Comparison of the progression-free survival between robot-assisted thymectomy and video-assisted thymectomy for thymic epithelial tumors: a propensity score matching study

Ergonomic Assessment of Robotic versus Thoracoscopic Thymectomy

Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.

Surgical treatment of thymic epithelial tumors: a narrative review

Background and Objective

Thymic epithelial tumors (TETs) are scarce neoplasms of the prevascular mediastinum. Included in this diverse category of lesions are thymomas and thymic carcinomas (TCs). Surgery is the mainstay of treatment of tumors that are deemed resectable. However, up till now, optimal surgical access has been a subject of debate. The advent of new techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), challenged the median sternotomy which was traditionally considered the access of choice. This review aims to demonstrate the current evidence concerning the surgical treatment of TET and to enlighten other controversial issues about surgery.

Methods

PubMed research was conducted using the terms [surgery] AND [thymic epithelial tumors] OR [thymomas] and [surgical treatment] AND [thymic epithelial tumors] OR [thymomas]. Papers concerning pediatric cases and non-English literature papers were excluded. Individual case reports were also excluded.

Key Content and Findings

Minimally invasive surgical techniques (MIST) such as VATS and RATS are increasingly applied in early-stage TET. Although numerous published studies have demonstrated better perioperative outcomes in early-stage TET, long-term follow-up data are still required to demonstrate the oncological equivalent of MIST to open surgery. Resection of stage III TET is more challenging. Thymectomy can be expanded en bloc to include the major vascular structures, lung, pleura, phrenic, or vagus nerve in these individuals. There is no agreement on the ideal surgical access and traditionally these patients underwent open sternotomy, sometimes combined with a thoracic access. Evidence concerning the treatment of stage IVA disease is mainly derived from retrospective case series which are highly heterogeneous in terms of the number of enrolled patients, histology, degree of pleural involvement, and timing of presentation.

Conclusions

New techniques in the field of minimally invasive surgery are gaining acceptance for early-stage TET but longer follow-up periods are warranted to prove their oncological outcomes. On the contrary, these techniques should be used cautiously in case of locally advanced tumors. Surgeons must not forget that the main objective is the complete resection of the lesion, which is one major predictive factor for increased survival.

Meta-analysis of clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors

OBJECTIVE

Comparing the clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors using meta-analysis.

METHODS

Computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science databases for literature comparing the clinical effects of video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) in treating mediastinal tumors, with the retrieval time limit from the establishment of the database to September 2023. Two evaluators independently screened the literature, extracted data, and assessed the risk of bias. Meta-analysis was performed using RevMan 5.4.

RESULTS

A total of 19 articles were included, with a total of 3517 patients. The results of the Meta-analysis showed that the RATS group had less intraoperative bleeding [MD =  - 5.20, 95%CI (- 9.28, - 1.12), P = 0.01], lower rate of conversion to thoracotomy [OR = 0.41, 95%CI (0.23, 0.72), P = 0.002], lower rate of total postoperative complications [OR = 0.57, 95%CI (0.34, 0.95), P = 0.03], shorter postoperative drainage time [MD =  - 0.72, 95%CI (- 1.13, - 0.32), P = 0.0004], and shorter postoperative hospital stay [MD =  - 0.90, 95%CI (- 1.16, - 0.65), P < 0.001], in comparison with the VATS group. There was an insignificant difference between the two groups in terms of tumor size [MD =  - 0.02, 95%CI (- 0.33, 0.30), P = 0.91] and operation time [MD = 0.17, 95%CI (- 7.61, 7.94), P = 0.97]. However, in regards to hospitalization costs [MD = 2634.75, 95%CI (991.62, 4277.88), P = 0.002], the RATS group was more expensive than the VATS group.

CONCLUSION

Robot-assisted mediastinal tumor resection surgery has more advantages in terms of intraoperative bleeding, conversion to thoracotomy rate, total postoperative complication rate, postoperative drainage time, and postoperative hospital stay, in comparison with thoracoscopic-assisted mediastinal tumor resection surgery. There is an insignificant difference in tumor size and operation time between the two surgeries. However, robot-assisted mediastinal tumor resection surgery increases hospitalization costs.

Robot-assisted surgery outperforms video-assisted thoracoscopic surgery for anterior mediastinal disease: a multi-institutional study

Anterior mediastinal procedures are increasingly being performed using robot-assisted thoracic surgery (RATS) or video-assisted thoracoscopic surgery (VATS). While both approaches have shown superior outcomes compared to open surgery, their comparative benefits are not as distinct. The aim of this retrospective study was to bridge this knowledge gap using a multicenter dataset. Patients who underwent elective minimally invasive surgery for anterior mediastinal disease between 2015 and 2022 were deemed eligible. The study participants were grouped based on whether a robot was used or not, and perioperative outcomes were compared. To mitigate selection bias, inverse probability of treatment weighting (ITPW) was applied using the propensity score. The final analysis included 312 patients (RATS = 120; VATS = 192). Following the application of IPTW, RATS was found to be associated with a longer operating time (215.3 versus 139.31 min, P < 0.001), fewer days with a chest tube (1.96 versus 2.61 days, P = 0.047), and a shorter hospital stay (3.03 versus 3.91 days, P = 0.041) compared to VATS. Subgroup analyses indicated that the benefit of RATS in reducing the length of hospital stay was particularly pronounced in patients with tumors larger than 6 cm (mean difference [MD] =  - 2.28 days, P = 0.033), those diagnosed with myasthenia gravis (MD =  - 3.84 days, P = 0.002), and those who underwent a trans-subxiphoid surgical approach (MD =  - 0.81 days, P = 0.04). Both VATS and RATS are safe and effective approaches for treating anterior mediastinal disease. However, RATS holds distinct advantages over VATS including shorter hospital stays and reduced chest tube drainage periods.

Significance of the Surgical Treatment with Lymph Node Dissection for Neuroendocrine Tumors of Thymus

BACKGROUND

Neuroendocrine tumors of a thymus (NETTs) are rare, accounting for approximately 2-5% of all thymic epithelial tumors, and have a poor prognosis due to frequent lymph nodes or distant metastasis.

METHODS

We retrospectively reviewed the clinicopathological background and outcomes of 40 patients who underwent resection or surgical biopsy with histologically diagnosed NETTs from 1986 to 2022.

RESULTS

The most common pathological type was atypical carcinoid. Surgical resection was performed in 35 patients, with lymph node dissection in 33 and surgical biopsy in five. The overall survival (OS) rate for all patients was 81.4% and 52.3% at 5 and 10 years, respectively. The 2-year survival rate was 20% for the biopsy group, which was significantly worse than that of the resected group (p < 0.001). The relapse-free survival rates were 61.7% and 37.6% at 5 and 10 years, respectively, in 34 patients with complete resection. The univariate analysis revealed better the OS rate in the resected cases but with no significant differences between histological grade, lymph node metastasis, tumor size, or Ki67 index.

CONCLUSIONS

Surgical complete resection is considered to improve prognosis regardless of histologic type. NETTs frequently develop lymph node metastasis, thus, lymph node dissection seems necessary for complete resection.

Robotic Mediastinal Tumor Resections: Position and Port Placement

This study aimed to determine the optimal position and port placement during robotic resection for various mediastinal tumors. For anterior mediastinal tumors, total or extended thymectomy is commonly performed in the supine position using the lateral or subxiphoid approach. Although it is unclear which approach is better during robotic thymectomy, technical advantages of subxiphoid approach are beneficial for patients with myasthenia who require extended thymectomy. Partial thymectomy is performed in the supine position using a lateral approach. Superior, middle, and posterior mediastinal tumors are resected in the decubitus position using the lateral approach, whereas dumbbell tumor resection, which requires a posterior approach, can be performed in the prone position. The position and port placement should be chosen depending on the size, location, and aggressiveness of the tumor. In this study, we describe how to choose which of these different robotic approaches can be used based on our experience and previous reports.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for treatment of patients with thymoma: A systematic review and meta-analysis

Background

Surgical resection of the thymus is indicated in the presence of primary thymic diseases such as thymoma. Video‐assisted thoracoscopic surgery (VATS) and robot‐assisted thoracic surgery (RATS) offer a minimally invasive approach to thymectomy. However, there is no clear conclusion whether RATS can achieve an equal or even better surgical effect when compared with VATS in treatment of thymoma. We performed this meta‐analysis to explore and compare the outcomes of RATS versus VATS for thymectomy in patients with thymoma.

Methods

PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were searched for full‐text literature citations. The quality of the articles was evaluated using the Newcastle–Ottawa Scale and the data analyzed using Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis was conducted.

Results

A total of 11 studies with 1418 patients, of whom 688 patients were in the RATS group and 730 in the VATS group, were involved in the analysis. Compared with VATS, RATS was associated with less blood loss in operation, lower volume of drainage, fewer postoperative pleural drainage days, shorter postoperative hospital stay, and fewer postoperative complications. There was no significant difference in operative time and patients with or without myasthenia gravis between the two groups.

Conclusions

RATS has more advantages over VATS, indicating that RATS is better than VATS in terms of postoperative recovery. We look forward to more large‐sample, high‐quality randomized controlled studies published in the future.

Does robotic-assisted thymectomy have advantages over video-assisted thymectomy in short-term outcomes? A systematic view and meta-analysis

OBJECTIVES

A thymic epithelial tumour is the most common primary tumour in the anterior mediastinum of adults. A few retrospective studies compared the short-term outcomes between robotic-assisted thymectomy (RAT) and video-assisted thymectomy (VAT). So, it is necessary to conduct a meta-analysis to further compare these 2 surgical techniques.

METHODS

EMBASE, Medline and Web of Science were used. Thesaurus terms and medical subject headings were used in Medline and EMBASE, respectively. The Newcastle-Ottawa scale was used for grading because the included studies were all case-control studies.

RESULTS

Nine studies were included in the meta-analysis with a total of 723 patients, including 315 patients in the RAT group and 408 patients in the VAT group. The meta-analysis [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.06-0.94; P = 0.041], indicating that RAT yielded a significantly lower rate of conversion compared with VAT. Duration of drainage with RAT was significantly less than that with VAT (weighted mean difference = -1.10; 95% CI -1.98 to -0.22; P = 0.014). The pooled analysis (weighted mean difference = -103.6; 95% CI -199.21 to -7.98; P = 0.034) suggested that patients in the RAT group had less drainage than those in the VAT group. The recurrence rates in both groups were comparable (OR 0.19, 95% CI 0.03-1.20; P = 0.078).

CONCLUSIONS

RAT has advantages over VAT in terms of short-term outcomes such as shorter duration of drainage, less total drainage and a lower rate of conversion. The recurrence rate was comparable between the 2 techniques. Therefore, RAT could be considered as an alternative treatment for diseases of the thymus.