Perioperative outcomes and nodal station assessment after robotic-assisted versus video-assisted thoracoscopic segmentectomy for early-stage NSCLC: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Lymph node stations P<0.001; Hospital stay P=0.015; Operative time P=0.732; Overall complications P=0.745; 30-day readmission P=0.257

• Effect Size: RATS associated with more lymph node stations examined (WMD=1.16) and shorter hospital stay (WMD=−0.75 days); no significant differences in operative time, drainage duration, overall complications, air leak, pneumonia, or 30-day readmission

• Primary Outcome: Lymph node stations examined and perioperative safety outcomes in RATS versus VATS segmentectomy for early-stage NSCLC

• Nnt Or Sensitivity: No NNT calculable from available data; WMD of 1.16 additional lymph node stations and 0.75 fewer hospital days represent modest absolute differences of uncertain clinical threshold significance

• Confidence Interval: Lymph node stations: 95% CI 0.51 to 1.81; Hospital stay: 95% CI −1.36 to −0.15; Operative time: 95% CI −8.80 to 12.52 (non-significant); Overall complications OR 0.94 (95% CI 0.67–1.34)

Clinical Application

RATS is technically feasible for segmentectomy but requires significant capital investment in robotic platforms, dedicated surgical training, and institutional credentialing. Operative times are comparable to VATS, suggesting no efficiency penalty once proficiency is established. The modest reduction in hospital stay may offer marginal health system cost offsets, though robotic consumable costs likely outweigh these savings in most settings. In Australia, robotic surgical systems (predominantly the da Vinci platform) are available at major metropolitan public and private hospitals, but access is highly variable and concentrated in high-volume thoracic surgery centres. RATS segmentectomy is not separately reimbursed under the Medicare Benefits Schedule (MBS) with a distinct item number from VATS; billing typically occurs under existing thoracoscopic resection codes. The Therapeutic Goods Administration (TGA) has approved robotic surgical systems for thoracic use. RACGP and thoracic surgery guidelines (ANZSCTS) do not currently recommend RATS over VATS for early-stage NSCLC based on available evidence. The findings of this meta-analysis do not provide sufficient evidence to justify preferential adoption of RATS in Australian public health settings, where cost-effectiveness and equitable access are paramount considerations. Prospective Australian registry data would be valuable. Patients with early-stage NSCLC (clinical stage I–II) who are candidates for sublobar resection via minimally invasive thoracoscopic segmentectomy at centres with both RATS and VATS capability

Abstract

The relative benefits of Robotic-assisted thoracoscopic segmentectomy (RATS) versus video-assisted thoracoscopic segmentectomy (VATS) for early-stage NSCLC remain uncertain. This meta-analysis compared perioperative outcomes, lymph node assessment, and postoperative safety between the two approaches. PubMed, Cochrane Library, Embase, and Web of Science were searched from inception to April 2026. Comparative studies of RATS versus VATS segmentectomy for early-stage NSCLC were included. Outcomes were pooled as weighted mean differences or odds ratios with 95% confidence intervals. Random-effects models were used for substantial heterogeneity (I² >50% or P < 0.05); otherwise, fixed-effects models were applied. Leave-one-out sensitivity plots are provided in the supplementary materials. Nine retrospective comparative studies involving 19,805 patients were included. Robotic-assisted segmentectomy was associated with a greater number of lymph node stations examined (WMD = 1.16, 95% CI: 0.51, 1.81, P < 0.001) and a shorter length of hospital stay (WMD = - 0.75, 95% CI: -1.36, - 0.15, P = 0.015). No significant differences were observed in operative time (WMD = 1.86, 95% CI: -8.80, 12.52, P = 0.732), duration of drainage (WMD = - 0.37, 95% CI: -0.79, 0.06, P = 0.090), overall complications (OR = 0.94, 95% CI: 0.67, 1.34, P = 0.745), air leak (OR = 1.02, 95% CI: 0.54, 1.91, P = 0.949), pneumonia (OR = 1.33, 95% CI: 0.89, 1.99, P = 0.170), or 30-day readmission (OR = 1.09, 95% CI: 0.94, 1.26, P = 0.257). Current retrospective evidence suggests that RATS may offer more examined lymph node stations and shorter hospital stay without increased morbidity, but these findings are limited by risk of bias and should not be interpreted as evidence of oncologic superiority.

References

1. 1.Yu, Y.-H., Huang, Y.-P., Yu, A.-B., Li, Y., Sun, P., Liu, X., & Tian, Y.-H. (2026). Perioperative outcomes and nodal station assessment after robotic-assisted versus video-assisted thoracoscopic segmentectomy for early-stage NSCLC: a systematic review and meta-analysis. Lung Cancer. https://doi.org/10.1016/j.lungcan.2025.108438