Pulmonary lobectomy for cancer: Systematic review and network meta-analysis comparing open, video-assisted thoracic surgery, and robotic approach

Background: Although minimally invasive lobectomy has gained worldwide interest, there has been debate on perioperative and oncological outcomes. The purpose of this study was to compare outcomes among open lobectomy, video-assisted thoracic surgery lobectomy, and robotic lobectomy. Methods: PubMed, EMBASE, and Web of Science databases were consulted. A fully Bayesian network meta-analysis was performed. Results: Thirty-four studies (183,426 patients) were included; 88,865 (48.4%) underwent open lobectomy, 79,171 (43.2%) video-assisted thoracic surgery lobectomy, and 15,390 (8.4%) robotic lobectomy. Compared with open lobectomy, video-assisted thoracic surgery, lobectomy and robotic lobectomy had significantly reduced 30-day mortality (risk ratio = 0.53; 95% credible intervals, 0.40–0.66 and risk ratio = 0.51; 95% credible intervals, 0.36–0.71), pulmonary complications (risk ratio = 0.70; 95% credible intervals, 0.51–0.92 and risk ratio = 0.69; 95% credible intervals, 0.51–0.88), and overall complications (risk ratio = 0.77; 95% credible intervals, 0.68–0.85 and risk ratio = 0.79; 95% credible intervals, 0.67–0.91). Compared with video-assisted thoracic surgery lobectomy, open lobectomy, and robotic lobectomy had a significantly higher total number of harvested lymph nodes (mean difference = 1.46; 95% credible intervals, 0.30, 2.64 and mean difference = 2.18; 95% credible intervals, 0.52–3.92) and lymph nodes stations (mean difference = 0.37; 95% credible intervals, 0.08–0.65 and mean difference = 0.93; 95% credible intervals, 0.47–1.40). Positive resection margin and 5-year overall survival were similar across treatments. Intraoperative blood loss, postoperative transfusion, hospital length of stay, and 30-day readmission were significantly reduced for minimally invasive approaches. Conclusion: Compared with open lobectomy, video-assisted thoracic surgery lobectomy, and robotic lobectomy seem safer with reduced 30-day mortality, pulmonary, and overall complications with equivalent oncologic outcomes and 5-year overall survival. Minimally invasive techniques may improve outcomes and surgeons should be encouraged, when feasible, to adopt video-assisted thoracic surgery lobectomy, or robotic lobectomy in the treatment of lung cancer.