Comparative analysis of video-assisted thoracoscopic surgery vs robotic-assisted thoracoscopic surgery for esophageal leiomyoma enucleation: a multi-institutional propensity score-weighted study.

BACKGROUND: Evidence from comparative studies of video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) for the management of esophageal leiomyoma remains limited. Therefore, the present study compared the perioperative outcomes of VATS and RATS. METHODS: This multi-institutional retrospective study included 112 patients (VATS group, n = 84; RATS group, n = 28) treated at three tertiary centers between January 2010 and June 2025. The primary outcomes were intraoperative mucosal injury and postoperative esophageal leakage. Propensity score inverse probability of treatment weighting (IPTW) was applied to minimize selection bias. RESULTS: The VATS and RATS groups had comparable baseline characteristics, including age (mean, 43.6 vs. 40.7 years, p = 0.252), sex (male, 69.0 vs. 71.4%, p = 1.0), and body mass index (24.5 vs. 24.6 kg/m2, p = 0.856). Following IPTW adjustment, the rates of mucosal injury (11.4 vs. 12.8%, p = 0.864) and esophageal leakage (4.2 vs. 4.7%, p = 0.912) were comparable between the groups. RATS was associated with a significantly lower conversion rate (5.7 vs. 0%, p = 0.02) than VATS. Intraoperative blood loss (78.5 vs. 55.32 mL, p = 0.106) and 30-day postoperative complication rates were similar between the groups (11.9 vs. 17.4%, p = 0.693). CONCLUSIONS: Overall, RATS demonstrated superior intraoperative stability, as reflected by a significantly lower conversion rate while maintaining postoperative safety comparable to VATS. This multicenter analysis supports the feasibility and safety of RATS for the enucleation of esophageal leiomyomas.