Comparative analysis of safety and outcomes of Non-intubated versus intubated uniportal video-assisted thoracic surgery using propensity score matching: a single-center experience expanding indications beyond traditional restrictions.

BACKGROUND

Non-intubated uniportal video-assisted thoracoscopic surgery (NI-UVATS) has emerged as an alternative to conventional intubated approaches, yet its applicability across diverse patient populations and procedure types remains undefined. We evaluated perioperative outcomes of NI-UVATS vs. intubated UVATS (I-UVATS) in an unrestricted cohort.

METHODS

This retrospective cohort study analyzed 289 consecutive VATS procedures (January 2017-June 2025) at a single center. Patients underwent either I-UVATS (n = 166) or NI-UVATS (n = 123) based on surgeon and anesthesiologist preference. Primary outcome was serious complications (composite of mortality, reintubation, pneumonia, or reoperation). Secondary outcomes included 30-day mortality, length of stay, and procedure-specific complications. Propensity score matching (1:1) was performed to address baseline imbalances. Post-hoc stratification by procedural complexity was conducted.

RESULTS

After propensity score matching, 98 patients in each group were analyzed. Despite matching, significant procedural heterogeneity persisted: anatomical resections comprised 36.7% of I-UVATS vs. 5.1% of NI-UVATS procedures (p < 0.001). For low-complexity procedures (n = 118), serious complications occurred in 10.8% I-UVATS vs. 7.4% NI-UVATS (p = 0.545). For medium-complexity procedures (decortications, n = 37), serious complications were comparable (16.0% I-UVATS vs. 16.7% NI-UVATS, p = 0.959). The limited number of NI-UVATS anatomical resections (n = 5) precluded meaningful comparison for high-complexity procedures. Operative time was longer in NI-UVATS (median 52 vs. 37 min, p = 0.042). Overall serious complications occurred in 14.3% I-UVATS vs. 11.2% NI-UVATS patients (p = 0.522). Thirty-day mortality was 12 (12.2%) in I-UVATS vs. 7 (7.1%) in NI-UVATS (p = 0.240), and surgery-related mortality at 1 year was 10 (10.2%) vs. 15 (15.3%), respectively (p = 0.291).

CONCLUSIONS

NI-UVATS demonstrated safety and feasibility for low-to-medium complexity thoracic procedures within current real-world selection patterns. The marked procedural imbalance (36.7% vs. 5.1% anatomical resections) reflects contemporary practice where surgeons reserve NI-UVATS for lower-complexity interventions. These findings support NI-UVATS implementation for appropriately selected patients undergoing diagnostic and pleural procedures, while anatomical resections remain predominantly performed under intubation. Procedure-specific randomized trials are needed to define the role of NI-UVATS in complex resections.