Robotic-assisted versus video-assisted thoracoscopic anatomical lung resection for early-stage non-small cell lung cancer: a systematic review and meta-analysis.

Non-small cell lung cancer (NSCLC) represents 80-85% of lung cancer cases. Anatomical resection remains the cornerstone treatment for early-stage disease. Video-assisted (VATS) and robotic-assisted (RATS) thoracic surgery are alternatives to thoracotomy, though RATS's advantages over VATS remain controversial. We conducted this systematic review and meta-analysis to compare their perioperative and oncologic outcomes for anatomical resection in early-stage NSCLC. We searched PubMed, Cochrane Library, CINAHL, Web of Science, ClinicalTrials.gov, LILACS, and Google Scholar from October 8, 2025, updated June 15, 2026, for studies comparing RATS and VATS in adults with early-stage (up to IIA) NSCLC undergoing anatomical resection. Non-anatomical resections, hybrid techniques, and neoadjuvant therapy were excluded. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane RoB 2.0. Pooled estimates (odds ratios [OR] or mean differences [MD], 95% CI) were generated in Review Manager; certainty was graded using GRADE. Registered with PROSPERO (CRD420251229273). Twenty-eight studies (3 randomized, 25 observational; 68,349 participants) were included. Survival endpoints could not be pooled due to heterogeneity. RATS showed fewer conversions to thoracotomy (OR 0.54; 95% CI 0.50-0.58), shorter hospital stay (MD -0.33 days; -0.61 to -0.06), and greater lymph node retrieval (MD 0.82; 95% CI 0.35-1.30), with no differences in perioperative outcomes. Heterogeneity was substantial and largely unexplained. Oncologic endpoints could not be quantitatively compared. Perioperative advantages favoring RATS were modest, heterogeneous, and of low-to-very-low certainty. Adequately powered randomized trials are needed. No external funding was received.