Reply: Video-assisted thoracoscopic surgery versus robotic assisted surgery: Can they both co-exist?

Abstract

The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. More than ever, driven by advancements in the technology, thoracic surgeons are using a robotic platform to perform anatomical pulmonary resection. There is an intense debate whether robotic-assisted surgery (RAS) offers any advantage over the video-assisted thoracoscopic surgery (VATS) technique. Several retrospective institutional studies and large database studies reported, for the most part, equivalent short-term safety profiles but greater costs associated with RAS.1Louie B.E. Wilson J.L. Kim S. Cerfolio R.J. Park B.J. Farivar A.S. et al.Comparison of video-assisted thoracoscopic surgery and robotic approaches for clinical stage I and stage II non–small cell lung cancer using the Society of Thoracic Surgeons database.Ann Thorac Surg. 2016; 102: 917-924.8Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar,2Bao F. Zhang C. Yang Y. He Z. Wang L. Hu J. Comparison of robotic and video assisted thoracic surgery for lung cancer: a propensity-matched analysis.J Thorac Dis. 2016; 8: 1798-1803Crossref PubMed Scopus (37) Google Scholar The article by Zhang and colleagues3Zhang Y. Zhang J. Li H. Robotic segmentectomy: we are still on the way.J Thorac Cardiovasc Surg. 2020; 160: e87-e88Abstract Full Text Full Text PDF PubMed Google Scholar similarly shows VATS and robotic segmentectomy have an equivalent short-term clinical outcome with increased direct cost. RAS showed improved ability to perform lymphadenectomy, yet the oncologic benefit is less than clear. One may then wonder what is the utility of the robotic approach when the RAS costs more without clear clinical benefits? The debate over medical robotics is nothing new; it has challenged and, in certain fields, shifted the treatment paradigm. This change was the most notable in the urology field, where RAS is now the most common approach for radical prostatectomy in the United States. Yet, in early-phase adoption, the cost effectiveness of robotic surgery over laparoscopic surgery and open surgery was often questioned and debated. It was found that the robotic surgery was associated with greater cost compared with laparoscopic surgery without significant clinical benefit.4Lotan Y. Cadeddu J.A. Gettman M.A. The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques.J Urol. 2004; 172: 1431-1435Crossref PubMed Scopus (224) Google Scholar More contemporary studies have shown, however, that robotic surgery is either comparable or costs less compared with laparoscopic and open prostatectomy.5Kockerling F. Robotic vs. standard laparoscopic technique—what is better?.Front Surg. 2014; 1: 15PubMed Google Scholar It can be surmised that as the experience and data regarding robotic anatomic pulmonary resection matures, a better understanding of the optimal minimally invasive surgical approach will emerge in the future. A recent study published using more contemporary data, for instance, indicates that once a hospital performs 25 or more pulmonary resections, the cost of the RAS and VATS is equivalent.6Nguyen D.M. Sarkaria I.S. Song C. Reddy R.M. Villamizar N. Herrera L.J. et al.Clinical and economic comparative effectiveness of robotic-assisted, video-assisted thoracoscopic and open lobectomy.J Thorac Dis. 2020; 12: 296-306Crossref PubMed Scopus (8) Google Scholar Until better understanding of the superiority of one technique over the other, the VATS and RAS should be viewed as complementary, and not competing, approaches and the decision for the operative approach should be guided by practice patterns, institutional resources, and individual surgeon experience. Robotic segmentectomy: We are still on the wayThe Journal of Thoracic and Cardiovascular SurgeryVol. 160Issue 2PreviewIn their Commentary, Song and Flores1 propose several thoughtful questions and describe certain limitations of robotic segmentectomy. We cannot agree with them more. However, we are still willing to clarify the question inherent to their Commentary. Full-Text PDF