Robotic-Assisted, Video-Assisted, and Open Sleeve Lobectomy After Neoadjuvant Therapy for Non-Small Cell Lung Cancer: A Systematic Review and Network Meta-Analysis

Background: Neoadjuvant therapy, particularly chemoimmunotherapy, has transformed the management of locally advanced non-small cell lung cancer (NSCLC). However, treatment-induced hilar fibrosis and tissue adhesions may increase the complexity of subsequent surgical resection, especially for technically demanding procedures such as sleeve lobectomy. The optimal surgical approach—robotic-assisted thoracic surgery (RATS), video-assisted thoracoscopic surgery (VATS), or open thoracotomy—remains uncertain in this setting. Methods: A systematic review and network meta-analysis (NMA) were conducted in accordance with PRISMA and PRISMA-NMA guidelines. PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to present. Studies comparing RATS, VATS, and open sleeve lobectomy in NSCLC patients following neoadjuvant therapy were included, while mixed cohorts were excluded to ensure data homogeneity. Primary outcomes included postoperative complications, 30-day mortality, operative time, and intraoperative blood loss. Secondary outcomes included R0 resection rate, lymph node harvest, conversion rate, bronchial anastomosis time, and length of hospital stay. A frequentist network meta-analysis was performed. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated. Heterogeneity was assessed using I² statistics, and treatment ranking was performed using SUCRA. Results: Five retrospective studies comprising 175 patients were included (RATS: 39, VATS: 114, Open: 22). Postoperative complications were comparable across approaches, with no statistically significant differences between RATS and VATS (OR 1.35, 95% CI 0.38–4.7), RATS and Open (OR 1.9, 95% CI 0.25–13.8), or VATS and Open (OR 0.22, 95% CI 0.03–1.6), although a trend favoring VATS was observed. Mortality rates were low and did not significantly differ between groups. Minimally invasive approaches (RATS and VATS) were associated with reduced intraoperative blood loss (MD approximately −70 to −100 mL) and shorter hospital stay (reduction of ~1–3 days) compared to open thoracotomy. RATS demonstrated a trend toward higher lymph node harvest (mean difference ~2–3 nodes) and showed a 0% conversion rate, whereas VATS conversion ranged from 4.7% to 30%. SUCRA ranking indicated that RATS had the highest probability of being the optimal approach (0.78), followed by VATS (0.64) and open thoracotomy (0.21). Heterogeneity was low to moderate (I² 0–40%), with no significant inconsistency detected. Conclusions: Minimally invasive sleeve lobectomy, including both RATS and VATS, appears to be safe and feasible for NSCLC patients following neoadjuvant therapy. RATS demonstrated favorable trends in technical outcomes, including lower conversion rates and improved lymph node harvest, and ranked highest in SUCRA analysis. However, given the limited sample size and observational nature of the included studies, these findings should be interpreted with caution. Further large-scale prospective and randomized studies are required to determine the optimal surgical approach in this setting. Systematic Review Registration: PROSPERO CRD420261358976.