Selected studies
A total of 2829 potential articles published before December 2020 were found from databases. After duplicates were removed, 1872 articles were initially evaluated by carefully reading the titles and abstracts, of which 1708 studies were excluded because they were review articles, case reports, animal experimental studies, letters, meeting abstracts, comments and other non-related studies. 164 potential articles were further assessed through reading the full texts, and finally, according to inclusion and exclusion criteria, a total of 18 retrospective studies were included in the final meta-analysis [26-43]. The flow chart of the screening strategies, which contains reasons for the exclusion of studies, is depicted in Fig. 1.
Study characteristics and quality
A total of 18 studies with 11247 patients, of whom 5114 patients were in the RATS group and 6133 in the VAST group, were involved in the analysis. Five included studies were published in Chinese [30,31,35-37], and 13 were published in English [26-29,32-34,38-43]. Among the 18 studies, 11 studies were from China [27,30,31,33-37,39,41,42], 6 from the USA [26,28,29,32,38,43] and 1 from Japan [40]. The basic characteristics of the included studies are listed in Table 1. The quality assessment of the included studies according to the NOS is elucidated in Table 2. It showed that 9 of the 18 included studies had 7 stars [27,28,31-33,35-37,41], 4 had 8 stars [26,30,34,42], and 5 had 9 stars [29,38-40,43].
Table 1 Characteristics of the included studies
|
Study
|
Year
|
Country
|
Design
|
Study Period
|
Group
|
Cases
|
Mean
age
|
Sex
(M/F)
|
Surgical techniques
|
Tumor Site
(Right/Left)
|
TNM stage
(I/II/III,IV)
|
Lee[26]
|
2015
|
USA
|
R
|
2009-2014
|
RATS
|
53
|
71.00
|
30/23
|
4 arms
|
99/59
|
NA
|
|
|
|
|
|
VATS
|
158
|
72.00
|
56/102
|
2 ports
|
34/19
|
NA
|
Bao[27]
|
2016
|
China
|
R
|
2014-2015
|
RATS
|
69
|
58.60
|
26/43
|
NA
|
NA
|
65/1/3
|
|
|
|
|
|
VATS
|
69
|
59.90
|
22/47
|
NA
|
NA
|
59/6/4
|
Oh[28]
|
2017
|
USA
|
R
|
2011-2015
|
RATS
|
2951
|
66.90
|
1369/1582
|
NA
|
NA
|
NA
|
|
|
|
|
|
VATS
|
2951
|
66.70
|
1373/1578
|
NA
|
NA
|
NA
|
Yang[29]
|
2017
|
USA
|
R
|
2002-2012
|
RATS
|
172
|
68.00
|
74/98
|
3 arms or 4 arms
|
110/62
|
133/29/10
|
|
|
|
|
|
VATS
|
141
|
67.50
|
53/88
|
3 ports
|
88/53
|
114/21/6
|
Liu[30]
|
2018
|
China
|
R
|
2012-2017
|
RATS
|
134
|
62.14
|
67/67
|
NA
|
81/53
|
134/0/0
|
|
|
|
|
|
VATS
|
213
|
61.30
|
118/95
|
NA
|
117/96
|
213/0/0
|
Ma[31]
|
2019
|
China
|
R
|
2016-2017
|
RATS
|
37
|
61.14
|
26/11
|
NA
|
23/14
|
NA
|
|
|
|
|
|
VATS
|
43
|
58.36
|
25/18
|
NA
|
27/16
|
NA
|
Merritt[32]
|
2019
|
USA
|
R
|
2014-2018
|
RATS
|
114
|
64.82
|
46/68
|
4 arms
|
61/53
|
71/27/9
|
|
|
|
|
|
VATS
|
114
|
62.52
|
49/65
|
3 ports
|
68/46
|
79/22/9
|
Li JT[33]
|
2019
|
China
|
R
|
2013-2016
|
RATS
|
230
|
55.60
|
76/154
|
NA
|
152/78
|
230/0/0
|
|
|
|
|
|
VATS
|
230
|
56.00
|
80/150
|
NA
|
162/68
|
230/0/0
|
Li[34]
|
2019
|
China
|
R
|
2014-2017
|
RATS
|
36
|
57.20
|
17/19
|
NA
|
23/13
|
0/16/20
|
|
|
|
|
|
VATS
|
85
|
59.70
|
38/47
|
NA
|
51/34
|
0/36/49
|
Tong[35]
|
2020
|
China
|
R
|
2016-2018
|
RATS
|
33
|
61.97
|
19/14
|
2 arms
|
0/33
|
24/6/3
|
|
|
|
|
|
VATS
|
41
|
62.24
|
27/14
|
3 ports
|
0/41
|
28/8/5
|
Huang[36]
|
2020
|
China
|
R
|
2019-2019
|
RATS
|
23
|
53.98
|
10/13
|
3 arms
|
15/8
|
19/2/2
|
|
|
|
|
|
VATS
|
30
|
56.39
|
17/13
|
3 ports
|
19/11
|
22/6/2
|
Tian[37]
|
2020
|
China
|
R
|
2015-2018
|
RATS
|
283
|
57.90
|
128/155
|
3 arms
|
283/0
|
226/45/12
|
|
|
|
|
|
VATS
|
296
|
58.76
|
118/178
|
4 ports
|
296/0
|
240/35/21
|
Veluswamy[38]
|
2020
|
USA
|
R
|
2008-2013
|
RATS
|
338
|
73.00
|
148/190
|
NA
|
NA
|
241/62/35
|
|
|
|
|
|
VATS
|
1230
|
72.00
|
542/688
|
NA
|
NA
|
918/214/98
|
Zhou[39]
|
2020
|
China
|
R
|
2011-2018
|
RATS
|
50
|
54.70
|
15/35
|
4 arms
|
27/23
|
50/0/0
|
|
|
|
|
|
VATS
|
80
|
57.70
|
26/54
|
4 ports
|
31/49
|
80/0/0
|
Haruki[40]
|
2020
|
Japan
|
R
|
2011-2018
|
RATS
|
49
|
70.00
|
21/28
|
4 arms
|
32/17
|
43/3/3
|
|
|
|
|
|
VATS
|
49
|
68.00
|
24/25
|
3 ports
|
26/23
|
42/1/6
|
Zhang[41]
|
2020
|
China
|
R
|
2015-2019
|
RATS
|
257
|
53.53
|
84/173
|
4 arms
|
127/130
|
NA
|
|
|
|
|
|
VATS
|
257
|
52.21
|
89/168
|
NA
|
124/133
|
NA
|
Qiu[42]
|
2020
|
China
|
R
|
2012-2017
|
RATS
|
40
|
61.40
|
36/4
|
3 arms
|
24/16
|
NA
|
|
|
|
|
|
VATS
|
38
|
61.70
|
34/4
|
2 ports or 3 ports
|
17/21
|
NA
|
Kneuertz[43]
|
2020
|
USA
|
R
|
2012-2017
|
RATS
|
245
|
65.30
|
47/53
|
4 arms
|
61/40
|
86/10/5
|
|
|
|
|
|
VATS
|
118
|
64.60
|
45/55
|
4 ports
|
58/42
|
90/6/4
|
R retrospective, RATS robot-assisted thoracic surgery, VATS video-assisted thoracic surgery, M male, F female, NA not available
|
Table 2 Assessment of the quality of the studies based on the NOS
|
|
Study
|
Selection (Out of 4)
|
Comparability (Out of 2)
|
Outcomes (Out of 3)
|
Total
(Out of 9)
|
(1)
|
(2)
|
(3)
|
(4)
|
(5)
|
(6)
|
(7)
|
Lee[26]
|
*
|
*
|
*
|
*
|
*
|
*
|
*
|
*
|
8
|
Bao[27]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Oh[28]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Yang[29]
|
*
|
*
|
*
|
*
|
**
|
*
|
*
|
*
|
9
|
Liu[30]
|
*
|
*
|
*
|
*
|
*
|
*
|
*
|
*
|
8
|
Ma[31]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Merritt[32]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Li JT[33]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Li[34]
|
*
|
*
|
*
|
*
|
**
|
*
|
*
|
|
8
|
Tong[35]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Huang[36]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Tian[37]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Veluswamy[38]
|
*
|
*
|
*
|
*
|
**
|
*
|
*
|
*
|
9
|
Zhou[39]
|
*
|
*
|
*
|
*
|
**
|
*
|
*
|
*
|
9
|
Haruki[40]
|
*
|
*
|
*
|
*
|
**
|
*
|
*
|
*
|
9
|
Zhang[41]
|
*
|
*
|
*
|
*
|
**
|
*
|
|
|
7
|
Qiu[42]
|
*
|
*
|
*
|
*
|
*
|
*
|
*
|
*
|
8
|
Kneuertz[43]
|
*
|
*
|
*
|
*
|
**
|
*
|
*
|
*
|
9
|
(1) Representativeness of the exposed cohort, (2) selection of the non-exposed cohort, (3) ascertainment of exposure, (4) demonstration that outcome of interest was not present at start of study, (5) assessment of outcome, (6) was follow-up long enough for outcomes to occur, (7) adequacy of follow-up of cohorts
|
|
Short-term outcomes
All results of meta-analysis for short-term outcomes are shown in Fig. 2, Fig. 3 and Fig. 4, which are summarized in Table 3. Thirteen studies reported the operative time. Because of significant heterogeneity (I2 = 97%, P < 0.001), a random effect model was adopted. The pooled data based on 13 studies revealed no significant difference between the groups of RATS and VATS (WMD = -0.79, 95% CI -15.65~14.06, P = 0.920) (Fig. 2a). The EBL was reported in 7 studies. Because there was significant heterogeneity between the 7 studies (I2 = 93%, P < 0.001), a random-effect model was used. Pooled analysis of the data showed that the EBL was less in RATS than VATS (WMD = -50.40, 95% CI -90.32~-10.48, P = 0.010) (Fig. 2b). The data regarding the conversion cases were reported in 12 studies. Because of the lack of high heterogeneity (I2 = 37%, P = 0.100), a fixed effect model was adopted. Meta-analysis showed that the conversion rate of RATS group was lower than that of VATS group (OR = 0.50, 95% CI 0.43~0.60, P < 0.001) (Fig. 2c).
Eight studies reported the number of dissected lymph nodes stations. The pooled results showed that the number of dissected lymph nodes stations was more in RATS than VATS (WMD = 0.51, 95% CI 0.15~0.86, P = 0.005) (Fig. 3a), with a high heterogeneity (I2 = 86%, P < 0.001), which made a random effect model adopted. The number of dissected lymph nodes was described in 14 studies. Significant heterogeneity was observed in the 14 studies (I2 = 93%, P < 0.001), so a random effect model was adopted. Pooled analysis showed that the number of dissected lymph nodes of RATS group was more than that of VATS group (WMD = 1.72, 95% CI 0.63~2.81, P = 0.002) (Fig. 3b).
The time of chest tube drainage was reported in 9 studies. Pooled analysis of the data showed that the time of chest tube drainage was shorter in RATS than VATS (WMD = -0.61, 95% CI -0.78~-0.44, P < 0.001) (Fig. 4a). The pooled result was measured using a fixed effect model due to the lack of high heterogeneity (I2 = 37%, P = 0.120). Fourteen studies reported the length of hospital stay. A random effect model was adopted because of significant heterogeneity (I2 = 80%, P < 0.001). The result of pooled analysis revealed that the length of hospital stay was shorter in RATS than that of VATS (WMD = -1.12, 95% CI -1.58~-0.66, P < 0.001) (Fig. 4b). Fifteen studies including a total of 10619 patients presented the overall postoperative complication and a fixed effect model was used due to no significant heterogeneity (I2 = 11%, P = 0.330). Pooled analysis showed that the rate of overall postoperative complication was lower in RATS than VATS (OR = 0.90, 95% CI 0.83~0.99, P = 0.020) (Fig. 4c). Moreover, six studies reported the postoperative mortality and no significant difference was identified between the two groups (OR = 0.99, 95% CI 0.68~1.45, P = 0.970) (Fig. 4d), with no significant heterogeneity (I2 = 37%, P = 0.160), which made a fixed effect model used.
Long‑term outcomes
All results of meta-analysis for long-term outcomes are shown in Fig. 5, which are outlined in Table 3. Four studies described the OS and no significant difference could be found in OS between the two techniques (HR = 1.02, 95% CI 0.82~1.26, P = 0.880) (Fig. 5a). Because of the lack of significant heterogeneity (I2 = 28%, P = 0.240), a fixed effect model was adopted. The DFS outcomes were recorded in 2 studies. Pooled analysis showed no significant heterogeneity (I2 = 0%, P = 0.490), which made a fixed effect model adopted. The pooled results indicated that the DFS outcomes were similar between the two groups (HR = 1.03, 95% CI 0.66~1.61, P = 0.890) (Fig. 5b). Cancer recurrence was reported in six studies and the pooled data indicated that the recurrence rate of RATS was lower than that of VATS (OR = 0.51, 95% CI 0.36~0.72, P < 0.001). A fixed effect model was used due to the lack of high heterogeneity (I2 = 0%, P = 0.490) (Fig. 5c).
Table 3 Results of the meta-analysis
|
Outcomes
|
No. of studies
|
Sample size
|
Heterogeneity
|
Overall effect size
|
95% CI of overall effect
|
P Value
|
RATS
|
VATS
|
I2(%)
|
P Value
|
Operation time (min)
|
13
|
3995
|
4211
|
97
|
<0.001
|
WMD=-0.79
|
-15.65~14.06
|
0.920
|
Estimated blood loss (mL)
|
7
|
385
|
483
|
93
|
<0.001
|
WMD=-50.40
|
-90.32~-10.48
|
0.010
|
Conversion
|
12
|
4441
|
4461
|
37
|
0.100
|
OR=0.50
|
0.43~0.60
|
<0.001
|
Dissected lymph node stations
|
8
|
997
|
1144
|
86
|
<0.001
|
WMD=0.51
|
0.15~0.86
|
0.005
|
Dissected lymph nodes
|
14
|
1396
|
1564
|
93
|
<0.001
|
WMD=1.72
|
0.63~2.81
|
0.002
|
Time of chest tube drainage (days)
|
9
|
892
|
1075
|
37
|
0.120
|
WMD=-0.61
|
-0.78~-0.44
|
<0.001
|
Length of hospital stay (days)
|
14
|
4225
|
4489
|
80
|
<0.001
|
WMD=-1.12
|
-1.58~-0.66
|
<0.001
|
Overall complications
|
15
|
4890
|
5729
|
11
|
0.330
|
OR=0.90
|
0.83~0.99
|
0.020
|
Mortality
|
6
|
3623
|
4587
|
37
|
0.160
|
OR=0.99
|
0.68~1.45
|
0.970
|
Overall survival
|
4
|
659
|
1471
|
28
|
0.240
|
HR=1.02
|
0.82~1.26
|
0.880
|
Disease-free survival
|
2
|
76
|
123
|
0
|
0.490
|
HR=1.03
|
0.66~1.61
|
0.890
|
Recurrence rate
|
6
|
605
|
631
|
0
|
0.490
|
OR=0.51
|
0.36~0.72
|
<0.001
|
Sensitivity analysis
We performed a sensitivity analysis for high-quality studies with more than 7 stars. The results of the sensitivity analysis showed that there were no significant difference between RATS and VATS on conversion rate (OR = 0.97, 95% CI 0.55~1.73, P = 0.930, I2 = 0%) (Fig. 6a), the number of dissected lymph node stations (WMD = 0.49, 95% CI -0.25~1.22, P = 0.190, I2 = 90%) (Fig. 6b), the number of dissected lymph nodes (WMD = 2.22, 95% CI -0.33~4.77, P = 0.090, I2 = 94%) (Fig. 6c), and the rate of overall postoperative complication (OR = 1.01, 95% CI 0.82~1.24, P = 0.940, I2 = 20%) (Fig. 6d), but the tendency was not changed. Compared with the overall outcomes, no significant changes were found in the remaining results. The results are shown in the Supplementary.
Publication of bias
A funnel plot of the overall complication was used to assess publication bias. The bilaterally symmetrical funnel plot of overall complication showed that no obvious evidence of publication bias was observed (Fig. 7).