Postoperative pain management and hospital outcomes following robotic-assisted thoracoscopic surgery for non-small cell lung cancer: a propensity score-matched study

Background: Few studies have evaluated the benefits of robotic-assisted thoracoscopic surgery (RATS) through patient-reported pain scores or combined inpatient and outpatient medication administration compared to video-assisted thoracoscopic surgery (VATS) for non-small cell lung cancer (NSCLC). The purpose of this study was to directly compare differences in hospital length of stay (LOS) and postoperative pain levels in patients undergoing RATS or VATS for NSCLC. Methods: This retrospective cohort study evaluated patients undergoing Stage I NSCLC surgery from January 1, 2016, to January 1, 2024 at Stony Brook University Hospital. Propensity score matching was performed between the VATS and RATS cohorts by age, sex, race, ethnicity, tumor location and laterality, and preoperative pulmonary function testing. Intraoperative techniques, pain scores (0–10), inpatient opioid and non-opioid analgesic use, and discharge medication prescriptions were compared between cohorts. Hospital LOS was compared between cohorts using Kaplan-Meier curves and a Cox proportional hazards model. Results: Before propensity score matching, the analysis included 160 patients with Stage I NSCLC (VATS cohort: 58 patients; RATS cohort: 102 patients). After propensity score matching, each cohort included 52 patients (mean age of both cohorts: 68.6 years). The median LOS was 4.60 days [interquartile range (IQR), 3.96–7.11 days] for the VATS cohort and 2.98 days (IQR, 2.07–4.20 days) for the RATS cohort (P<0.001). Kaplan-Meier and Cox proportional hazards model of time to hospital discharge indicated greater likelihood of discharge at all time points for the RATS cohort compared to the VATS cohort [hazard ratio (HR) 1.88, 95% confidence interval (CI): 1.27–2.78, P=0.001). All medication counts were normalized by LOS. The median opioid usage, calculated as oral morphine milligram equivalents (OMME), was 22.52 mg/day (IQR, 12.3–34.6 mg/day) for the VATS cohort and 33.90 mg/day (IQR, 19.6–51.4 mg/day) for the RATS cohort (P=0.04). Daily IV hydromorphone usage was higher in the VATS cohort (median 0.47 mg/day; IQR, 0.02– 0.88 mg/day) compared to the RATS cohort (P=0.03); median oral oxycodone usage was higher in the RATS cohort (13.71 mg/day; VATS: 2.09 mg/day, P<0.001). At discharge, RATS patients were more likely to be prescribed oxycodone 5 mg (86.5% vs. 67.3%, P=0.04) and other multimodal non-opioid analgesics. While not statistically significant, a higher proportion of VATS patients reported no pain at follow-up (51.9% vs. 26.9%, P=0.06). Conclusions: RATS was associated with a significantly shorter hospital LOS, but greater inpatient opioid usage compared to VATS. Additionally, patients in the RATS cohort received more oral opioids and multimodal outpatient prescriptions at discharge, suggesting a shift toward oral-based pain management strategies in RATS.