Robotic-Assisted Thoracoscopic Surgery (RATS) Versus Video-Assisted Thoracoscopic Surgery (VATS) Lobectomy for Stage I or II Non-small Cell Lung Cancer

 

OR time (mins)

Rate of conversion (%)

EBL (mL)

Complications (%)

Median LOS (days)

# of lymph nodes dissected

Lymph node stations biopsied

Initial VATS (n = 40)

257 ± 57

7.5

374 ± 374

32.5

9 (6–34)

29 (15–56)

8 (5–11)

Recent VATS (n = 40)

161 ± 39

5

245 ± 173

17.5

7 (4–16)

26 (12–46)

7.5 (5–10)

RAL (n = 40)

240 ± 62

0

219 ± 123

10

6 (4–22)

22 (7–45)

7 (2–10)


Modified from Jang et al. [3]

VATS video-assisted thoracic surgery, RAL robotic assisted lobectomy, EBL estimated blood loss, LOS length of stay, OR operating room



Cerfolio et al. [5], from Birmingham, Alabama, reported a retrospectively matched result of completely portal lobectomy with four arms against nerve- and rib-sparing thoracotomies in 2011. RATS (106 patients) were performed by a single surgeon between February 2010 and April 2011. The propensity matched thoracotomy patients (318 patients) were from their previously collected data set. The statistically significant findings that favored robotics approach over open thoracotomy were estimated blood loss (EBL), chest tube duration, hospital days, morbidity and verbal pain scores 3-weeks postoperatively (Table 12.2). They concluded that robotic lobectomy is safe, allows achieving R0 resection, obtaining adequate numbers of lymph nodes and sampling adequate lymph node stations.


Table 12.2
Key clinical outcomes


























































 
EBL (mL, median and SD)

OR time (h, median and SD)

# of N2 nodes and stations removed (median)

# of N1 nodes and stations removed (median)

Chest tube days (median and range)

Hospital days (median and range)

Morbidity

Operative mortality

Verbal pain score 3 weeks postop

Robotic (n = 106)

30 ± 26

2.2 ± 1.0

12, 5

5, 3

1.5 (1–6)

2.0 (1–7)

28 (27 %)

0

2.5 (0–7)

Thoracotomy (n = 318)

90 ± 22

1.5 ± 0.8

11, 5

4, 3

3.0(1–67)

4.0(1–67)

120 (38 %)

11 (3 %)

4.4 (0–8)

P value

0.03

<0.001

0.906, >0.999

0.89, >0.999

<0.001

0.01

0.05

0.11

0.04


Modified from Cerfolio et al. [5]

EBL estimated blood loss, SD standard deviation, N2 ipsilateral mediastinal node, N1 ipsilateral hilar node, OR operating room

Louie et al. [6] recently published a case-control analysis of consecutive completely portal anatomic (lobectomy or segmentectomy) (CPR) lung resection and VATS anatomic resections performed between May 2009 and October 2011. They included patients with solitary pulmonary metastasis and benign lung conditions (bronchiectasis, congenital malformations and localized fungal infections) for a total of 46 RATS and 34 VATS patients included in the study. The only statistically significant difference in demographics was the Eastern Cooperative Oncology Group (ECOG) performance status which, for unclear reasons, favored RATS. Key clinical outcomes between the two approaches were similar (Table 12.3). The authors concluded that RATS resulted in similar surgical outcomes as VATS and that the two MIS platforms can be seen as complimentary to each other. However, long-term follow-up or potential cost differences were not addressed.


Table 12.3
Key clinical outcomes







































Characteristics

Robotic

VATS

P value

Lesion size in cm, median (range)

2.8 (0.9–7.2)

2.3 (0.9–4.9)

0.07

Mean operative time (mins)

213

207

0.61

Length of stay (days), median (range)

4 (2–21)

4.5 (2–22)

0.63

ICU stay (days)

0.92

0.64

0.43

Estimated blood loss (mL)

153

134

0.36


Modified from Louie et al. [6]

ICU intensive care unit, VATS video-assisted thoracic surgery

At the Western Thoracic Surgical Association meeting in 2013, Lee et al. [7] from Ridgewood, NJ compared their experience of 20 RATS versus 32 VATS performed by a single surgeon between 2011 and 2012. Neither group required conversion to thoracotomy. The only statistically significant finding was the median operating time for RATS was 153 min versus 130 min in VATS (p = 0.02) (Table 12.4). In conclusion, they supported the utilization of robotics in minimally invasive thoracic surgery as an alternative platform to VATS.


Table 12.4
Key clinical outcomes











































 
Robotic (n = 20)

VATS (n = 32)

P value

Median operating time

153

130

0.02

Hospital LOS

3

3
 

Number of lymph nodes

17.5

15.5

0.28

Morbidity

10

15.6

0.69

Mortality

0

3

0.99

Cost (in US $)

48,116

48,015

0.84


Modified from Lee et al. [7]

LOS length of stay, VATS video-assisted thoracic surgery

A recent report by Deen et al. [8] performed a retrospective cost analysis comparing open, VATS and RATS lobectomies and segmentectomies in 190 patients (71 open, 59 RATS and 60 VATS) performed during a similar period. The operative time was longest in RATS, 223 min, versus 202 min in VATS (p = 0.0.045) and 180 min in open (p = <0.001) but RATS had the shortest inpatient days: RATS 4.62 days versus 4.75 days in VATS (p = 0.777) and 5.47 days in open (p = 0.054). The overall, total and procedure costs per case with RATS approach were 17,011.02, 15,811.02 and 14,650.02 (in US $) respectively. Statistically significant cost differences were shown for overall and total cost when compared to VATS (overall (in US$) 13,829.09 (p = <0.001), total 13,662.60 (p = 0.019)). The statistically significant reasons for the higher costs in RATS were shown to be operating room costs and the cost of supplies. The authors observed that to render the RATS costs equivalent to those of VATS, the RATS operating room times needed to be decreased by 68 min per case or the hospital length of stay decreased by 1.86 days. Their conclusion was that VATS, when compared to open and RATS, was the less expensive approach to lobectomy and/or segmentectomy. Their analysis also suggested that for RATS to be financially viable one needed to either significantly reduce operative times or the costs of RATS supplies.

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Dec 30, 2016 | Posted by in CARDIOLOGY | Comments Off on Robotic-Assisted Thoracoscopic Surgery (RATS) Versus Video-Assisted Thoracoscopic Surgery (VATS) Lobectomy for Stage I or II Non-small Cell Lung Cancer
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