International Society For Minimally Invasive Cardiothoracic Surgery

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The Association Of Robotic Lobectomy Volume And Nodal Upstaging In Non-small Cell Lung Cancer
Olugbenga T. Okusanya, Waseem Lutfi, Nicholas Baker, Rajeev Dhupar, Neil A. Christie, Ryan M. Levy, Nalyn Siripong, Li Wang, James D. Luketich, Inderpal S. Sarkaria.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objectives: Several studies have demonstrated increased rates of nodal upstaging with open surgery as compared to Video Assisted Thorascopic Surgery (VATS). Some believe this is due to the technical challenge of VATS nodal sampling. However, with the improved dexterity associated with robotic surgery, it is possible that with increasing experience and technical ability, lymph node harvest and lymph node upstaging may improve. We sought to investigate the rates of lymph node harvest and upstaging for robotic lobectomies performed at hospitals with varying robotic experience. Methods: The National Cancer Data Base was queried for patients with clinical stage I and II non-small cell lung cancer who received lobectomy between 2010-2014. Nodal upstaging for all open, VATS and robotic lobectomies over this time period were compared. Next, hospitals were stratified into four volume categories based on the number of robotic resections performed per year: low at ≤12, low-middle 13 to 24, middle-high 25 to 48 and high volume at more than 48. Lymph node counts and pathologic upstaging (clinical N0 to pathologic N1 or N2) were compared among these volume categories and to the VATS and open surgery groups. Results: 57,262, 23,802, and 9,129 lobectomies were performed open, VATS and robotically. Mean lymph node counts were 10.0, 11.5, and 11.5 for open, VATS, and robotic lobectomies respectively while nodal upstaging rates were 12.9%, 11.6%, and 11.4% respectively. 2,989 (32.5%) robotic lobectomy patients were treated at low-volume hospitals, 2,639 (28.9%) treated at low-middle-volume hospitals, 1,977 (21.7%) treated at middle-high-volume hospitals, and 1,524 (16.7%) treated at high-volume hospitals. Compared to low-volume hospitals, on multivariable analysis high-volume robotic centers had increased nodal harvest (linear regression coefficient = 2.75, P<0.001) and nodal upstaging rates (Odds Ratio = 1.33, P<0.001). Compared to open lobectomies, robotic lobectomies performed at high-volume centers had higher mean node counts (12.6 vs. 10.0, P<0.001) but similar rates of nodal upstaging (13.4% vs. 12.9%, P=0.537). Conclusion: Robotic lobectomies performed at hospitals with high robotic volume have greater lymph node harvest and upstaging than low-volume hospitals, as well as increased lymph node harvest and similar upstaging rates to that of open lobectomies.

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