Long-term oncologic outcomes after non-intubated versus intubated video-assisted thoracoscopic surgery for non-small cell lung cancer: a systematic review and meta-analysis.

BACKGROUND: Non-intubated video-assisted thoracoscopic surgery (NIVATS) is increasingly used for selected non-small cell lung cancer (NSCLC) patients, but its long-term oncologic outcomes versus conventional VATS remain unclear. We therefore conducted this systematic review and meta-analysis to compare long-term oncologic outcomes between NIVATS and conventional intubated video-assisted thoracoscopic surgery (VATS). METHODS: We searched major databases and trial registries through June 30, 2026 for comparative studies evaluating NIVATS or spontaneous ventilation VATS versus intubated or mechanical ventilation VATS in NSCLC. The primary outcomes were overall survival (OS) and disease-free survival or recurrence-free survival (DFS/RFS). Secondary oncologic outcomes included recurrence, R0 resection, total lymph node assessment, N1 and N2 lymph node assessment, and lymph node station or group assessment. Hazard ratios (HRs), risk ratios (RRs), and mean differences (MDs) with their 95% confidence intervals (CIs) were pooled using random-effects models. Risk of bias was assessed using the Risk of Bias 2 (RoB 2) tool and the Newcastle-Ottawa Scale (NOS), and the certainty of evidence was evaluated using the GRADE framework. RESULTS: Seventeen comparative studies were included in the qualitative synthesis. NIVATS was associated with lower pooled hazards for OS compared with intubated VATS (HR 0.66, 95% CI 0.48-0.91; I2 = 0.0%; GRADE certainty: low) and lower pooled hazards for DFS/RFS (HR 0.66, 95% CI 0.50-0.87; I2 = 0.0%; GRADE certainty: low). These findings remained stable in sensitivity analyses. No significant difference was observed in total lymph nodes harvested or R0 resection rate. Recurrence showed a borderline lower risk after NIVATS, although follow-up definitions varied across studies. The randomized study was judged as having some concerns, and observational studies were generally moderate to high quality. CONCLUSIONS: In selected NSCLC patients, NIVATS does not appear to compromise long-term oncologic outcomes versus conventional intubated VATS. The observed survival advantage likely reflects selection bias and residual confounding, as NIVATS is often used in patients with favorable tumor features, operative suitability, or cardiopulmonary reserve. These findings support NIVATS as feasible under strict selection by experienced teams. Prospective multicenter studies with standardized protocols and long-term follow-up are needed to confirm its oncologic safety. SYSTEMATIC REVIEW REGISTRATION: crd.york.ac.uk/prospero/display_record.php?ID=CRD420261437783, identifier CRD420261437783.