Robotic-assisted vs video-assisted thoracoscopic lobectomy for non-small cell lung cancer: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials on surgical quality, perioperative, and oncologic outcomes.

The comparative effectiveness of robotic-assisted thoracoscopic surgery (RATS) versus video-assisted thoracoscopic surgery (VATS) for non-small cell lung cancer (NSCLC) lobectomy remains controversial despite the widespread adoption of robotic technology. This systematic review and meta-analysis evaluated randomized controlled trial evidence comparing surgical quality, perioperative outcomes, and oncologic efficacy between these minimally invasive approaches. This review was prospectively registered with PROSPERO (CRD42025113692). We systematically searched MEDLINE, Embase, Cochrane CENTRAL, Scopus, and Web of Science from inception to August 2025 for randomized controlled trials comparing RATS with VATS lobectomy in patients with NSCLC. The primary outcomes included overall postoperative complications, conversion to thoracotomy, and perioperative mortality. The secondary outcomes included operative time, hospital length of stay, lymph node yield, and long-term survival. Random-effects meta-analyses were performed using the GRADE certainty assessment. Four randomized controlled trials involving 548 patients (257 RATS, 291 VATS) were included. No significant differences were observed in overall postoperative complications (OR 0.84, 95% CI 0.57-1.23), conversion to thoracotomy (OR 0.53, 95% CI 0.17-1.64), or perioperative mortality (OR 0.34, 95% CI 0.04-3.34). Operative time showed a non-significant trend toward longer duration with RATS (MD + 13.70 min, 95% CI - 4.34 to 31.74). The two groups did not differ significantly in terms of hospital length of stay, lymph node yield, blood loss, or chest tube duration. Long-term disease-free survival (HR 0.83, 95% CI 0.48-1.42) and overall survival (HR 0.64, 95% CI 0.34-1.23) were comparable between the approaches. Evidence certainty was predominantly low to very low owing to imprecision and risk of bias. Current randomized evidence demonstrates clinical equivalence between RATS and VATS lobectomy for NSCLC in terms of perioperative and oncologic outcomes. Therefore, the choice of approach should be based on other factors, such as institutional factors, cost-effectiveness, and surgeon expertise. Given the small evidence base and low-to-very-low certainty for several outcomes, these findings should be interpreted cautiously and updated as additional randomized evidence accrues.