Joshua Parreco, MD, Kandace Kichler, MD, Marcus Eby, MD, Rennier Martinez, MD, Robert Scoma, MD. University of Miami
Introduction: Robotic-assisted thymectomy for the treatment of myasthenia gravis and anterior mediastinal masses has been successfully reported around the world. The purpose of this systematic review and meta-analysis was to evaluate and compare the results of the robotic-assisted approach to the more traditional video-assisted or transsternal approaches.
Methods: Studies involving robotic-assisted thymectomy were systematically reviewed. Studies comparing robotic-assisted thymectomy (RAT) to video-assisted thymectomy (VAT) or transsternal thymectomy (TST) were included in the meta-analysis and analyzed using random or fixed effect models to determine the mean difference or odds ratio.
Results: Twenty-three studies were identified and included 731 patients undergoing RAT. This included 484 patients with myasthenia gravis and 216 patients with a thymoma. The rate of conversion to open was 3.0% with the most common reasons for conversion being invasive thymoma (63.6%) and desaturation (18.2%). Complications occurred at a rate of 6.8% with the most frequent complications being myasthenic crisis (20.0%) and pleural effusion (10.0%). Eight studies were included in the meta-analysis for a total of 211 patients undergoing RAT. Three of these studies compared patients undergoing RAT to 164 patients undergoing VAT and five studies compared patients undergoing RAT to 152 patients undergoing TST. There were no significant differences in operative time between RAT and TST [mean difference (MD) -12.60; 95% confidence interval (CI) -97.43 to 72.22 min; p = 0.77] or between RAT and VAT [MD 0.92; 95% CI -19.86 to 21.70; p = 0.93]. A shorter hospital stay was found for patients undergoing RAT versus TST [MD -4.09; 95% CI -5.92 to -2.26 days; p < 0.01]. However, there was no difference in hospital stay when comparing RAT to VAT [MD -1.51; 95% CI -4.45 to 1.43 days; p = 0.32]. TST was associated with more postoperative complications than RAT [odds ratio (OR) 0.30; 95% CI 0.13 to 0.69; p < 0.01]. When comparing RAT to VAT there was no difference in postoperative complications [OR 1.43; 95% CI 0.51 to 3.96; p = 0.49] or conversion to open [OR 0.67; 95% CI 0.09 to 5.19; p = 0.70].
Conclusions: RAT did not appear to add a significant amount of operative time compared to VAT or TST. However, patients undergoing RAT had a decreased length of stay and lower complication rates compared to TST. There was no difference in hospital stay, complication or conversion rates compared to VAT.
Figure 1: Morbidity, robotic-assisted versus transsternal thymectomy