Robotic- Versus Video-Assisted Thoracoscopic Lobectomy and Persistent Air Leak: A Systematic Review and Meta-Analysis.

INTRODUCTION: Minimally invasive approaches are widely adopted for anatomical lung resection in early-stage non-small cell lung cancer, with video-assisted thoracoscopic surgery (VATS) representing the established standard. Robotic-assisted thoracoscopic surgery (RATS) has emerged as an alternative platform, although its clinical advantages remain uncertain. Persistent air leak (PAL) is a common complication following lobectomy, occurring in up to 8%-19% of patients and contributing to prolonged hospitalization and morbidity. Prior comparative studies of RATS and VATS have been limited by heterogeneity in operative procedures and inclusion of sublobar resections. This study aimed to compare PAL following RATS versus VATS lobectomy, restricting inclusion to lobectomy-only cohorts to reduce procedural heterogeneity. METHODS: A systematic review and meta-analysis of studies comparing RATS and VATS lobectomy was performed. Exclusively lobectomy-only cohorts were included to reduce procedural heterogeneity. The primary outcome was PAL (> 5 days). Random-effects models were used to calculate pooled risk ratios (RR). RESULTS: Thirteen studies comprising 16 252 patients (RATS, n = 2427; VATS, n = 13 825) were included. There was no significant difference in PAL between RATS and VATS (RR, 1.01; 95% CI, 0.75-1.37; p = 0.93). Moderate heterogeneity was observed (I2 = 44%). No evidence of publication bias was identified (Egger's test; intercept -0.54; 95% CI, -1.74 to 0.67; p = 0.41). Secondary outcomes were largely comparable, although length of stay was modestly shorter following RATS. DISCUSSION: In this lobectomy-restricted analysis, surgical platform was not associated with differences in persistent air leak. These findings suggest that PAL is primarily driven by patient- and technique-related factors rather than operative platform. Restriction to lobectomy improves comparability relative to prior studies. However, incomplete baseline reporting and observational design limit causal inference. CONCLUSIONS: In lobectomy-only cohorts, RATS and VATS are associated with comparable rates of persistent air leak. Surgical platform alone does not appear to independently influence this outcome.