Which is the best surgical approach for thymectomy: robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS), thoracotomy (TORA) or subxiphoid video-assisted thoracoscopic surgery (SPT)?-a systematic review and network meta-analysis

Background: Thymectomy is indicated in the presence of primary thymic diseases such as thymoma. However, there is no clear conclusion which is the best surgical approach for thymectomy. We performed this network meta-analysis (NMA) to compare the outcomes of different surgical approaches for thymectomy. Methods: An exhaustive search of PubMed, Excerpt Medica Database (EMBASE), Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted to identify relevant studies from inception to May 1, 2024. Direct and indirect evidence was combined to calculate the odds ratios (ORs) or standardized mean differences (SMDs), along with their 95% confidence intervals (CIs). Cluster analyses were adopted to compare the outcomes of different surgical approaches according to the similarity of two variables. Publication bias was detected by comparison-adjusted funnel plots. Results: Fifty-eight studies were enrolled in this NMA, involving four surgical approaches: thoracotomy (TORA), robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS) and subxiphoid video-assisted thoracoscopic surgery (SPT). The results indicated that in terms of blood loss, RATS was the least, and TORA had more blood loss than VATS and SPT. As for pleural drainage volume, TORA had more pleural drainage volume than VATS and SPT. In terms of visual analogue scale (VAS) score, VATS and TORA had higher VAS scores than SPT. The complete stable remission (CSR) of RATS was superior to that of VATS and TORA. Conclusions: SPT has faster postoperative recovery and less postoperative pain, and other perioperative outcomes are not inferior to other surgical approaches. RATS is safer and has certain clinical advantages in CSR. We look forward to more large-sample, high-quality randomized controlled studies published in the future.