Robotic-assisted versus video-assisted thoracoscopic surgery for non-small cell lung cancer after neoadjuvant immunotherapy: a systematic review and meta-analysis.

Administering upfront immunomodulatory agents has completely redefined the clinical pathways for operable non-small cell lung cancer (NSCLC); however, the subsequent inflammatory response and hilar fibrosis have increased the technical complexity of surgical resections. Although robotic-assisted thoracic surgery (RATS) offers theoretical advantages in visualization and precision over video-assisted thoracoscopic surgery (VATS) to address these challenges, comparative evidence between the two platforms in the post-immunotherapy setting remains limited. This investigation sought to juxtapose the operative viability and safety metrics between robotic and video-assisted thoracic platforms following neoadjuvant immunotherapy for NSCLC. A systematic search was conducted across PubMed, Cochrane, and EMBASE databases, identifying five studies involving 984 patients. Analyzed outcomes included conversion to open thoracotomy, operative time, intraoperative bleeding, complete resection rate, blood transfusion, lymph node yield, and explored lymph node stations. RATS was associated with a significantly lower rate of conversion to thoracotomy (OR 0.28, 95% CI 0.13–0.65; P = 0.003), as well as more dissected lymph nodes (MD 4.04, 95% CI 0.93–7.16; P = 0.01) and explored lymph node stations (MD 1.22, 95% CI 0.26–2.18; P = 0.01). There were no major differences in rates of complete resection, length of surgery, blood loss, or the need for transfusions. Both robotic surgery and video-thoracoscopy demonstrated equivalent perioperative and oncological safety. However, RATS was associated with significantly lower rates of conversion to thoracotomy, particularly in cases involving dense hilar fibrosis, and achieved a more comprehensive lymph node assessment compared to VATS.