Abstract
Thymoma is the most common primary mediastinal tumor in adults, typically excised in a single operation. Less invasive approaches, specifically robotic-assisted thymectomy surgery (RATS) and video-assisted thoracoscopic surgery (VATS), have gained popularity subsequent to conventional open thymectomy via median sternotomy. To determine the best surgery for thymoma, this systematic review and meta-analysis compared RATS, VATS, and total thymectomy in terms of efficacy, safety, and prognosis. Literature databases were systematically reviewed for publications, including PubMed, Scopus, and Google Scholar, till February 2025, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria sectioning the articles based on comparison of RATS to VATS or open thymectomy, as well as quantitative outcomes of reoperation, total survival, recurrence, perioperative complications, length of procedure, and length of stay. The risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Eleven articles met the eligibility criteria, and data were analyzed using random-effects model meta-analysis on RevMan (Cochrane, London, UK). RATS had comparable operation times to VATS (pooled mean difference: 4.49 minutes; 95% CI: -39.87 to 48.84; I² = 98%); it was, however, linked with fewer total complications (mean difference: -3.78; 95% CI: -3.89 to -3.70) and less intraoperative blood loss (mean difference: -25.01 mL; 95% CI: -38.03 to -12.00; I² = 0%). Also, RATS showed a reduction in pleural drainage time compared to VATS (mean difference: -0.66 days; 95% CI: -0.97 to -0.35; I² = 0%). RATS led to shorter hospital stays than open thymectomy (mean difference versus VATS: -0.28 days; 95% CI: -1.36 to 0.80; I² = 91%; versus open: -1.38 days; 95% CI: -2.33 to -0.43; I² = 14%) and fewer postoperative complications than open thymectomy but not differences in oncologic outcomes, including mortality and rates of recurrence. The I² values ranged widely from 0% to 98%, indicating variable heterogeneity across outcomes, which limits interpretability in some comparisons. Most studies included were retrospective cohorts, and the risk of bias was inconsistent, with one study deemed to be at low risk and seven deemed to have some concerns. Overall heterogeneity between outcomes ranged from low to moderate (I² = 0%-98%). Issues with costs and surgeon experience variability, however, continue to be major impediments to routine use of RATS. Given the retrospective nature of most included studies and high heterogeneity in key outcomes, conclusions about RATS's comparative advantage should be interpreted cautiously. While RATS demonstrates similar oncologic outcomes with fewer complications and shorter hospital stays, its routine use remains constrained by cost, surgeon training requirements, and a lack of high-quality prospective data. Future multicenter randomized controlled trials and cost-effectiveness studies are necessary to clarify its long-term role in thymoma surgery.