Robotic vs. video-assisted thoracoscopic surgery for resectable non-small cell lung cancer: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The comparative efficacy and safety of robotic-assisted thoracoscopic surgery (RATS) vs. video-assisted thoracoscopic surgery (VATS) for resectable non-small cell lung cancer (NSCLC) remain debated. This meta-analysis aims to integrate the latest evidence, including the pivotal RVlob and RAVAL trials, to assess perioperative and oncological outcomes. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing RATS and VATS for NSCLC. Databases were searched from inception to February 2026. The primary outcomes included surgical safety and complications. Secondary outcomes encompassed perioperative clinical metrics, oncological efficacy, and cost-effectiveness. RESULTS: Five RCTs (7 publications) involving 712 patients were included. RATS was associated with significantly reduced intraoperative blood loss [mean differences (MD) =-62.3 mL, 95% confidence interval (CI): -119.3 to -5.3, P=0.03] and a higher number of lymph nodes retrieved (MD =2.56, 95% CI: 0.53 to 4.58, P=0.01). Postoperative pain scores were significantly lower in the RATS group (MD =-0.33, 95% CI: -0.36 to -0.31, P<0.001). However, RATS incurred significantly higher hospitalization costs, driven by indirect equipment expenses. No significant differences were observed regarding conversion to thoracotomy [risk ratio (RR) =0.67, P=0.19], overall complications (RR =0.91, P=0.52), operative time (MD =4.92 min, P=0.45), or long-term survival [3-year overall survival (OS) RR =1.02, P=0.38]. CONCLUSIONS: Current evidence suggests that RATS is a safe and effective alternative to VATS. While RATS demonstrates technical advantages in specific metrics, it shows comparable major clinical outcomes to VATS. However, the higher economic burden associated with robotic technology remains a significant consideration.