Minimizing Access, Maximizing Outcomes: A comparative analysis of uniportal and multiportal approaches in robotic-assisted NSCLC resections

Background: Lung cancer remains the leading cause of cancer-related mortality in the United States with non-small cell lung cancer (NSCLC) making up the majority of cases. Surgical resection is a cornerstone of treatment for this disease, with minimally invasive techniques like the multiportal robotic-assisted thoracic surgery (mRATS) approach evolving to improve precision and outcomes. More recently, uniportal robotic assisted thoracic surgery (uRATS) has been shown to be a feasible single-incision alternative that may reduce trauma, scarring, and post-operative pain. Publications suggest that this approach is both feasible and safe, but evidence in regards to comparative effectiveness and outcomes relative to the traditional mRATS approach remains limited. Objectives: This review evaluates recent evidence for the treatment of NSCLC, specifically regarding the uRATS approach as compared to the traditional mRATS approach in terms of a variety of intra-operative and post-operative patient outcomes. Design: Multi-study review Methods: A systematic literature search of PubMed and Embase was performed using the following search criteria (abbreviated): “uRATS” AND “mRATS” AND “NSCLC”, yielding 91 results. Only studies with direct comparison of uRATS and mRATS patient outcomes were considered. Further inclusion and exclusion criteria were applied, with 3 remaining recent articles being examined for outcomes, validity assessments, and evidence assignments. Results: Study 1: uRATS and mRATS showed comparable operative, oncologic, and complication outcomes, but uRATS was associated with significantly lower intra/post-op analgesic requirements and ICU/hospital stay lengths, despite longer robot docking times. Level of evidence: 2b. Study 2: uRATS procedures performed with the Da Vinci SP system demonstrated shorter operative times and less blood loss, but had less lymph nodes dissected and showed no difference in other relevant outcomes like length of hospital stay or chest tube duration. Level of evidence: 2b. Study 3: uRATS associated with shorter hospital stay lengths, shorter operative times, , less post-op complications, and earlier chest tube removals than mRATS. Lymph node yield, ICU stay length, reintervention, and 30-day mortality were not different between groups. Level of evidence 2b. Conclusion: Current literature suggests that uRATS is a safe and feasible alternative to mRATS for NSCLC resection, with potential advantages including shorter operative times, shorter hospital stays, earlier chest tube removal, reduced blood loss, lower analgesic requirement, and less perioperative complications, while maintaining comparable oncologic outcomes. However, these findings are limited by small sample sizes, short follow-up periods, and nonrandomized study designs. Larger prospective randomized trials with long-term follow-up are required to confirm whether uRATS is truly superior to mRATS.