A commentary on “Long-term outcomes of robotic vs. open thyroidectomy for differentiated thyroid cancer: efficacy, safety and quality of life”

Dear Editor, We read with interest the large retrospective cohort by Qin and Liu[1] comparing robotic (RT) and open (OT) thyroidectomy for differentiated thyroid cancer (DTC). The authors conclude that RT confers lower recurrence, fewer complications and better quality-of-life (QoL), and therefore “affirm RT as a valuable surgical option.” While the dataset is impressive, we respectfully submit that the evidence presented is insufficient to change clinical practice for three reasons. First, the authors report a lower recurrence rate in the RT group compared to the OT group (1.82% vs. 2.29%, P = 0.02). This finding contrasts with several previous meta-analyses and cohort studies, which have shown comparable oncological outcomes between the two approaches. For instance, a systematic review by Pan et al. found no significant difference in recurrence rates between robotic and open thyroidectomy for thyroid cancer[2]. Similarly, A recent retrospective study by Li et al reported equivalent recurrence rates between bilateral axillo-breast approach robotic thyroidectomy and open thyroidectomy[3]. Additionally, the prognostic difference is small and could reflect unmeasured confounding despite propensity-score matching (PSM). PSM balances only observed covariates; surgeon selection, intra-operative decision-making and molecular risk features (BRAF V600E, TERT promoter, RAS) were not adjusted for. A 0.47 % absolute difference in recurrence corresponds to a number-needed-to-treat of ~213, a benefit that can be erased by residual confounding[4]. The multivariable Cox model identified extracapsular invasion and nodal burden – not surgical approach – as the dominant drivers of recurrence, underscoring that biology trumps access. Second, the follow-up schema is asymmetric. Median follow-up was 45–48 months, yet the tail of the RFS curve hinges on a handful of patients still under observation beyond 100 months, making any apparent late divergence more noise than signal (Figure 2). Such sparse late data render the crossing of Kaplan–Meier curves hypothesis-generating rather than definitive. The absence of late events in RT is encouraging, but the wide confidence intervals (HR 0.53, 95 % CI 0.34–0.83) are compatible with both meaningful benefit and marginal effect. Third, the authors state that “patients opted for RT or OT of their own volition,” yet omit the price tag. A single robotic thyroidectomy costs US $4000 per case more than OT without reducing length of stay[5]. In the absence of cost-effectiveness data, this extra financial burden should be explicitly disclosed and factored into clinical decision-making. Finally, the study’ s QoL assessments, including SCAR-Q and SF-36, robustly favor RT, particularly in cosmetic and psychosocial domains. This is a well-documented advantage of remote-access approaches[6]. However, the generalizability of these findings may be limited by the exclusive use of UABA and BABA approaches in the RT group. Transoral and axillary approaches, which are increasingly adopted, may yield different QoL and complication profiles[7]. Future comparative studies should include a broader range of robotic access routes to provide a more comprehensive evaluation. In summary, Qin and Liu should be congratulated for the largest long-term comparison to date. Yet the claim that RT is “superior” to the gold standard OT remains premature. Only a multicentre, prospective, randomised trial – stratified by molecular profile and with blinded outcome adjudication – can resolve whether the small observed benefit is real or an artefact of selection. Until then, the default standard for DTC remains open thyroidectomy by a high-volume endocrine surgeon; robotic access should be offered within informed discussions that include cost, availability and the current evidence gap.