We sought to compare outcomes of robotic-assisted (RATS) and video-assisted thoracoscopic (VATS) resection of non-small cell lung cancer (NSCLC) after neoadjuvant chemoimmunotherapy. A retrospective database of patients treated with neoadjuvant chemoimmunotherapy followed by resection for NSCLC after between 2019 and 2025 at six centers in the US, France and Germany was analyzed. Patients undergoing RATS and VATS were included. Patient selection, extent of resection, pathologic and short-term outcomes were compared by operative approach. Inverse probability of treatment weights (IPTW) based on propensity scores were applied to balance the groups for outcome comparisons. A total of 276 patients were included, of which 243 (88.0%) were approached by RATS and 33 (12.0%) VATS. Baseline characteristics were similar in both cohorts. Bronchoplasty (n = 8) or angioplasty (n = 6) were performed only using RATS. Conversion to thoracotomy was significantly higher with VATS (27.3% vs. 5.8%, p < 0.001). Oncologic outcomes, including R0 resection, lymph node harvest, major pathologic response, and pathologic complete response, were comparable. Overall complications were similar (33.3% vs. 35.8%, p = 0.78), but VATS had higher rates of major complications (21.2% vs. 7.8%, p = 0.01), respiratory failure (12.1% vs. 3.7%, p = 0.03), and unplanned reoperation (12.1% vs. 0.8%, p < 0.001). IPTW-adjusted analyses confirmed lower conversion (26.1% vs. 7.2%, p = 0.005) and major complication rates (22.7% vs. 7.4%, p = 0.01) with RATS, with no differences in overall complications (34.5% vs. 35.8%, p = 0.91) or length of stay (5.0 vs. 4.6 days, p = 0.46). Both RATS and VATS are feasible approaches for NSCLC resection following neoadjuvant chemoimmunotherapy and achieve comparable oncologic outcomes. However, RATS was associated with substantially lower conversion to thoracotomy and fewer major postoperative complications, while maintaining equivalent resection quality. These findings support an expanded role for robotic-assisted resection in the management of appropriately selected patients after neoadjuvant chemoimmunotherapy.
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