Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases.

OBJECTIVE: The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions. SUMMARY BACKGROUND DATA: Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors. RESULTS: A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007). CONCLUSIONS: Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: An Analysis of 5721 Cases.

OBJECTIVE: The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL). SUMMARY BACKGROUND DATA: Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. METHODS: Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage. RESULTS: A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS ( P < 0.0001) and OL ( P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate ( P <0.0001), shorter hospital stay ( P <0.0001) and a lower postoperative transfusion rate ( P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. CONCLUSIONS: RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS.

Robotic resection of Stage III lung cancer: an international retrospective study.

OBJECTIVES: Minimally invasive surgery is accepted for early-stage lung cancer, but its role in locally advanced disease is controversial, especially using a robotic platform. The aim of this retrospective study was to assess the safety and effectiveness of robot-assisted resection in patients with Stage IIIA non-small-cell lung cancer (NSCLC) or carcinoid tumours in the series as a whole and in different subgroups according to adjuvant treatment. METHODS: This was a retrospective multicentre study of consecutive patients with clinically evident or occult N2 disease (210 NSCLC and 13 carcinoid) who, in 2007-2016, underwent robot-assisted resection at 7 high-volume centres. Perioperative outcomes, recurrences and overall survival were assessed. RESULTS: N2 disease was diagnosed preoperatively in 72 (32%) patients and intraoperatively in 151 (68%) patients. Surgical margins were negative in 98.4% of cases with available data. Thirty-four (15.2%) patients received neoadjuvant treatment, 140 (63%) patients received postoperative treatment, and 49 (22%) patients underwent surgery only. There were 22 (9.9%) conversions to thoracotomy, 23 (10.3%) had serious (Grades III-IV) postoperative morbidity and the mean hospital stay was 5.3 days. Complications and outcomes did not differ significantly between treatment groups. Of the 34 patients who were given neoadjuvant chemotherapy, all had R0 resection, 5 (15%) patients required conversion but none required conversion because of bleeding and 4 (12%) patients had Grade III or IV postoperative complications. After a median of 18 (interquartile range 8-33) months, 3-year overall survival in NSCLC patients was 61.2% and 60.3% (P = 0.6) of patients in the subgroup were given induction treatment. However, overall survival was significantly better (P = 0.012) in NSCLC patients with ≤2 positive nodes (vs >2). Nineteen (8.5%) patients developed local recurrence. CONCLUSIONS: Robot-assisted lobectomy is safe and effective in patients with Stage III NSCLC or carcinoid tumours with low conversions and complications. Among patients with NSCLC, including those who were given induction chemotherapy, survival was similar to that reported for open surgery.

The long-term survival of robotic lobectomy for non-small cell lung cancer: A multi-institutional study.

OBJECTIVE: Our objective is to report the world's largest series with the longest follow-up of robotic lobectomy for non-small cell lung cancer (NSCLC). METHODS: This was a multi-institutional retrospective review of a consecutive series of patients from 4 institutions' prospective robotic databases. RESULTS: There were 1339 patients (men 55%, median age 68 years). The median operative time was 136 minutes, median number of lymph nodes was 13 (5 N2 stations and 1 N1), median blood loss was 50 cc, and 4 (0.005%) patients received intraoperative transfusions. Conversions occurred in 116 patients (9%) and for bleeding in 24 (2%). Median length of stay was 3 days. Major morbidity occurred in 8%. The 30-day and 90-day operative mortality was 0.2% and 0.5%, respectively. Follow-up was complete in 99% of patients with a median follow-up of 30 months (range 1-154 months). The 5-year stage-specific survival was: 83% for the 672 patients with stage IA NSCLC, 77% for the 281 patients with stage IB, 68% for the 118 patients with stage IIA, 70% for 99 patients with IIB, 62% for 143 patients with stage IIIA (122 had N2 disease, 73%), and 31% for 8 patients with stage IIIB (none had N3 disease). The cumulative incidence of metastatic NSCLC was 15% (128 patients, 95% confidence interval, 13%-18%). The cumulative incidence of local recurrence in the ipsilateral operated chest was 3% only (26 patients, 95% confidence interval, 2%-5%). CONCLUSIONS: The oncologic results of robotic lobectomy for NSCLC are promising, especially for patients with pathologic N2 disease. However, further follow-up and studies are needed.

Robotic assisted lobectomy for locally advanced lung cancer.

Some series report the use of video-assisted thoracic surgery (VATS) in patients with locally advanced non-small cell lung cancer (NSCLC) but, few studies describe the use of the robotic approach specifically for locally advanced disease. One potential advantage of the robotic approach over traditional VATS is the increased radicality. While the benefit of the robotic approach over open thoracotomy is directly related to reduced surgical trauma and the improved tolerability in fragile patients that have received induction treatment. In case of occult N2 disease, robotic assisted surgery can translate into a quicker recovery with improved compliance with adjuvant treatments following surgery. Technical details are reported and described. The robotic instrument technology allows sharp and controlled dissection compared to the typical blunt sweeping methods used in most VATS lobectomy techniques. The authors believe that robotic technology favors a more radical resection in the case of complex locally advanced tumors. Robotic technology has some limitations that have affected adoption such as significant capital and maintenance costs, reduced operating room efficiencies, and a steep learning curve.

Pulmonary resection using a total endoscopic robotic video-assisted approach.

We have developed a robotic video-assisted thoracoscopic technique (RVATS) for lung resection that could encourage broader use of minimally invasive lobectomy. During December 2006 to September 2010, RVATS was performed in 200 consecutive patients (90 women, 110 men) with the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). Pulmonary resection was performed through ports without the need for a utility incision. Data on patients' perioperative results were collected retrospectively. Robotic video-assisted pulmonary resection was accomplished in 197 of 200 patients. A total of 154 patients underwent lobectomy; 4 patients required bilobectomy, and 35 patients underwent segmentectomy. Three patients underwent a sleeve lobectomy, and 3 patients had an en-bloc resection with lobectomy. One patient received a left pneumonectomy. Three patients required conversion to a thoracotomy. The median operative time was 90 minutes. The median length of hospital stay was 3 days. 60-day mortality and morbidity was 2% and 26%, respectively. RVATS lung resection is technically feasible, safe, and results indicate the procedure is associated with reduced length of stay, low morbidity, and mortality.

Robotic-assisted Heller myotomy for esophageal achalasia: feasibility, technique, and short-term outcomes.

Laparoscopic Heller myotomy is the standard surgical treatment for esophageal achalasia. The incidence of esophageal perforation is about 5-10%. Robotic-assisted Heller myotomy (RAHM) offers results at least as good as those from laparoscopic procedures, additionally yielding fewer intraoperative complications. The aim of this study was to demonstrate the safety and feasibility of RAHM and its value in the treatment of esophageal achalasia. We analyzed demographics, preoperative symptoms, esophagograms, esophageal manometry, intraoperative and postoperative data of all the patients who underwent RAHM for achalasia at three institutions: 36 women and 37 men, mean age 45 ± 16 (13-87) years. Dysphagia was present in 100% of patients. Thirty-three patients (45%) had had previous endoscopic treatment: 23 patients had pneumatic dilation, four patients had Botox injections, and six patients had both. Surgical time averaged 119 min (range of 62-211); blood loss averaged 23 ml; no mucosal perforations were observed; length of hospitalization was 1.5 days; there were no deaths. At 12 months, 96% of patients had relief of their dysphagia. In conclusion, RAHM is safe and effective since there were no intraoperative esophageal perforations and relief of symptoms was achieved in 96% of the patients.

Total port-access robot-assisted pulmonary lobectomy without utility thoracotomy.

Robot-assisted lobectomy has been reported elsewhere as a feasible technique for lobectomy. We report a modification of the previously reported technique using a complete port-access approach without utility thoracotomy.