Ann Surg Oncol (2024) 31:2470–2481

https://doi.org/10.1245/s10434-023-14767-8

ORIGINAL ARTICLE – THORACIC ONCOLOGY

Comparison Results of Three‑Port Robot‑Assisted and Uniportal

Video‑Assisted Lobectomy for Functional Recovery Index
in the Treatment of Early Stage Non‑small Cell Lung Cancer:
A Propensity Score‑Matched Analysis
Haixiao Diao, MD1, Lin Xu, MD2, Xiao Li, MD1, Yancheng Wang, MD3, and Zhongmin Peng, MD1

1
Shandong Provincial Hospital, Shandong University, Jinan, China; 2Shandong Provincial Hospital Affiliated to Shandong
First Medical University, Jinan, China; 3Shandong Provincial Hospital, Shandong First Medical University, Jinan, China

ABSTRACT The physical score of the RATS group was higher than the
Background. Minimally invasive lobectomy is the stand- UVATS group (p = 0.04), according to the Leicester Cough
ard treatment for early stage non-small cell lung cancer Questionnaire.
(NSCLC). The aim of this study is to investigate postopera- Conclusion. RATS was associated with severe short-term
tive recovery in a prospective trial of discharged patients postoperative pain but less postoperative complications.
with early stage non-small cell lung cancer undergoing
robot-assisted thoracic surgery (RATS) versus uniportal Keywords Robot-assisted thoracic surgery · Uniportal
video-assisted thoracic surgery (UVATS). video-assisted thoracic surgery · Postoperative
Patients and Methods. This is a prospective and obser- rehabilitation · Propensity score-matched analysis
vational study. From 9 September 2022 to 1 July 2023, 178
patients diagnosed with NSCLC admitted to the Department
of Thoracic Surgery of Shandong Provincial Hospital signed Lung cancer was the leading cause of cancer death in
informed consent and underwent lobectomy by RATS and 2020, according to GLOBOCAN. There were 2.2 million
UVATS. The functional recovery index included MD Ander- new cancer cases and 1.8 million deaths in 2020, which is
son Symptom Inventory, Christensen Fatigue Scale, EORTC about one in ten diagnosed advanced cancer cases (11.4%)
QLQ-C30, and Leicester Cough Questionnaire. and one in five deaths (18.0%).1 The 5-year survival rate of
Results. After propensity score-matched analysis, each patients with diagnosed lung cancer is only 10–20%.2 How-
group included 42 cases. For the baseline characteristics of ever, owing to development of high-resolution computed
patients, operation time (p = 0.01) and length of stay (p = tomography (CT), more early stage non-small cell lung can-
0.04) were shorter in the RATS group. The number of lymph cers (NSCLCs) were identified. In these patients, lobectomy
nodes resected in the RATS group was much more than in remains the gold-standard curative treatment method.3,4
the UVATS group. According to our investigation, appetite With the progress of thoracoscopic technology, minimally
loss, nausea, diarrhea, and cough severity after RATS were invasive surgery (MIS) has become a well-established treat-
better than after UVATS. After the first week, pain severity ment for early stage NSCLC.5 Robot-assisted and unipor-
degree of the RATS group was higher than UVATS, while tal video-assisted thoracoscopic surgery are the two most
there was no difference during the second and third week. widely used MIS modalities. Compared with uniportal
video-assisted thoracic surgery (UVATS), robot-assisted
© The Author(s) 2023
thoracic surgery (RATS) provides an amplified, high-defi-
nition, three-dimensional (3D) visualization of the surgical
First Received: 27 September 2023
Accepted: 21 November 2023
field, and the flexible robotic arms help the surgeon complete
Published online: 17 December 2023 complex operations. However, UVATS had fewer surgical
incisions. In a randomized clinical trial, Jin et al.6 reported
Z. Peng, MD that RATS and UVATS had comparable perioperative
e-mail: pzm0803@163.com

Vol:.(1234567890)
Comparison Results of Three‑Port Robot‑Assisted … 2471

outcomes, but the RATS group had a significantly higher of multiple lung surgeries; (4) patients with previous neo-
number of lymph nodes harvested than UVATS. However, adjuvant therapy; (5) patients with pathology proven posi-
the influence of the two modalities on postdischarge rehabili- tive for small cell lung cancer; (6) patients with a history of
tation and delayed complications are still unknown. malignancy; or (7) follow-up data that could not be obtained.
This study aims to investigate the postoperative recov-
ery of discharged patients from RATS and UVATS, such as
Preoperative Preparation
activity, pain, exhaustion, sleep quality, and cough sever-
ity. Postoperative recovery is a complex process involving
Patients in the study had 2–3 days to finish all neces-
multiple dimensions, both physical and psychological, even
sary preoperative examinations, including to assess car-
at the social level.7 We adopted portable digital equipment
diopulmonary function (pulmonary function test, electro-
to monitor patients’ activity, providing objective data. We
cardiographic, cardiac ultrasonography, and coronary CT
also sent questionnaires to obtain fatigue scores, Numerical
performed if necessary). To determine the tumor stage, abdo-
Rating Scale of pain, and cough degree scores.8 Overall,
men and adrenal ultrasound, chest CT, and brain CT were
we compare and evaluate the after-discharge patients who
performed. These examinations ensured safety of surgery
underwent RATS and UVATS in multiple dimensions, such
and excluded metastasis of cancer. In addition, Enhanced
as the psychological, physical, and social.
Recovery After Surgery (ERAS) was implemented through-
out treatment in our thoracic surgery department.9
PATIENTS AND METHODS

We carried out this prospective, observational study at Surgical Technique and Postoperative Hospital Stay
the thoracic surgery department of Shandong Provincial
Hospital affiliated with Shandong First Medical University. The skin incision made in UVATS was located between
Every participant received an informed consent form and the midaxillary line and anterior axillary line of the fourth
was informed of the details of the study during the preop- or fifth intercostal space and was approximately 4 cm long.
erative conversation. This study was also approved by the The machine used during RATS was da Vinci Si (Intuitive
Ethics Committee on Biomedical Research of Shandong Surgical, Sunnyvale, California). We adopted a three-arm
Provincial Hospital. approach, which is a slightly modified version described by
We prospectively included patients with suspected or Dylewski.10 We incised a 4-cm incision in the fifth intercos-
diagnosed clinical stage I, stage II, and stage IIIA non- tal space on the anterior axillary line as an assistant utility
small cell lung cancer (NSCLC) from 9 September 2022 to port and first instrument port, then incised a 1-cm incision
1 July 2023. All patients were Chinese. The patients who in the eighth intercostal space on the midaxillary line as a
underwent RATS or UVATS lobectomy were recruited in lens port. A 1-cm incision made in the eighth intercostal
our study. space behind the posterior axillary line served as the second
In our hospital, a thoracoscope can be used to complete instrument port. A distance of 8 cm was kept between each
stage I and stage II without lymph node metastasis NSCLC port. The lymph node approach was identical in RATS and
lobectomy or segmentectomy; however, complex operations UVATS and was done in accordance with National Com-
such as sleeve lobectomy are difficult, and there is a high prehensive Cancer Network (NCCN) guidelines. Generally,
possibility of conversion to open thoracotomy. Generally, patients with NSCLC should receive N1 and N2 nodule
some conditions such as thoracic dense adhesion, bronchial resection and at least three mediastinal lymph node station
invasion, chest wall invasion, hilar-dense nodal invasion, samplings or a LN dissection (left: 4L, 5L, 6L, 7L, 8L, 9L
previous chemotherapy, and previous thoracic surgery are groups; right: 2R, 4R, 7R, 8R, 9R groups).11 One drainage
no longer regarded as absolute contraindications. tube (24FR) was placed in all patients. The drainage tube
Additionally, the inclusion criteria were as follows: (1) of UVATS patients was placed dorsal of incision, while the
patients aged between 18 and 80 years, (2) patients who drainage tube of RATS patients was placed through the lens
underwent RATS or UVATS lobectomy, (3) patients with port.
pathology proven positive for NSCLC, and (4) patients with All patients were treated with low-molecular-weight
well-tolerated cardiopulmonary function. The exclusion cri- heparin to prevent thrombus after surgery, unless the drain-
teria were as follows: (1) patients who underwent segmen- age fluid was bright red in color. Postoperative analgesia
tectomy, sleeve lobectomy, or wedge resection; (2) patients was provided by non-steroidal anti-inflammatory drugs
with limited mobility (such as those who use wheelchairs or (NSAIDs). Opioids were used if the effect of the NSAIDs
require assistance when walking) or unhealthy mental con- was unsatisfactory. The afternoon of the day after surgery, a
ditions (including anxiety, depression, schizophrenia, and DR scan was arranged for all patients to exclude atelectasis
other psychological disorders); (3) patients with a history and pleural effusion. Patients were discharged on the second
2472 H. Diao et al.

day or third day once the chest drain was removed and no in this study to study the pathogenesis and treatment of
complications occurred. postoperative fatigue syndrome.
In addition, the baseline characteristics and periopera-
tive outcomes were recorded, including: age, gender, body
mass index (BMI), smoking history, pulmonary function EORTC QLQ‑C3017
[maximal voluntary ventilation (MVV), forced expiratory
volume in 1 s (FEV1), and diffusing capacity of the lung for The EORTC QLQ-C30 is a comprehensive assessment
CO (DLCO-SB)], American Society of Anesthesiologists- of the quality of life (QOL) of patients with cancer from
physical status (ASA-PS), Charlson Comorbidity index,12 multiple dimensions, such as physical, psychological, and
operation time, surgical site, lymph node dissection number, social functioning. The validated and relevant question-
length of hospital stay, postoperative drainage time, volume naire, the EORTC QLQ-C30, is one of the most widely
of drainage, perioperative complications, reintervention rate, used quality-of-life questionnaires in cancer research.18
reoperation rate, and mortality. The length of hospitalization The EORTC QLQ-C30 has the 15 following items: global
was calculated by the number of postoperative hospitaliza- health status (health status of the whole body), func-
tion nights. tion subscales (physical functioning, role functioning,
emotional functioning, cognitive functioning, and social
Postoperative Follow‑Up Parameters after Discharge functioning) and symptom subscales/items (fatigue, pain,
nausea and vomiting, dyspnea, appetite loss, insomnia,
For follow-up, all questionnaires were obtained by constipation, diarrhea, and financial impact of the dis-
WeChat, which is a chat tool in China. Patients are generally ease). A high score for a functional scale represents a high/
reviewed at around the fourth week after discharge; in total, healthy level of functioning; a high score for the global
we collected 3 weeks of after-surgery patient data. The ques- health status represents a high QOL, but a high score for a
tionnaires were sent to patients every week (on day 7, day symptom scale represents a high level of symptomatology.
14, and day 21). If the questionnaire could not be returned The analysis of the questionnaire scores was performed
within 1 day, the patient would be reminded, and samples according to the EORTC QLQ-C30 scoring manual.
longer than 2 days were discarded.
For daily activity and sleep time, we used smart bands
(Mi Band 6,13,14 Xiaomi Corporation, Beijing, China) to MD Anderson Symptom ­Inventory19
monitor. They are unobtrusive, waterproof wristwear devices
with a light sensor and 1-week battery life that automatically The MD Anderson Symptom Inventory scale is
records daily activity and sleep time. They can record daily designed to capture the severity of the patient’s symptoms,
steps, 1 day of total sleep time, and heart rate. as well as the extent to which these symptoms interfere
For our study, all the rating scales are shown below. with daily life, and this scale is used in the follow-up inves-
tigation of various cancers. The MD Anderson Symptom
Numerical Rating Scale (NRS)15 Inventory has the following items: pain, fatigue, nausea,
disturbed sleep, distress/feeling upset, shortness of breath,
The Numerical Rating Scale is one of the most commonly difficulty remembering, lack of appetite, drowsiness, dry
used pain scales in medicine. We used this scale to assess the mouth, sadness, vomiting, numbness/tingling, walking,
degree of postoperative pain in patients. The NRS consists of activity, working (including housework), relations with
a digital version and a visual analogue scale. Due to the limi- other people, and enjoyment of life mood. Higher scores
tations of our questionnaire, this study only has the digital indicate more severe symptoms. Other studies have shown
version. Patients chose the score according to their own pain that a rating of 5 or greater (on a 0–10 numeric rating
degree, and the higher the score, the higher the pain degree. scale) indicates a moderate-to-severe symptom that sig-
nificantly impairs daily functioning.20
Christensen Fatigue Scale (CFS)16

The purpose of the Christensen Fatigue Scale was to Outcomes

assess patient fatigue in our study. The scale evaluated
fatigue on a scale of 1–10. Patients reporting a higher The outcomes were the difference of the perioperative
score (10) means they feel more fatigued. This scale is outcomes and the short-term (3-week) post-discharge
a single, self-rated scale that has been used in multiple index between the RATS group and the UVATS group to
clinical studies and is applicable to most questionnaires determine which surgical method is superior.
due to its simplicity. The fatigue scale model was used
Comparison Results of Three‑Port Robot‑Assisted … 2473

Statistical Analysis RESULTS

We analyzed the factors of the patients as comprehen- Patient Enrollment and Questionnaire Collection
sively as possible. To mitigate the impact of nonrandom
patient allocation and control for confounding variables, As shown in Fig. 1, from 9 September 2022 to 1 July
we employed a propensity score-matching (PSM) analysis 2023, 178 patients were eligible, with a total of 62 patients
including age, gender, BMI, MVV, FEV1, DLCO-SB, smok- who underwent RATS and 116 patients who underwent
ing status, Charlson Comorbidity Index, and length of the UVATS, and 12 excluded. Among those 12, 6 had benign
tumor. Match tolerance was 0.02. All analyses were per- tumors, 2 had small cell lung cancers, and 4 had converted
formed with SPSS 26.0 (IBM-SPSS Inc, Armonk, NY). All to thoracotomies during operation. We sent questionnaires to
discrepancies in both outcomes were tested using a t-test all of the 166 enrolled patients. However, only 141 patients
when expressing normal distribution. The median [inter- finished questionnaires and were available for further
quartile range (IQR)] and rank sum test were utilized for analysis. Finally, 50 patients who underwent RATS and 91
non-normally distributed data. A chi-square test was used patients who underwent UVATS were included. After PSM,
for dichotomous variables. Two-sided p-value < 0.05 was 42 patients in each group were well matched by a 1:1 PSM
considered statistically significant. Visio 2021 (Microsoft, algorithm.
USA) was used to draw a flow diagram.
Baseline Characteristics and Perioperative Outcomes

Patient baseline characteristics are listed in Table 1. Oper-

ation time [107 (90–121.25) min vs. 120 (103.75–130) min;
p = 0.01] and length of stay [3 (2–3) days vs. 3 (3–4) days;

FIG. 1  RATS, Robot-assisted thoracic surgery; UVATS, uniportal Video-Assisted Thoracic Surgery
2474 H. Diao et al.

TABLE 1  Baseline characteristics

Characteristics All patients Propensity score-matched patients

RATS (n = 50) UVATS (n = 91) p-value RATS (n = 42) UVATS (n = 42) p-value

Age (years) 56.6 58.03 0.21 57.89 57.05 0.65

BMI (kg/m2) 24.98 25.21 0.71 25.02 24.59 0.53
Gender (male %) 22 (44%) 32 (35%) 0.44 18 (43%) 18 (43%) 1.00
Smoking status 11 (22%) 23 (25.2%) 0.47 11 (26%) 10 (23%) 0.80
FEV1 (%) 97.39% 99.90% 0.33 98.19% 97.96% 0.95
MVV (%) 92% 90.37% 0.59 91.64% 89.40% 0.59
DLCO-SB (%) 90.00% 90.60% 0.57 87.37% 88.20% 0.82
Charlson Comorbidity Index 2.775 2.573 0.45 2.79 2.5 0.34
ASA physical status 0.39 0.24
1–2 47 (94%) 83 (93%) 40 (95%) 37 (88%)
3–4 3 (6%) 7 (7%) 2 (5%) 5(12%)
Operation time (min, IQR) 110 (90–122.5) 120 (110–137.5) 0.01 107 (90–121.25) 120 (103.75–130) 0.01
Total drainage volume(ml, IQR) 350(255–500) 410(262.5–600) 0.10 355 (260–447.5) 380 (250– 450) 0.74
Duration of chest drainage (days, IQR) 2(2–3) 2(2–3) 0.02 2 (2–3) 2(2–3) 0.13
Length of stay (days, IQR) 3(2–3) 3(3–4) 0.01 3(2–3) 3(3–4) 0.04
Morbidity 2 (4%) 3 (3%) 0.83 1 (2%) 1 (2%) 1.00
Reinsertion of chest drain 0 1 0.46 0 0 1.00
Reoperation 0 0 1.00 0 0 1.00
Mortality 0 0 1.00 0 0 1.00
Lobe
RUL 21 28 18 17
RML 3 7 3 3
RLL 10 14 8 5
LUL 8 22 6 13
LLL 8 20 7 4
pT stage 0.48 0.63
Tis 4 2 3 2
1a 4 8 2 3
1b 24 47 22 28
1c 13 17 10 7
2a 4 12 4 1
2b 0 2 0 0
3 1 3 1 1
4 0 0 0 0
Clinical TNM stage 0.21 0.76
IA1 8 4 6 3
IA2 26 48 22 25
IA3 11 29 9 11
IB 2 5 2 2
IIA 1 3 1 1
IIB 1 2 1 0
IIIA 1 0 1 0
Pathology 0.15 0.09
Adenocarcinoma 43 85 37 41
Squamous 7 6 5 1
Solid (n, %) 22 (44%) 34 (37%) 0.44 18(43%) 15 (35%) 0.50
Length of tumor (cm, IQR) 1.60 (1.20–2.45) 1.80 (1.20–2.35) 0.47 1.7 (1.2– 2.5) 1.5 (1.2–1.9) 0.18
Lymphadenectomy 10 (6–13) 9 (7–13) 0.29 10 (6.75–13) 8 (6–11) 0.04

IQR interquartile range, FEV1 forced expiratory volume in 1 s, RUL right upper lobe, RML right middle lobe, RLL right lower lobe, LUL left
upper lobe, LLL left lower lobe
Comparison Results of Three‑Port Robot‑Assisted … 2475

p = 0.04] of the RATS group were shorter than the UVATS TABLE 2  EORTC QLQ-C30 data for first week after discharge
group. Lymphadenectomy in the RATS group was more than After propensity score-matched
the UVATS group (p = 0.04). Age (p = 0.65), BMI (p =
RATS (n = 42) UVATS (n = 42) p-value
0.53), gender (male %, p = 1.00), smoking status (p = 0.80),
FEV1 (p = 0.95), MVV (p = 0.59), DLCO-SB (p = 0.82), Function subscale (mean)
Charlson Comorbidity Index (p = 0.34), ASA physical sta- Physical functioning 59.21 57.94 0.75
tus (p = 0.24), solid nodules proportion (p = 0.50), tumor Role functioning 38.49 53.97 < 0.01
pathology (p = 0.09), length of tumor (p = 0.18), duration Emotional function- 71.03 68.85 0.66
of chest drainage (days), and total drainage volume (p = ing
0.74) had no statistical difference between the RATS and Cognitive functioning 78.97 79.37 0.94
UVATS groups. Social functioning 64.68 71.83 0.24
Symptoms subscale (mean)
Fatigue 56.88 52.91 0.44
Post‑discharge Physical Index Nausea and vomiting 13.49 14.68 0.77
Pain 62.30 45.24 < 0.01
Daily steps (week 1: p = 0.094, week 2: p = 0.15, week 3: Dyspnea 54.76 51.59 0.66
p = 0.83) and sleep duration (week 1: p = 0.28, week 2: p = Insomnia 40.48 46.83 0.39
0.33, week 3: p = 0.98) after discharge also had no statistical Appetite loss 37.30 32.54 0.47
difference between the two groups. Constipation 29.37 23.02 0.32
Diarrhea 15.08 17.46 0.68
Financial difficulties 73.02 75.40 0.71
EORTC QLQ‑C30 Results
Global health status (mean)
43.25 52.78 < 0.01
Analyzing the EORTC QLQ-C30 results, in the first
week, physical functioning (p = 0.75), emotional function-
ing (p = 0.66), cognitive functioning (p = 0.94), social func-
TABLE 3  EORTC QLQ-C30 data for second week after discharge
tioning (p = 0.24), fatigue (p = 0.44), nausea and vomiting
(p = 0.77), dyspnea (p = 0.66), insomnia (p = 0.39), appetite After propensity score-matched
loss (p = 0.47), constipation (p = 0.32), diarrhea (p = 0.68), RATS (n = 42) UVATS (n = 42) p-value
and financial difficulties (p = 0.71) did not differ signifi-
cantly between the two groups (Tables 2, 3, 4). However, Function subscale (mean)
role functioning (38.49 vs. 53.97, p < 0.01), pain (62.30 vs. Physical functioning 69.37 68.41 0.81
45.24, p < 0.01), and global health status (43.25 vs. 52.78, p Role functioning 60.71 60.32 0.95
< 0.01) of patients in the RATS group were worse than those Emotional function- 75.60 76.39 0.85
ing
in the UVATS group. In the second week, all the indicators
Cognitive functioning 82.14 79.76 0.61
have no statistical differences, which also means that the
Social functioning 67.46 74.60 0.15
role functioning, pain, and global health status of the RATS
Symptoms subscale (mean)
group were improved. In the third week, there was a shift in
Fatigue 44.44 43.39 0.83
the data, and global health status (67.46 vs. 56.15, p = 0.03),
Nausea and vomiting 6.35 10.71 0.15
appetite loss (16.67 vs. 26.98, p = 0.04), and diarrhea (7.14
Pain 42.46 34.13 0.11
vs. 15.08, p = 0.04) scores of the RATS group were better
Dyspnea 41.27 40.48 0.89
than the UVATS groups. The rest of the data did not show
Insomnia 35.71 34.92 0.90
an obvious difference.
Appetite loss 23.02 25.40 0.65
Constipation 20.63 15.87 0.41
Leicester Cough Questionnaire Diarrhea 7.14 11.90 0.24
Financial difficulties 22.22 27.78 0.36
The Leicester Cough Questionnaire showed that the Global health status (mean)
scores had no significant difference between the two groups 52.58 57.34 0.33
in the first and second weeks (Tables 5, 6, 7). In the third
week after discharge, the psychological score (p = 0.18) and
social score (p = 0.27) had no significant difference between the two groups. The physical score of the RATS group was
higher than the UVATS group (5.11 vs. 4.58 p = 0.04).
2476 H. Diao et al.

TABLE 4  EORTC QLQ-C30 data for third week after discharge TABLE 7  Leicester Cough Questionnaire score for third week after
discharge
After propensity score-matched
3 weeks Propensity score-matched patients
RATS (n = 42) UVATS (n = 42) p-value
RATS (n = 42) UVATS (n = 42) p-value
Function subscale (mean) (mean) (mean)
Physical functioning 76.51 74.76 0.68
Physical 5.11 4.58 0.04
Role functioning 68.25 70.63 0.63
Psychological 5.27 4.90 0.18
Emotional function- 78.77 72.42 0.16
ing Social 5.42 5.08 0.27
Cognitive functioning 83.33 77.78 0.22 Total scores 21.56 19.49 0.06
Social functioning 76.98 71.83 0.26
Symptoms subscale (mean)
Fatigue 36.24 35.45 0.87 first week. In the second week, all the symptoms did not
Nausea and vomiting 8.33 11.90 0.27 differ significantly between the two groups. After the third
Pain 32.54 32.14 0.94 week, the degrees of nausea [0 (0–1) vs. 1 (1–2), p = 0.02]
Dyspnea 31.75 34.13 0.68 and lack of appetite [2 (1–3) vs. 3 (0–3), p = 0.04] of the
Insomnia 25.40 27.78 0.70 UVATS group were higher than that of the RATS group
Appetite loss 16.67 26.98 0.04 (Table 8).
Constipation 15.87 15.08 0.86
Diarrhea 7.14 15.08 0.04 Christensen Fatigue Scale
Financial difficulties 19.84 27.78 0.19
Global health status (mean) For the Christensen Fatigue Scale, no significant differ-
67.46 56.15 0.03 ence between the two groups was observed (week 1: p =
0.82, week 2: p = 0.75, week 3: p = 0.44; Table 9).

TABLE 5  Leicester Cough Questionnaire score for first week after DISCUSSION
discharge
1 week Propensity score-matched patients Lung cancer is associated with high mortality and high
morbidity.1 Lobectomy is the standard surgical approach for
RATS (n = 42) UVATS (n = 42) p-value
(mean) (mean) stages I–II non-small cell lung cancer.21 However, the best
method remains unclear. RATS and UVATS are the main-
Physical 4.30 4.29 0.97 stream methods of lobectomy. Jin et al. concluded that RATS
Psychological 4.62 4.89 0.39 and UVATS had similar perioperative results.6 Su Yang et al.
Social 4.95 4.91 0.92 found that the RATS is associated with less bleeding and
Total scores 13.86 14.09 0.80 more complete lymphadenectomy than UVATS.22 However,
while both of the above studies research the short-term out-
come of patients, neither study has reported a comparison of
TABLE 6  Leicester Cough Questionnaire score for second week the impact of 3–4 weeks of rehabilitation between discharge
after discharge and return to work for RATS versus UVATS.6 In our pro-
2 weeks Propensity score-matched patients spective study, we used the rating scale and portable elec-
tronic devices to explore and evaluate the true impact of the
RATS (n = 42) UVATS (n = 42) p-value
(mean) (mean) two surgical methods. We found that RATS is associated
with improved QOL in the third week after discharge.
Physical 4.81 4.73 0.71 Postoperative pain is an aspect that cannot be ignored. We
Psychological 4.92 5.01 0.76 noticed that in the first week after discharge, RATS caused
Social 5.07 5.22 0.59 worse patient pain than UVATS. According to our inter-
Total scores 19.58 20.31 0.49 view, in the first week, all the symptoms of the two groups
differentiated only in pain, which was not only reflected in
the EORTC QLQ-C30 but also in the MD Anderson Symp-
MD Anderson Symptom Inventory tom Inventory. This result is similar to the Novellis et al.
findings published in 2021.23 In terms of patient daily dis-
The pain severity degree of the RATS group was higher turbance items, the two tables also showed differences in
than the UVATS group (5.02 vs. 4.10, p = 0.04) after the the daily activities of patients. We can thus infer that pain
Comparison Results of Three‑Port Robot‑Assisted … 2477

TABLE 8  MD Anderson RATS VATS p-value

Symptom Inventory with
propensity score-matched 1 week
Symptom items
Pain (mean) 5.02 4.10 0.04
Fatigue (IQR) 4 (3–6) 5 (3–7) 0.89
Nausea (IQR) 1 (0–3) 1 (0–3) 0.98
Disturbed sleep (IQR) 4 (1.75– 6) 2.5 (1–5.25) 0.37
Distress/feeling upset (IQR) 2 (0–5) 2 (1–6) 0.60
Shortness of breath (IQR) 5 (2–6) 4 (2–6.25) 0.89
Difficulty remembering (IQR) 2 (0–4) 2 (1–3.25) 0.31
Lack of appetite (IQR) 3 (1–4) 2 (0.75–5) 0.52
Drowsiness (IQR) 2 (1–4.25) 3.5 (1–5) 0.61
Dry mouth (IQR) 3 (1–5.25) 2 (1–5) 0.26
Sadness (IQR) 2 (0–5.25) 1 (0.75–4) 0.87
Vomiting (IQR) 0 (0–2) 0 (0–2.25) 0.66
Numbness/tingling (IQR) 2 (0–4) 1 (0–3) 0.16
Interference items
Activity (IQR) 3 (1–5) 3 (1.75–5) 0.66
Mood (IQR) 3 (1–5) 3 (1–5.25) 0.73
Working (including housework, IQR) 4.5 (2–7) 5 (1.75–7.25) 0.88
Relations with other people (IQR) 1.5 (0–4.25) 0.5 (0–4) 0.46
Walking (IQR) 3 (2–4.25) 3 (0–4) 0.21
Enjoyment of life (IQR) 3 (1–4) 3 (1–5) 0.87
2 weeks
Symptom items
Pain (mean) 3.26 3.62 0.47
Fatigue (IQR) 3 (2–4) 4 (2–6.5) 0.17
Nausea (IQR) 0 (0–1) 1 (0–3) 0.03
Disturbed sleep (IQR) 2 (0–4.25) 2 (1–4.25) 0.61
Distress/feeling upset (IQR) 2 (1–4) 2 (1–4.25) 0.85
Shortness of breath (IQR) 3 (2–5) 4 (1–5.25) 0.87
Difficulty remembering (IQR) 1 (0–3) 2.5 (1–3) 0.14
Lack of appetite (IQR) 2 (1–3.25) 2 (1–5) 0.31
Drowsiness (IQR) 2 (1–3) 2 (1–5) 0.42
Dry mouth (IQR) 3 (1–5) 2 (1–5) 0.86
Sadness (IQR) 2 (0–4) 2 (1–4) 0.77
Vomiting (IQR) 1 (0–3) 0 (0–2) 0.18
Numbness/tingling (IQR) 2 (0–4.25) 1 (0–3) 0.50
Interference items
Activity 3 (1–4) 3 (1–5.25) 0.47
Mood 2.5 (0.75–4) 2 (1–4.25) 0.49
Working (including housework) 3 (2–5.25) 4.5 (2–6.25) 0.55
Relations with other people 1 (0–3.25) 1.5 (0–4.25) 0.45
Walking 2 (1–4) 3 (1–5) 0.80
Enjoyment of life 2 (1–4) 2.5 (1–5) 0.66
3 weeks
Symptom items
Pain (mean) 2.93 2.55 0.26
Fatigue (IQR) 3 (2–5) 3 (1–5) 0.43
Nausea (IQR) 0 (0–1) 1 (1–2) 0.02
Disturbed sleep (IQR) 2 (1–4) 1 (0–4) 0.19
Distress/feeling upset (IQR) 2 (1–3.25) 1 (0–4.25) 0.43
2478 H. Diao et al.

Table 8  (continued) RATS VATS p-value

Shortness of breath (IQR) 3 (2–4) 4 (2–5.25) 0.51

Difficulty remembering (IQR) 2(1–4) 2 (0–4) 0.54
Lack of appetite (IQR) 2 (1–3) 3 (0–3) 0.04
Drowsiness (IQR) 2 (1–3) 1 (0–3) 0.16
Dry mouth (IQR) 2 (1–3) 1 (0–3.25) 0.34
Sadness (IQR) 1.5 (1–3) 1 (0–4) 0.65
Vomiting (IQR) 0 (0–1) 0 (0–1) 0.40
Numbness/tingling (IQR) 2 (1–4) 1 (0–3) 0.10
Interference items
Activity (IQR) 3 (1–4) 2 (1–4.25) 0.55
Mood (IQR) 2.5 (1–4) 2 (1–5) 0.92
Working (including housework) (IQR) 3 (2–5) 3 (1–4.25) 0.62
Relations with other people (IQR) 2 (1–4) 1.5 (0–4) 0.43
Walking (IQR) 3 (1–4) 2.5 (1–4) 0.44
Enjoyment of life (IQR) 2 (1–4) 2 (0–5) 0.67

IQR interquartile range

TABLE 9  Christensen Fatigue Scale main symptoms of patients at 1 week after discharge. The
Propensity score-matched patients
median severity scores of pain and shortness of breath in
the RATS groups were more than 5 points (0–10). The
RATS UVATS (n = 42) p-value median severity scores of fatigue in the UVATS group
(n = 42)
were more than 5 points (0–10). By the end of the second
1 week, median (IQR) 3 (3–6) 3 (3–6) 0.82 week after discharge, the above symptoms were signifi-
2 weeks, median (IQR) 3 (3–5) 3 (2.75–6) 0.75 cantly improved in both groups with all the median sever-
3 weeks, median (IQR) 3 (3–4) 3 (2.75–4) 0.44 ity scores reduced to less than 5 points. However, no sig-
nificant difference was observed between the two groups.
IQR interquartile range
In addition, the nausea and lack of appetite severity were
better in the RATS group. The results indicated that the
indirectly affects the daily activities of patients. We believe life quality of three-port RATS is not inferior to UVATS
that this phenomenon might be due to the intercostal nerve but is even better than UVATS. However, the symptoms
being crushed and injured during RATS.24 The swing of could be improved by preoperative intervention. For exam-
the mechanical arm to the ribs as well as intercostal nerve ple, preoperative administration of steroids drugs could
damage cannot be negligible. The strength of the mechanical reduce postoperative fatigue and pain caused by surgical
arm in RATS is greater when compared with the UVATS inflammatory factors, and preoperative exercise of lung
assistant manual swing thoracoscope. In addition, three-port function can reduce postoperative shortness of breath.26–28
RATS destroys two rib intercostal muscles, whereas UVATS Cough after lobectomy is also a common compli-
only destroys one; another reason might be that RATS may cation. 29 Wu et al. reported that lymphadenectomy is
cause prolonged postoperative pain. Now, the single port da strongly associated with a short-term cough.30 There are
Vinci SP has been used in clinical practice and postoperative a number of scholars who believe that injury of the vagus
pain may be relieved due to the development of technique nerve and stimulation of the trachea are the main causes of
progression.25 Moreover, the intercostal muscles are respira- a postoperative cough.31 In our study, the number of lymph
tory muscles, which have an impact on lung function. How node dissection in the RATS group was higher than that in
RATS affects lung function is still unknown and should be the UVATS group, which means that the trachea and vagus
evaluated in future studies. If the best solution is relieving nerve are prone to be damaged. However, our follow-up
pain, then we could prescribe NSAID drugs for patients dis- data suggest that the results are contrary. The cough was
charged from hospital, but at the same time, the side effects more severe in the UVATS group than in the RATS group.
of this drug class, such as gastric mucosal damage, cannot We attribute these phenomena to the delicate manipulation
be ignored. of the RATS. The RATS vision system makes it easier to
According to the MD Anderson Symptom Inventory in distinguish tissue boundaries.32
our study, pain, fatigue, and shortness of breath were the
Comparison Results of Three‑Port Robot‑Assisted … 2479

The assembly of the robot is time consuming and may RATS lymph node excision suggest a greater advantage in
result in prolonged operation time. Nonetheless, our data the treatment of lung cancer than UVATS. However, the data
suggest that the operation time of RATS is less than UVATS. in our study did not support the hypothesis. A long-term
We believe that the RATS provides an amplified, high-defi- survival study is requisite.
nition, three-dimensional (3D) visualization of the surgical Although RATS has many advantages, the expense is an
field through employment of a stereoendoscope, which could issue that cannot be ignored. Cost was not analyzed in our
provide 3D sense and distance to the target for surgeons.33 study. In Shandong Provincial Hospital affiliated with Shan-
This is especially true when separating the blood vessels and dong First Medical University, the da Vinci robot costs about
trachea in the lobectomy. The robotic arm could readily raise $2900 USD once and is not covered by most commercial and
target blood vessels and the trachea, allowing the assistant to government insurance. The cost significantly limits the use
quickly sever and resect them with endoscopic staplers. The of RATS.45,46 In our study, the financial difficulty rates in
fully exposing surgical field, the flexible mechanical arm, EORTC QLQ-C30 were not statistically significant between
and clear 3D imaging could help the surgeon complete each the RATS and UVATS groups, because the choice of surgi-
operation easily and quickly.34 However, it is worth noting cal method is the patient’s own decision. The high cost of
that any technique has its learning curve, and robotic surgery robots is the reason why we did not perform a randomized
is no exception. Increased experience with robotic opera- control trial.
tions will dramatically reduce operation time,35 and shorter This study has several limitations. First, in our study, we
anesthetic procedure time would result in the use of fewer found patients in the UVATS group had more severe gas-
anesthesia drugs. Although the incidence of postoperative trointestinal reactions. However, the reasons for this need
complications was not statistically significant between the further research. Second, although we adopted a propen-
two groups in our study, it has been shown in other stud- sity score analysis to eliminate bias, the sample size of the
ies. Sinclair et al. and Apfel et al. concluded that the longer enrolled patients was still too small, and the results are not
the anesthesia time and the larger the anesthesia dose, the generalizable. Third, it takes about 2 days for patients to
higher the incidence of postoperative nausea and vomiting complete the necessary examinations before surgery, and the
(PONV).36,37 Kim et al. concluded that an increased risk of difference between the ward environment and the patient’s
venous thromboembolism is associated with an increased home environment makes it difficult to collect accurate base-
duration of anesthesia.38 line data before surgery. Lastly, it is also a pity that we have
Lymph node dissection is an important procedure for not yet compared the postoperative pulmonary function.
lobectomy, which is related to the postoperative pathologi- Follow-up pulmonary function testing was scheduled after
cal stage and further treatment options. The more lymph 6 months but has not yet been completed. Additionally, the
nodes examined results in more accurate nodal staging and short follow-up period of only 3 weeks post-discharge lim-
better long-term survival after resection of non-small cell ited the evaluation of long-term convalescence.
lung cancer.39 However, lymph node resection is associated
with a risk of chylothorax and nerve injury.40 Our data sug-
gested that more lymph nodes are removed by RATS, but the CONCLUSIONS
complications did not increase. This may be due to the flex-
ible mechanical arm of RATS, which could reduce the hand Three-port RATS and uniportal UVATS each have advan-
shaking of the surgeon.41 Thus, the complex mediastinal tages, and RATS is a safe and feasible alternative to VATS
lymph node resection under RATS could be easily accom- for patients with NSCLC. During the 3-week postoperative
plished.22,34 Fine manipulation by RATS could also reduce follow-up, RATS was associated with short-term postopera-
the tissue damage during surgery,42 which would result in a tive pain but less postoperative complications. Three-port
reduction of drainage volume. However, this phenomenon RATS was not inferior to uniportal UVATS with two addi-
was not observed in our study. Although median drainage tional portals.
volume of the RATS group is lower than the UVATS group,
it was not statistically significant. We thought it might be ACKNOWLEDGMENT This study was approved by the Biomedi-
cal Research Ethics Committee of Shandong Province and registered
because of more lymph nodes dissected. The advantages of
on the Chinese Clinical Trial Registry (ChiCTR2300067997). Writ-
RATS in dissecting lymph nodes might include less dam- ing—original draft preparation, Diao Haixiao; writing—review and
age to lymphatic vessels and their surrounding vessels.43 editing, Peng Zhongmin and Xu Lin; investigation, Wang Yancheng
More lymph nodes dissected means more tissue damaged and Li Xiao. We extend our sincere gratitude to all individuals who
actively participated in the study.
and increased postoperative drainage.44 All in all, RATS is
more suitable for those who had difficulty with dissection,
AUTHOR CONTRIBUTIONS DH was responsible for writing—
especially for those who underwent neoadjuvant therapy or original draft preparation, PZ and XL for writing—review and editing,
had suspected lymph node metastasis. The advantages of and WY and LX for investigation.
2480 H. Diao et al.

DISCLOSURE This study was approved by the Biomedical 13. Concheiro-Moscoso P, Groba B, Martínez-Martínez F, et al. Use
Research Ethics Committee of Shandong Province and registered on of the Xiaomi Mi Band for sleep monitoring and its influence
the Chinese Clinical Trial Registry (ChiCTR2300067997). None of the on the daily life of older people living in a nursing home. Digit
authors have identified a conflict of interest. Health. 2022;29(8):20552076221121160.
14. Pino-Ortega J, Gómez-Carmona C, Rico-González M. Accuracy
of Xiaomi Mi Band 2.0, 3.0 and 4.0 to measure step count and
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