Abstract
Background
Currently, the comparative efficacy of different robotic surgical systems in the treatment of lung cancer remains unclear. This study aimed to systematically evaluate the differences in efficacy between uniportal robotic-assisted thoracoscopic surgery (URATS) and multiportal robotic-assisted thoracoscopic surgery (MRATS) for the treatment of non-small cell lung cancer (NSCLC).
Methods
PubMed, Cochrane Library, Web of Science, and Embase were searched from database inception to March 2026 following standardized retrieval procedures. Two authors independently performed literature retrieval, preliminary screening, full-text reassessment, raw data extraction, and cross-checking. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies, and all statistical analyses were performed using Stata 17.0. This study has been registered on the INPLASY platform (protocol registration number: INPLASY202670008).
Results
Nine studies involving 1,827 patients were ultimately included. NOS assessment indicated that all included studies were of moderate-to-high quality. The pooled meta-analysis showed that, compared with MRATS, URATS was associated with a longer operative time [weighted mean difference (WMD) =14.70, 95% confidence interval (95% CI): 6.06–23.35, P=0.04, I2=24.5%] but a shorter length of hospital stay (WMD =−1.07, 95% CI: −1.36 to −0.77), P<0.01, I2=43.3%). No significant differences were observed in 1-year all-cause mortality, infection, air leak, hemothorax, duration of chest tube drainage, intraoperative blood loss, or number of dissected lymph nodes.
Conclusions
Compared with MRATS, URATS for NSCLC was associated with a longer operative time but a shorter hospital stay, while no statistically significant differences were observed in the other assessed outcomes. These findings suggest that URATS may be a feasible minimally invasive surgical approach for NSCLC, although further prospective studies are warranted.
Keywords: Uniportal thoracoscopic surgery, multiportal thoracoscopic surgery, non-small cell lung cancer (NSCLC), robotic-assisted surgery, systematic review and meta-analysis
Highlight box.
Key findings
• This study, for the first time, conducted a systematic review and meta-analysis to compare the efficacy and safety of uniportal robotic-assisted thoracic surgery (URATS) vs. multiportal robotic-assisted thoracic surgery (MRATS) in the management of non-small cell lung cancer (NSCLC).
• Meta-analytic results demonstrated that URATS was associated with a longer operative time but a shorter length of hospital stay compared to MRATS. No statistically significant differences were observed between the two groups in terms of 1-year all-cause mortality, infection, air leakage, hemothorax, chest tube drainage duration, intraoperative blood loss, or the number of lymph nodes dissected.
What is known and what is new?
• Robot-assisted thoracic surgery (RATS) has been widely applied in the treatment of NSCLC, but the advantages and disadvantages of different surgical approaches (single-port vs. multi-port) remain inconclusive.
• This study is the first systematic review and meta-analysis comparing URATS and MRATS in the treatment of NSCLC, systematically integrating existing evidence to clarify the differences and similarities between the two surgical approaches across various clinical outcome measures, providing the most comprehensive quantitative evidence available in this field to date.
What is the implication, and what should change now?
• Although URATS involves a longer operative time, it can shorten hospitalization duration and offers safety and oncological outcomes comparable to MRATS, making it an innovative minimally invasive technique with clinical potential.
• In clinical decision-making, surgeons may individualize the choice of surgical approach based on patient-specific conditions and their own experience; future high-quality, large-sample prospective studies are needed to further validate these conclusions.
Introduction
Lung cancer is the second most commonly diagnosed cancer worldwide and remains the leading cause of cancer-related mortality, imposing a substantial burden on global public health (1). Low-dose spiral computed tomography (CT) screening enables the early detection of lung cancer lesions and facilitates timely targeted interventions, thereby significantly reducing disease-related mortality (2). Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancer cases (3). For patients with early-stage NSCLC, lobectomy has long been considered the preferred surgical treatment approach (4,5). With continuous advances in surgical technologies, minimally invasive surgery, particularly robotic-assisted thoracoscopic surgery (RATS), has become an important direction in the surgical management of NSCLC (6-8). Minimally invasive approaches offer several advantages, including reduced surgical trauma and accelerated postoperative recovery. In addition, RATS provides enhanced benefits, such as three-dimensional visualization of the operative field, tremor elimination, fine manipulation, and improved surgical precision (9,10). Previous studies have reported that RATS achieves comparable clinical outcomes to thoracotomy in patients with NSCLC (11).
During the early development of RATS, multiportal RATS (MRATS) represented the primary focus of the research (12). However, MRATS often requires multiple incisions for surgical manipulation, which may increase surgical trauma. In 2021, Gonzalez-Rivas first used the da Vinci robotic system to perform uniportal RATS (URATS) lobectomy in patients with NSCLC (13). Since then, increasing evidence has demonstrated the efficacy and safety of URATS for the treatment of NSCLC (13-16). Compared with MRATS, URATS adopts a lateral view, which may shorten the surgeon’s learning curve. However, differences in efficacy between these two minimally invasive surgical techniques remain unclear. Therefore, we conducted this systematic review to compare the efficacy and safety of URATS and MRATS in patients with NSCLC, aiming to provide evidence-based guidance for selecting appropriate approaches in clinical practice. The protocol of this study was registered on the INPLASY platform (INPLASY202670008). We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1982/rc).
Methods
Search strategy
A comprehensive literature search was conducted using databases, including Cochrane Library, PubMed, Web of Science, and Embase, to identify studies evaluating the efficacy of uniportal and MRATS for the treatment of NSCLC from database inception to March 2026. In addition, clinical trial registry platforms were manually searched to identify potentially eligible studies that may have been missed during the database search. This study employed a search strategy combining subject headings and free-text terms. The main search terms included robotic-assisted surgery, RATS, NSCLC, URATS, MRATS, robotic surgical procedure, and other related terms. The search strategy was appropriately adjusted according to the specific requirements of each database.
Study selection
The literature screening and data extraction processes were independently performed by two researchers, and the extracted information was subsequently cross-checked to ensure accuracy and consistency. All disagreements were resolved through discussion or consultation with a third investigator. Only cohort studies published in English were included. The study population consisted of patients with NSCLC diagnosed by imaging examination or histopathological confirmation who underwent RATS. The included studies were divided into two intervention groups: the MRATS group, consisting of NSCLC patients who received MRATS, and the URATS group, consisting of NSCLC patients who received URATS. The main exclusion criteria were as follows: (I) duplicate publications; (II) reviews and meta-analyses; (III) case reports and correspondence articles; (IV) studies with unavailable raw data or incomplete information; and (V) non-clinical studies, including animal experiments and cell experiments.
Outcome measures
The outcome measures evaluated in this study included multiple aspects. One-year all-cause mortality was defined as the primary outcome. Secondary outcome measures included perioperative complications (including infection, air leak, and hemothorax), operative time, intraoperative blood loss, duration of thoracic drainage, length of hospital stay, and the number of dissected lymph nodes.
Data extraction
The extracted information included the following categories: (I) baseline characteristics, including first author, publication year, country, study type, sample size, and participant characteristics such as age, sex, body mass index (BMI); (II) disease-related variables, including tumor size, histological type, and clinical stage; (III) preoperative assessment data, including pulmonary function indicators and the ratio of measured to predicted diffusing capacity of the lung for carbon monoxide; (IV) primary outcome measures, including 1-year postoperative all-cause mortality, perioperative complications, infection, pneumothorax, and hemothorax; and (V) study quality assessment and other relevant materials.
Study quality assessment
The Newcastle-Ottawa Scale (NOS) was used to assess the quality of all included cohort studies. The scoring criteria were defined as follows: studies with a total score above 7 were considered high quality, those scoring 4 to 7 were classified as moderate quality, and those scoring below 4 were considered low quality. Quality assessment was jointly completed by two independent researchers. Any disagreements were resolved through discussion or consultation with a third investigator to ensure the reliability and consistency of the results.
Statistical analysis
The meta-analysis was performed using Stata 17.0 statistical software (StataCorp LLC, College Station, TX, USA). For binary variables, the odds ratio (OR) was calculated as the effect measure, while the weighted mean difference (WMD) was used to evaluate continuous variables. All effect sizes were reported with 95% confidence interval (95% CI), and a P<0.05 was considered statistically significant. Statistical heterogeneity among the included studies was assessed using the I2 statistic and P value. When I2<50% and P>0.05, indicating low heterogeneity, a fixed-effects model was applied; otherwise, a random-effects model was used. For major outcome measures with substantial heterogeneity, sensitivity analyses were conducted to identify potential sources of heterogeneity. Publication bias was assessed using funnel plots and Egger’s test when applicable.
Results
Study selection
The initial database search identified 50 potentially relevant articles. After removing 13 duplicates, 5 non-empirical articles, including reviews, meta-analyses, and case studies, were excluded. During the preliminary screening, 19 articles that did not meet the criteria were removed. Following reassessment, another 9 articles were excluded due to failure to meet the requirements. Ultimately, 9 studies (17-25) were included in this meta-analysis. The detailed literature screening process is shown in Figure 1.
Figure 1.
Screening process for included literature.
Characteristics and quality assessment of included studies
A total of 9 studies were included in this meta-analysis (17-25). All included studies adopted a cohort study design, and the NOS scale was used to assess potential risk of bias. The quality assessment results showed that all included studies achieved NOS score greater than 7, indicating high methodological quality. The baseline characteristics of the included study are summarized in Table 1, and the quality assessment results are shown in Table 2.
Table 1. Baseline data sheet (URATS group/MRATS group).
| Study | General characteristics | Type of surgical robot | Tumor clinical features | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nation | Study design | Sample size | Male (%) | Age (years) | BMI (kg/m2) | Davinci robot platform | Type of surgery | No. of ports | FEV1 (%) | DLCO (%) | Tumor size (cm) | Adenocarcinoma (%) | Stage I | Stage II | Stage III | Stage IV | |
| Manolache et al., 2023 (23) | Romania | Cohort study | 101/101 | 59.4/62.4 | 63.0/69.0 | NR | SP/Xi | Segmentectomy/Lob | 1/4 | 90.0/95.0 | 76.0/79.0 | NR | 41.6/64.4 | 26.7/64.4 | 24.8/18.8 | 16.8/11.9 | 0.0/0.0 |
| Serratosa et al., 2025 (24) | Spain | Cohort study | 5/344 | 60.3/59.9 | 65.2/66.9 | 27.2/26.8 | SP/Xi | WR/WR | 1/4 | 92.6/94.6 | 81.7/80.5 | NR | NR | NR | NR | NR | NR |
| Chen et al., 2025 (18) | China | Cohort study | 153/200 | 39.9/43.0 | 58.1/59.8 | 24.8/24.7 | SP/Xi | Lob/Lob | 1/3 | 98.3/96.9 | 95.7/101.2 | 1.6/1.6 | 49.0/52.0 | NR | NR | NR | NR |
| Lee et al., 2025 (21) | South Korea | Cohort study | 113/226 | 43.4/52.2 | 65.0/64.0 | 24.2/23.7 | SP/Xi | Lob/Lob | 1/2 | NR | NR | 2.5/2.5 | 88.5/82.7 | NR | NR | NR | NR |
| Kuo et al., 2025 (20) | China | Cohort study | 18/18 | 27.8/61.1 | 62.0/68.0 | 23.8/23.6 | SP/Xi | Lob/Lob | 1/4 | 103.0/107.0 | NR | NR | 61.1/72.2 | 50.0/55.6 | 5.6/11.1 | 11.1/11.1 | 5.6/5.6 |
| Zhang et al., 2024 (25) | China | Cohort study | 148/148 | 35.1/31.8 | 57.0/55.0 | 22.8/23.2 | SP/Xi | Lob/Lob | 1/4 | 98.4/96.9 | 93.8/92.2 | NR | 93.7/92.2 | 78.4/75.0 | 16.9/17.6 | 4.7/7.4 | 0.0/0.0 |
| Lee et al., 2024 (22) | South Korea | Cohort study | 11/24 | 64.0/54.0 | 66.0/66.0 | 24.4/24.2 | SP/Xi | Lob/Lob | 1/2 | 83.0/85.0 | 80.0/80.0 | 6.0/5.5 | 55.0/71.0 | NR | NR | NR | NR |
| Kim et al., 2025 (17) | South Korea | Cohort study | 21/81 | 38.1/45.7 | 65.0/65.0 | 23.8/24.8 | NR | NR | 1/NR | 90.0/92.0 | 87.0/86.0 | 25.0/27.0 | 95.2/84.0 | NR | NR | NR | NR |
| Kawaguchi et al., 2025 (19) | Japan | Cohort study | 30/30 | 53.3/50.0 | 69.9/70.6 | 22.5/22.3 | SP/Xi | Lob/Lob | 1/4 | 76.6/76.5 | NR | 25.0/28.0 | 76.7/86.7 | 6.7/63.3 | 13.3/16.7 | 0.0/6.7 | 0.0/0.0 |
BMI, body mass index; DLCO, diffusion capacity for carbon monoxide; FEV1, forced expiratory volume in 1 second; Lob, lobectomy; MRATS, multi-port robot-assisted thoracoscopic surgery; NR, not reported; SP, single port; URATS, single-port robot-assisted thoracoscopic surgery; WR, wedge resection.
Table 2. Results of quality evaluation of original studies.
| Study | Selection | Comparability | Outcome | Total score |
|---|---|---|---|---|
| Manolache et al., 2023 | ★★ | ★★ | ★★★ | 7★ |
| Serratosa et al., 2025 | ★★★★ | ★★ | ★★★ | 9★ |
| Chen et al., 2025 | ★★★ | ★★ | ★★★ | 8★ |
| Lee et al., 2025 | ★★★ | ★★ | ★★★ | 8★ |
| Kuo et al., 2025 | ★★★ | ★★ | ★★ | 7★ |
| Zhang et al., 2024 | ★★★★ | ★★ | ★★★ | 9★ |
| Lee et al., 2024 | ★★★★ | ★★ | ★★★ | 9★ |
| Kim et al., 2025 | ★★★ | ★★ | ★★★ | 8★ |
| Kawaguchi et al., 2025 | ★★★★ | ★★ | ★★★ | 9★ |
★, indicates that the study met the corresponding NOS item and scored 1 point (maximum score: 9). NOS, Newcastle-Ottawa Scale.
Meta-analysis results
One-year all-cause mortality
A total of four studies reporting 1-year all-cause mortality were included in the meta-analysis (20,21,23,24). No significant heterogeneity was observed among the included studies (I2=0.0%). Fixed-effects meta-analysis showed no statistically significant difference in mortality between the two groups (OR =0.73, 95% CI: 0.19–2.73; P=0.64). Details are shown in Figure 2A and Table 3.
Figure 2.
Forest plots of individual outcome indicators. (A) One-year all-cause mortality. (B) Infection. (C) Pulmonary air leak. (D) Hemothorax. (E) Operation duration. (F) Operative bleeding. (G) Days of chest tube drainage. (H) Length of stay. (I) The number of lymph nodes dissected. CI, confidence interval; df, degrees of freedom; IV, inverse variance; WMD, weighted mean difference.
Table 3. Pooled results of meta-analysis.
| Outcomes | Studies | Heterogeneity test result | Effect model | Meta-analysis results | ||
|---|---|---|---|---|---|---|
| P value | I2 (%) | OR/WMD (95% CI) | P value | |||
| One-year all-cause mortality | 4 | 0.79 | 0.0 | Fixed | 0.73 (0.19, 2.73) | 0.64 |
| Infection | 4 | 0.18 | 39.1 | Fixed | 0.88 (0.36, 2.15) | 0.78 |
| Pulmonary air leak | 6 | <0.01 | 73.4 | Random | 0.44 (0.13, 1.43) | 0.17 |
| Hemothorax | 3 | 0.38 | 0.0 | Fixed | 0.48 (0.11, 2.10) | 0.33 |
| Operation duration (min) | 7 | 0.24 | 24.5 | Fixed | 14.70 (6.06, 23.35) | 0.04 |
| Operative bleeding (mL) | 4 | <0.01 | 87.7 | Random | −26.26 (−60.26, 7.73) | 0.13 |
| Days of chest tube drainage (days) | 8 | <0.01 | 69.5 | Random | −0.06 (−0.79, 0.67) | 0.87 |
| Length of stay (days) | 9 | 0.08 | 43.3 | Fixed | −1.07 (−1.36, −0.77) | <0.01 |
| The number of lymph nodes dissected | 6 | 0.34 | 11.8 | Fixed | −0.59 (−2.60, 1.42) | 0.56 |
CI, confidence interval; min, minute; OR, odds ratio; WMD, weighted mean difference.
Infection
A total of four studies reporting infection-related outcomes were included in this analysis (18-20,24). Heterogeneity assessment indicated a low level of statistical heterogeneity among the included studies (I2=39.1%). The results showed no significant difference in the incidence of infection between the two groups (OR =0.88, 95% CI: 0.36–2.15, P=0.78). The detailed results are shown in Figure 2B and Table 3.
Air leak
A total of six studies reporting air leak-related outcomes were included in this analysis (18-20,23-25). Significant heterogeneity was observed among the included studies (I2=73.4%). Random-effects meta-analysis showed no statistically significant difference in the incidence of air leak between the two groups (OR =0.44, 95% CI: 0.13–1.43, P=0.17). The detailed results are shown in Figure 2C and Table 3.
Hemothorax
A total of three studies (20,23,24) reporting hemothorax-related outcomes met the inclusion criteria and were included in this analysis. Heterogeneity assessment indicated low heterogeneity among the included studies (I2=0.0%); therefore, a fixed-effects model was applied. The pooled analysis showed no significant difference in the incidence of hemothorax between the two groups (OR =0.48, 95% CI: 0.11–2.10; P=0.33). The detailed results are shown in Figure 2D and Table 3.
Operative time
A total of seven studies were included in this analysis (17-19,21,22,24,25). Heterogeneity assessment indicated low heterogeneity among the included studies (I2=24.5%); therefore, a fixed-effects model was used. The meta-analysis showed that operative time was significantly longer in the URATS group compared with the MRATS group (WMD =14.70, 95% CI: 6.06–23.35; P=0.04). The detailed results are shown in Figure 2E and Table 3.
Intraoperative blood loss
A total of four studies reporting intraoperative blood were included in this analysis (18-20,25). Heterogeneity assessment indicate substantial heterogeneity among the included studies (I2=87.7%); therefore, a random effects model was applied. The results showed no significant difference in intraoperative blood loss between the URATS and MRATS groups (WMD =−26.26, 95% CI: −60.26 to 7.73; P=0.13). The detailed results are shown in Figure 2F and Table 3.
Duration of chest tube drainage
A total of eight studies reporting the duration of chest tube drainage were included in this analysis (17-22,24,25). Heterogeneity assessment revealed significant heterogeneity among the indicated studies (I2=69.5%); therefore, a random-effects model was applied. The results showed no statistically significant difference in the duration of chest tube drainage between the URATS and MRATS groups (WMD =−0.06, 95% CI: −0.79 to 0.67; P=0.87). The detailed results are presented in Figure 2G and Table 3.
Length of hospital stay
A total of nine studies reporting the length of hospital stay were included in this analysis (17-25). Heterogeneity assessment indicated no significant heterogeneity among the included studies (I2=43.3%); therefore, a fixed-effects model was applied. The results showed a significant difference in the length of hospital stay between the URATS and MRATS groups (WMD =−1.07, 95% CI: −1.36 to −0.77; P<0.01). Patients in the URATS group had a significantly shorter hospital stay compared with those in the MRATS group. The detailed results are shown in Figure 2H and Table 3.
Number of dissected lymph nodes
Five studies (17-22) provided data regarding the number of dissected lymph nodes. Due to the low heterogeneity observed across studies (I2=11.8%), a fixed-effects model was selected for meta-analysis. The results showed no statistically significant difference in the number of dissected lymph nodes between the URATS and MRATS groups (WMD =−0.59, 95% CI: −2.60 to 1.42; P=0.56). The detailed results are shown in Figure 2I and Table 3. In addition, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence assessment tool to evaluate all outcome measures, as shown in Table 4.
Table 4. GRADE evidence level assessment.
| Outcome | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Publication bias | Certainty assessment |
|---|---|---|---|---|---|---|---|
| One-year all-cause mortality (n=4) | Cohort study | Not serious | Not serious | Not serious | Not serious | Undetected | Moderate |
| Infection (n=4) | Cohort study | Not serious | Not serious | Not serious | Not serious | Undetected | Moderate |
| Pulmonary air leak (n=6) | Cohort study | Not serious | Serious | Not serious | Not serious | Undetected | Low |
| Hemothorax (n=3) | Cohort study | Not serious | Not serious | Not serious | Not serious | Undetected | Moderate |
| Operation duration (minutes) (n=7) | Cohort study | Not serious | Not serious | Not serious | Not serious | Undetected | Moderate |
| Operative bleeding (mL) (n=7) | Cohort study | Not serious | Serious | Not serious | Not serious | Undetected | Low |
| Days of chest tube drainage (days) (n=8) | Cohort study | Not serious | Serious | Not serious | Not serious | Undetected | Low |
| Length of stay (days) (n=9) | Cohort study | Not serious | Not serious | Not serious | Not serious | Undetected | Moderate |
| The number of lymph nodes dissected (n=6) | Cohort study | Not serious | Not serious | Not serious | Not serious | Undetected | Moderate |
GRADE, Grading of Recommendations Assessment, Development, and Evaluation.
Sensitivity analysis
Sensitivity analysis was performed by sequentially removing each individual study to evaluate the stability of the results. The results showed that all outcome measures remained stable after the removal of any single study, indicating that the conclusions of this meta-analysis were robust. Sensitivity analysis results are presented using 1-year all-cause mortality as an example (Figure 3).
Figure 3.
Results of sensitivity analysis of 1-year all-cause mortality. CI, confidence interval.
Publication bias
Publication bias for all outcome measures was assessed using Stata 17.0. Funnel plots were applied for qualitative analysis, while Egger’s test was performed for quantitative assessment. The results showed no obvious asymmetry in the funnel plots of the evaluated outcomes. The funnel plot for 1-year all-cause mortality is shown as an example in Figure 4. Egger’s test was further conducted to quantitatively evaluate publication bias for each outcome measure. The statistical results were as follows: 1-year all-cause mortality (P=0.40), infection (P=0.83), air leak (P=0.64), hemothorax (P=0.41), operative time (P=0.15), intraoperative blood loss (P=0.47), duration of chest tube drainage (P=0.40), length of hospital stay (P=0.71), and number of dissected lymph nodes (P=0.38). These findings demonstrated that no obvious publication bias was observed among the assessed outcome indicators. The Egger’s test results for 1-year all-cause mortality are shown in Figure 5.
Figure 4.
Funnel plot of 1-year all-cause mortality. ES, effect size; OR, odds ratio; se, standard error.
Figure 5.
Egger test results of 1-year all-cause mortality.
Discussion
To our knowledge, this is the first systematic review and meta-analysis to compare the efficacy of URATS and MRATS in patients with NSCLC. Through a standardized literature search and screening process, 9 studies involving a total of 1,827 patients were ultimately included. The pooled meta-analysis showed that, compared with MRATS, URATS for NSCLC was associated with a longer operative time but a shorter hospital stay. However, no significant differences were observed between the two groups regarding 1-year all-cause mortality, infection, air leak, hemothorax, duration of chest tube drainage, intraoperative blood loss, or number of dissected lymph nodes.
The study by Chen et al. (18) showed that MRATS was associated with a greater number of intraoperatively dissected lymph nodes, whereas Kim et al. (17) found no significant difference in the number of dissected lymph nodes between MRATS and URATS. Similarly, Manolache et al. (23) showed that URATS resulted in a shorter hospital stay, while Serratosa et al. (24) reported no significant difference in hospital stay between the two surgical approaches. These inconsistent findings indicate that the comparative efficacy remains controversial. Therefore, we conducted this systematic review and meta-analysis to comprehensively evaluate the clinical differences between URATS and MRATS. The meta-analysis showed no obvious differences between the URATS and MRATS groups in 1-year all-cause mortality, infection, air leak, hemothorax, duration of chest tube drainage, intraoperative blood loss, or number of dissected lymph nodes. For operative time, the pooled meta-analysis showed that the operative time was significantly longer in the URATS group than in the MRATS group. This difference may be mainly attribute to the fact that URATS is a relatively new minimally invasive technique introduced in 2021, and surgeons have had a shorter training period and less experience with this approach (22,26). In addition, during URATS procedure, all surgical instruments are inserted into the thoracic cavity through a single port, which increased the likelihood of instrument interference and technical challenges (27). The operative space in URATS is relatively limited; therefore, greater caution is required when dissecting critical structures and lymph nodes (22,26). Regarding the length of hospital stay, the pooled meta-analysis showed that patients in the URATS group had a significantly shorter hospitalization period than those in the MRATS group, which is consistent with previous findings (20). This advantage may be attributed to the fact that the multiple incisions required for MRATS can increase intercostal nerve stimulation and soft tissue injury, resulting in more severe postoperative pain, delayed early ambulation, thereby slowing postoperative recovery. In contrast, the single incision approach of URATS can effectively reduce intraoperative and postoperative inflammatory responses and tissue injury (28-32). Overall, this analysis confirms that URATS and MRATS are generally comparable in perioperative safety and oncological effectiveness, and both are safe and feasible minimally invasive approaches. Although the single-port operation of URATS may prolong operative time, its single-incision design significantly reduces chest wall trauma and intercostal nerve injury, resulting in less postoperative pain, earlier ambulation, shorter hospitalization, and accelerated recovery. Clinical decision-making should comprehensively consider surgeon experience, tumor characteristics, and the patient’s overall condition to achieve individualized selection of the optimal surgical approach. The learning curve for URATS was not consistently reported across the included studies. Differences in surgeon experience and familiarity with URATS may therefore have influenced operative time and perioperative outcomes, representing a potential source of bias with continuous improvements in URATS-specific instruments and increasing surgeon proficiency, the surgical efficiency of URATS is expected to further improve, and this technique may become one of the mainstream minimally invasive treatments for early-stage lung cancer treatment in the future.
Limitations
This study has several limitations. First, most of the included studies were single-center studies with relatively small sample sizes, which may limit the generalizability of the findings and reduce the statistical power of the analysis. Second, all included studies were retrospective in design, and some important clinical variables may not have been fully reported, potentially introducing selection bias. In addition, patients were recruited from different medical centers, and variations in surgeons’ experience levels and stages of the learning curve may have influenced surgical outcomes and introduced potential errors. Variations in the number of ports used for MRATS and differences in surgical procedures may have contributed to potential bias in the pooled outcomes.
Conclusions
Although no significant differences were observed between URATS and MRATS in 1-year all-cause mortality, infection, air leak, hemothorax, duration of chest tube drainage, intraoperative blood loss, or number of dissected lymph nodes, URATS was associated with a longer operative time but a shorter hospital stay. Compared with MRATS, URATS demonstrated comparable surgical efficacy and safety while providing advantages in postoperative recovery. The above evidence suggests that URATS is a potential surgical treatment for NSCLC patients. Further prospective, large sample size comparative studies with important oncologic and long-term end points are recommended.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Footnotes
Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1982/rc
Funding: This work was supported by the Gansu Provincial Natural Science Foundation (No. 26JRRA310) and the Internal Research Grants of the First Hospital of Lanzhou University (Nos. ldyyyn2025-110 and ldyyyn2025-266).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1982/coif). The authors have no conflicts of interest to declare.
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