Vacuum-assisted excision versus open surgery for intraductal lesions: a systematic review and meta-analysis of therapeutic effectiveness, safety, and patient-reported outcomes.

Background: Surgical decision-making for intraductal breast lesions has traditionally relied on physician expertise and imaging characteristics, lacking a comprehensive evaluation framework that integrates oncological efficacy, perioperative safety, and patient subjective experience. This study aimed to systematically synthesise the latest evidence and incorporate patient-reported outcomes (PROs) to construct a three-dimensional evaluation model, thereby providing an evidence base for the individualised selection between vacuum-assisted excision (VAE) and open surgery. Methods: A systematic comparison and descriptive analysis were performed across three dimensions: oncological efficacy, perioperative safety, and PROs. A total of 26 studies were included. Results: Meta-analysis revealed no significant difference in residual lesion rates between the VAE and open surgery groups [risk ratios (RR) =1.02; 95% confidence interval (CI): 0.29-3.57; P=0.97]. Notably, the VAE group demonstrated a 59% significant reduction in recurrence rates (RR =0.43; 95% CI: 0.21-0.86; P=0.02). Due to the lack of direct comparative data, malignancy detection rates were presented descriptively without statistical pooling, and no inferences regarding diagnostic superiority were drawn. Regarding perioperative safety, VAE was associated with a significantly shorter operative time [mean difference (MD) =-14.38 min; 95% CI: -17.09 to -11.67; P<0.01] and reduced intraoperative blood loss (MD =-9.10 mL; 95% CI: -11.29 to -6.92; P<0.01). Furthermore, VAE significantly lowered the risks of skin ecchymosis (RR =0.43; 95% CI: 0.20-0.95; P=0.04), wound infection (RR =0.31; 95% CI: 0.14-0.69; P=0.004), and breast deformity (RR =0.19; 95% CI: 0.05-0.74; P=0.02). For PROs, patients in the VAE group reported significantly higher cosmetic satisfaction (RR =1.34; 95% CI: 1.15-1.56; P<0.001) and lower postoperative pain scores (MD =-1.61; 95% CI: -2.68 to -0.54; P=0.003). Conclusions: VAE offers clear benefits such as being minimally invasive, supporting postoperative recovery, and improving cosmetic satisfaction, making it a preferred method for radiologically localised lesions. However, current evidence is insufficient to confirm VAE as a definitive treatment for malignant or high-risk intraductal conditions. Open surgery remains essential to ensure oncological safety through thorough margin assessment and accurate detection of malignancy; the potential clinical consequences of missing malignancy greatly outweigh minor cosmetic outcomes. Future treatment options should be guided by personalised decision-making that considers lesion characteristics and patient preferences.