Two studies were identified that compared robotic-assisted lung procedures to open surgery.
KQ1: What is the evidence of the clinical efficacy and effectiveness of robotic assisted surgery compared with open or laparoscopic approaches not using robotic assistance? Does robotic assisted surgery improve patient outcomes?
Systematic Review and Technology Assessment Findings
No SRs or TAs were identified that addressed this key question.
Individual Study Search Results (2002 to 2012)
The MEDLINE® search identified two comparative studies addressing robotic lung surgery. One study was a poor quality retrospective cohort study (n=36) that compared robotic
thoracoscopic resection to open sternotomy for the treatment of mediastinal tumors (Balduyck 2010). The Balduyck study was limited by its small sample size, limited patient characteristic descriptions, and differences between treatment groups (e.g., patients receiving open sternotomy had larger masses). The other study was a fair quality retrospective cohort study (n=108) that compared robotic lobectomy to open lobectomy for the treatment of lung cancer (Veronesi 2010). The Veronesi study (2010) used propensity-score matching to match patients in the two treatment groups, and was limited primarily by its retrospective nature.
Compared to open lobectomy, the robotic procedure was associated with shorter LOS
(p=0.002), but longer operating times (p<0.001) and lower lymph node yield (p=0.04) (Veronesi 2010).
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Compared to open sternotomy, robotic thoracoscopic resection was associated with less pain and higher QoL scores at three months post-op (p-values not reported), but statistically similar operating times and LOS (Balduyck 2010).
Overall Summary and Limitations of the Evidence
The strength of evidence comparing robotic and open median sternotomy is low for all reported outcomes. The robotic procedure may have had benefits over the open procedure, including less post-operative pain and higher QoL scores (Balduyck 2010). Additionally, the strength of evidence comparing robotic lobectomy to the open procedure is low for all outcomes, but suggests that robotic lobectomy was associated with shorter LOS, longer operating times, and lower lymph node yield than in the open surgical group (Veronesi 2010).
KQ2: For robotic assisted surgery, what is the evidence of the severity and incidence of safety or adverse event concerns compared with open or laparoscopic approaches?
Systematic Review and Technology Assessment Findings
No SRs or TAs were identified that address this key question.
Subsequently Published Studies (October 2009 to 2012)
Both Veronesi (2010) and Balduyck (2010) reported briefly on the safety and incidence of adverse events in robotic lung surgery as compared to open procedures. Both studies indicate that procedures are similar in terms of complication incidence, including need for transfusion and mortality rate.
Overall Summary and Limitations of the Evidence
The strength of the evidence on complications arising from robotic and open lung surgery is low, but consistently reports that the incidence of complications was similar between surgical modalities.
KQ3: What is the evidence that robotic assisted surgery has differential efficacy or safety issues in sub populations?
Systematic Review and Technology Assessment Findings
No SRs or TAs addressed this key question.
Individual Study Search Results (2002 to 2012)
The Veronesi study (2010) performed a subanalysis on perioperative outcomes based on the surgeon’s experience. Patients undergoing robotic procedures were stratified into those in the early robotic group, mid-robotic group, and late robotic group to assess how the outcomes of robotic surgery varied as the surgeon gained more experience. Veronesi reported that
operating time significantly decreased between the early robotic and late robotic groups, but was still significantly longer than the open surgery group. While LOS between the early robotic group and the open group were similar, the late robotic group had significantly shorter hospital stays than the open group.
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Overall Summary and Limitations of the Evidence
There is low strength of evidence suggesting that robotic lobectomy had differential efficacy depending on the surgeon’s level of experience. These findings are primarily limited by small sample size and observational study design.
KQ4: What is the evidence of cost and cost-effectiveness of robotic surgery compared with open or laparoscopic approaches?
Systematic Review and Technology Assessment Findings
No SRs or TAs addressed this key question.
Individual Study Search Results (January 2002 to 2012)
The Veronesi study (2010) briefly reports that robotic procedures cost € 2000 more than open procedures, but no details were provided on how this estimate was calculated.
An additional cost study (Park 2008) was identified that reported that the total hospital costs of robotic lobectomy were almost $4,000 lower than those of open lobectomy. However, the study was rated as poor quality because it lacked several important methodological features. Specifically, no sensitivity analysis was performed and no assumptions were stated.
Additionally, the patient characteristics from the underlying evidence were not described, and the authors stated that most patients undergoing robotic procedures were also undergoing concurrent procedures. However, it was difficult to ascertain whether or not the authors somehow accounted for this in their cost analysis.
Overall Summary and Limitations of the Evidence
There is mixed evidence on the costs of robotic lung surgery relative to open lung surgery. Both of the identified studies possess significant limitations that prohibit conclusions on this key question. The strength of evidence on economic outcomes is low.