid use. We found that there remained a trend in pain scores but it was no longer significant. MED requirement remained significant after correcting for these factors (Table 3).
Table 3
| Variables | RATS (N=78) | uVATS (N=50) | P value |
|---|---|---|---|
| Daily pain score | |||
| Day 1 | 5.0 (1.7) | 4.5 (2.3) | 0.20 |
| Adjusted β1 | (−) | −0.3 (−1.1, 0.4) | 0.39 |
| Day 2 | 4.9 (2.1) (n=57) | 4.4 (2.2) (n=44) | 0.21 |
| Adjusted β1 | (−) | −0.5 (−1.4, 0.4) | 0.27 |
| Day 3 | 4.2 (2.2) (n=29) | 3.0 (2.2) (n=30) | 0.03 |
| Adjusted β1 | (−) | −1.0 (−2.3, 0.3) | 0.11 |
| Day 4 | 4.8 (2.0) (n=11) | 2.7 (2.1) (n=16) | 0.01 |
| Adjusted β1 | (−) | −2.0 (−3.9, 0.0) | 0.052 |
| MED | |||
| Day 1 | 33.3 (37.9) | 23.8 (39.7) | |
| Log (MED +1) – day 1 | 2.7 (1.6) | 2.1 (1.6) | 0.06 |
| Adjusted β1 | (−) | −0.6 (−1.2, 0.0) | 0.07 |
| Day 2 | 30.0 (32.8) (n=57) | 22.3 (36.3) (n=44) | |
| Log (MED +1) – day 2 | 2.7 (1.5) | 2.0 (1.7) | 0.02 |
| Adjusted β1 | (−) | −0.7 (−1.4, 0.0) | 0.04 |
| Day 3 | 26.2 (26.2) (n=29) | 12.1 (20.8) (n=30) | |
| Log (MED +1) – day 3 | 2.6 (1.5) | 1.3 (1.6) | 0.002 |
| Adjusted β1 | (−) | −1.1 (−2.1, −0.2) | 0.02 |
| Day 4 | 38.1 (28.2) (n=11) | 11.6 (20.9) (n=16) | |
| Log (MED +1) – day 4 | 3.2 (1.3) | 1.3 (1.6) | 0.003 |
| Adjusted β1 | (−) | −1.9 (−3.1, −0.7) | 0.003 |
Regression coefficient from a linear regression model, adjusted for age, sex, body mass index, length of stay, chest tube duration, discharged with chest tube, and history of opioid use. Pain scores are subjective and measured on a scale 1 to 10. Data are presented as mean (standard deviation) or beta coefficient (95% confidence interval). RATS, robotic-assisted thoracoscopic surgery; uVATS, uniportal video-assisted thoracoscopic surgery; MED, morphine equivalent dose is measured in milligrams/24 hours.
RATS demonstrated improved lymph node dissection, with a significantly higher mean number of lymph nodes retrieved (15.3 versus 9.9, P=0.003) compared to uVATS (Table 4). Among the subgroup of patients with primary lung cancer (n=94), the median follow-up period was 15.6 months. The recurrence rates in the uVATS and RATS groups were 10.5% (4 out of 38 patients) and 12.5% (7 out of 56 patients), respectively (P=0.77). We found that 3 out of 56 lung cancer patients (5.4%) that underwent RATs lung resection were pathologic upstaged compared to 4 out of 38 lung cancer patients (10.5%) in the uVATS group (P=0.27). Furthermore, there were no significant differences in overall survival or time to cancer recurrence between uVATS and RATS patients.
Table 4
| Nodal dissection | RATS (N=56) | uVATS (N=34) | P value |
|---|---|---|---|
| Number of nodal stations | 6.1±1.8 | 3.9±1.5 | 0.001 |
| Number of lymph nodes | 15.3±9.5 | 9.9±6.9 | 0.003 |
Data are presented as mean ± standard deviation. RATS, robotic-assisted thoracoscopic surgery; uVATS, uniportal video-assisted thoracoscopic surgery.
Discussion
mVATS has been established as a significant advancement in thoracic procedure due to its propensity to decrease post-operative complications when compared with traditional thoracotomy. The use of multiple smaller incisions, as opposed to thoracotomy with rib-spreading, significantly minimizes the trauma inflicted upon the chest wall, muscles, and underlying tissues. This reduced trauma likely plays a pivotal role in decreasing post-operative complications such as wound infections, and chronic pain. The extensive chest wall dissection in thoracotomy can lead to impairment of pulmonary function, leading to atelectasis and pneumonia. In contrast, the more conservative nature of mVATS means that patients experience fewer pulmonary function disturbances, leading to a faster return of lung capacity and reduced incidence of post-operative respiratory complications (4-6). A previous meta-analysis that included seven randomized trials, demonstrated that VATS was associated with decreased cardiopulmonary complications, atrial fibrillation, pneumonia, atelectasis, and respiratory failure compared to thoracotomy (7).
RATS has seen rising popularity in recent years. A notable strength of RATS is its capability for superior lymph node dissection, demonstrated in non-randomized comparisons with VATS (8,9). Although enhanced lymph node dissection is a technical advantage, this may not necessarily translate to better survival outcomes (10). UVATS, pioneered and popularized by Gonzalez-Rivas, is another approach that has gathered increasing adoption in thoracic surgery (11). Studies evaluating this single-incision approach have suggested that there may be an association with reduced pain in comparison to mVATS (12,13). Since RATS requires multiple small incisions for port placement; pain and analgesia requirements are likely similar to that seen with mVATS. In our study uVATS exhibited advantages in opioid requirements, with patients reporting significantly lower MED requirements during their hospital stay.
Regarding perioperative outcomes, both uVATS and RATS demonstrated similar rates of adverse events and short-term mortality, reflecting their overall safety and feasibility. These findings are consistent with previous studies that have reported comparable complication rates between the two approaches (14). RATS was associated with a shorter hospital stay compared to uVATS, which aligns with previous studies (15). This difference may also have been related to differences in post-operative management protocols between surgeons. This includes decisions such as when to remove chest tubes or discharging patients home with chest tubes. Our findings point to RATS having an edge in lymph node dissection. This superiority may partly stem from the learning curve associated with the uVATS surgeon, who recently transitioned to this method. Both techniques showed equivalence in cancer-related outcomes at intermediate follow-up. These findings are consistent with previous studies that have demonstrated comparable oncological outcomes between uVATS and RATS for lung cancer resection (16,17).
We believe that our study sends a signal that may help in the design of a larger study. Our general impressions are that minimally invasive approaches remain superior to open approaches. Post-operative pain may be better with a single anterior uniportal approach compared to a multiport RATS or VATS approach. This is supported by other studies, notably the recent secondary analysis from the VIOLET study reported that pain scores and physical function were improved after discharge in the uVATS patients (18). In addition to the superior lymph node dissection with RATS, the RATS approach is easier to teach (particularly with dual console systems and simulation) and it is our impression that residents favor this when training.
It is important to acknowledge the limitations of our study, including its non-randomized and retrospective design, single-institution nature, and potential selection bias. Prospective studies with larger sample sizes and longer follow-up periods are needed to further validate our findings and provide more robust evidence on the comparative effectiveness of uVATS and RATS.
Conclusions
In conclusion, we aim to contribute to the existing body of literature and provide insight into the comparative effectiveness of uVATS and RATS for lung resection. Both approaches offer safe and feasible alternatives to traditional open thoracotomy. RATS demonstrated advantages in terms of shorter hospital stays and improved lymph node dissection, while uVATS provided superior pain control and reduced opioid requirements. Importantly, both techniques yielded similar oncological outcomes. Undertaking a prospective randomized study would be ideal, but would be difficult to perform as it is likely that surgeons will have a preferential approach. A prospective registry study would be pragmatic and also would allow the collection of the most reliable data to help delineate differences between the two techniques at a larger scale. Ultimately, the selection of the surgical approach should be tailored to individual patient factors, surgeon expertise, and institutional resources, and further prospective studies will help refine our understanding of the differences between these approaches.
Acknowledgments
The abstract was presented at the European Society of Thoracic Surgeons Annual Scientific Meeting, Milan, Italy, June 4–6, 2023.
Funding: None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-919/rc
Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-919/dss
Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-919/prf
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-919/coif). H.C.F. serves as an unpaid editorial board member of Journal of Thoracic Disease from April 2024 to June 2026. Benny Weksler received lecture fees from AstraZeneca and Merck, and has received a research grant from Atricure. The other 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. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The institutional review board (IRB) at Allegheny General Hospital reviewed and approved this study (No. 2024-004). An informed consent waiver was obtained from the IRB due to the retrospective nature of this study.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Mohiuddin K, Swanson SJ. Maximizing the benefit of minimally invasive surgery. J Surg Oncol 2013;108:315-9. [Crossref] [PubMed]
- Kumar A, Asaf BB. Robotic thoracic surgery: The state of the art. J Minim Access Surg 2015;11:60-7. [Crossref] [PubMed]
- Reinersman JM, Passera E, Rocco G. Overview of uniportal video-assisted thoracic surgery (VATS): past and present. Ann Cardiothorac Surg 2016;5:112-7. [Crossref] [PubMed]
- Detillon DDEMA, Veen EJ. Postoperative Outcome After Pulmonary Surgery for Non-Small Cell Lung Cancer in Elderly Patients. Ann Thorac Surg 2018;105:287-93. [Crossref] [PubMed]
- Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg 2010;139:976-81; discussion 981-3. [Crossref] [PubMed]
- Higuchi M, Yaginuma H, Yonechi A, et al. Long-term outcomes after video-assisted thoracic surgery (VATS) lobectomy versus lobectomy via open thoracotomy for clinical stage IA non-small cell lung cancer. J Cardiothorac Surg 2014;9:88. [Crossref] [PubMed]
- Ng CSH, MacDonald JK, Gilbert S, et al. Optimal Approach to Lobectomy for Non-Small Cell Lung Cancer: Systemic Review and Meta-Analysis. Innovations (Phila) 2019;14:90-116. [Crossref] [PubMed]
- Zhang J, Feng Q, Huang Y, et al. Updated Evaluation of Robotic- and Video-Assisted Thoracoscopic Lobectomy or Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis. Front Oncol 2022;12:853530. [Crossref] [PubMed]
- Velez-Cubian FO, Rodriguez KL, Thau MR, et al. Efficacy of lymph node dissection during robotic-assisted lobectomy for non-small cell lung cancer: retrospective review of 159 consecutive cases. J Thorac Dis 2016;8:2454-63. [Crossref] [PubMed]
- Montagne F, Chaari Z, Bottet B, et al. Long-Term Survival Following Minimally Invasive Lung Cancer Surgery: Comparing Robotic-Assisted and Video-Assisted Surgery. Cancers (Basel) 2022;14:2611. [Crossref] [PubMed]
- Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg 2013;95:426-32. [Crossref] [PubMed]
- Tamura M, Shimizu Y, Hashizume Y. Pain following thoracoscopic surgery: retrospective analysis between single-incision and three-port video-assisted thoracoscopic surgery. J Cardiothorac Surg 2013;8:153. [Crossref] [PubMed]
- Mier JM, Chavarin A, Izquierdo-Vidal C, et al. A prospective study comparing three-port video-assisted thoracoscopy with the single-incision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: a pilot study. Surg Endosc 2013;27:2557-60. [Crossref] [PubMed]
- Yang S, Guo W, Chen X, et al. Early outcomes of robotic versus uniportal video-assisted thoracic surgery for lung cancer: a propensity score-matched study. Eur J Cardiothorac Surg 2018;53:348-52. [Crossref] [PubMed]
- Park BJ, Melfi F, Mussi A, et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg 2012;143:383-9. [Crossref] [PubMed]
- Merritt RE, Abdel-Rasoul M, D'Souza DM, et al. Comparison of the long-term oncologic outcomes of robotic-assisted and video-assisted thoracoscopic lobectomy for resectable non-small cell lung carcinoma. J Robot Surg 2022;16:1281-8. [Crossref] [PubMed]
- Kneuertz PJ, D'Souza DM, Richardson M, et al. Long-Term Oncologic Outcomes After Robotic Lobectomy for Early-stage Non-Small-cell Lung Cancer Versus Video-assisted Thoracoscopic and Open Thoracotomy Approach. Clin Lung Cancer 2020;21:214-224.e2. [Crossref] [PubMed]
- Lim E, Harris RA, Batchelor T, et al. Outcomes of single- versus multi-port video-assisted thoracoscopic surgery: Data from a multicenter randomized controlled trial of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer. JTCVS Open 2024;19:296-308. [Crossref] [PubMed]
