Robotic vs thoracoscopic vs open lobectomy and segmentectomy for lung cancer: a multicenter cohort study in the ATS of Milan

The study aimed at comparing the effectiveness of open thoracotomy (OT), video-assisted thoracoscopic surgery (VATS), and robot-assisted thoracic surgery (RATS) for anatomical lung resection in early-stage non-small cell lung cancer. We conducted a multicenter cohort study across eight hospitals in the Milan health authority, including patients undergoing lobectomy or segmentectomy in 2016-2021 (retrospective) and 2023-2025 (prospective). Inverse probability weighting was used to estimate average treatment effects. Primary outcomes were postoperative complications, 30-day readmission, and conversion to thoracotomy; secondary outcomes were operative time, postoperative length of stay (PO-LOS), 180-day mortality, and overall survival. The analytic cohort included 1,605 patients (647 OT, 653 VATS, 305 RATS). Adjusted odds ratios (ORs) of conversion were higher with VATS than with RATS (OR 2.47, 95% CI 1.43-4.24). Adjusted overall survival was unfavorable for OT vs. RATS (hazard rate 1.51 95% CI 1.11-2.05). Adjusted PO-LOS was longer with OT and VATS versus RATS (OR 3.38, 95% CI 2.62-4.37; and 1.90, 1.47-2.44). OT had shorter operative time and higher frequency of complications than minimally invasive approaches. VATS had longer operative time than RATS. Thirty-day readmission and 180-day mortality were similar across approaches. RATS was associated with shorter hospitalization and fewer conversion than VATS and with better adjusted survival than OT; early mortality and readmission were similar across approaches.