Perioperative and Oncological Outcomes of Robotic-Assisted, Video-Assisted Thoracoscopic and Open Lobectomy for Patients with N1-Metastatic Non-Small Cell Lung Cancer: A Propensity Score-Matched Study

SIMPLE SUMMARY: Non-small cell lung cancer (NSCLC) is one of the most prevalent and deadly malignancies worldwide, and patients with metastatic N1 lymph nodes (LNs) are associated with a worse prognosis. Despite the fact that robotic-assisted thoracoscopic lobectomy (RATL) has been prevalently applied in treating early stage NSCLC, its advantages for patients with involved N1 LNs remain unknown. This retrospective study compared perioperative and oncological outcomes among RATL, video-assisted thoracoscopic lobectomy (VATL), and open lobectomy (OL) in a cohort of 855 consecutive cases with pathological N1 NSCLC, thereby aiming to assess the superiority of RATL over traditional surgical approaches for NSCLC patients with metastatic N1 LNs. RATL resulted in the most optimal surgical outcomes, the fastest recovery, and the lowest morbidities of postsurgical complications among the three surgical methods, and also assessed more N1 and total LNs and led to a higher incidence of postoperative upstaging than VATL, though it achieved comparable oncological outcomes in relation to VATL and OL. ABSTRACT: (1) Background: Despite the fact that robotic-assisted thoracoscopic lobectomy (RATL) has been prevalently applied for early stage non-small cell lung cancer (NSCLC), its superiorities are still to be fully revealed for patients with metastatic N1 lymph nodes (LNs). We aim to evaluate the advantages of RATL for N1 NSCLC. (2) Methods: This retrospective study identified consecutive pathological N1 NSCLC patients undergoing RATL, video-assisted thoracoscopic lobectomy (VATL), or open lobectomy (OL) in Shanghai Chest Hospital between 2014 and 2020. Further, perioperative and oncological outcomes were investigated. (3) Results: A total of 855 cases (70 RATL, 435 VATL, and 350 OL) were included. Propensity score matching resulted in 70, 140, and 140 cases in the RATL, VATL, and OL groups, respectively. RATL led to (1) the shortest surgical time (p = 0.005) and lowest intraoperative blood loss (p < 0.001); (2) the shortest ICU (p < 0.001) and postsurgical hospital (p < 0.001) stays as well as chest tube duration (p < 0.001); and (3) the lowest morbidities of postsurgical complications (p = 0.016). Moreover, RATL dissected more N1 (p = 0.027), more N1 + N2 (p = 0.027) LNs, and led to a higher upstaging incidence rate (p < 0.050) than VATL. Finally, RATL achieved a comparable 5-year disease-free and overall survival in relation to VATL and OL. (4) Conclusions: RATL led to the most optimal perioperative outcomes among the three surgical approaches and showed superiority in assessing N1 and total LNs over VATL, though it did achieve comparable oncological outcomes in relation to VATL and OL for N1 NSCLC patients.