European Journal of Cardio-Thoracic Surgery 54 (2018) 579–584 ORIGINAL ARTICLE

doi:10.1093/ejcts/ezy075 Advance Access publication 13 March 2018

Cite this article as: Marulli G, Comacchio GM, Schiavon M, Rebusso A, Mammana M, Zampieri D et al. Comparing robotic and trans-sternal thymectomy for early-
stage thymoma: a propensity score-matching study. Eur J Cardiothorac Surg 2018;54:579–84.

Comparing robotic and trans-sternal thymectomy for early-stage

thymoma: a propensity score-matching study†
Giuseppe Marullia,*‡, Giovanni Maria Comacchioa,‡, Marco Schiavona, Alessandro Rebussoa,
Marco Mammanaa, Davide Zampieria, Egle Perissinottob and Federico Reaa
a
Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy
b
Biostatistic Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy

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* Corresponding author. Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Via Giustiniani 2, 35100 Padova,
Italy. Tel: +39-049-8218740; fax: +39-049-8212242; e-mail: giuseppe.marulli@unipd.it (G. Marulli).

Received 11 September 2017; received in revised form 8 January 2018; accepted 2 February 2018

Abstract
OBJECTIVES: Minimally invasive techniques seem to be promising alternatives to open approaches in the surgical treatment of early-stage
thymoma, although there are controversies because of lack of data on long-term results. The aim of the study was to evaluate the surgical
and oncological results after robotic thymectomy for early-stage thymoma compared to median sternotomy.
METHODS: Between 1982 and 2017, 164 patients with early-stage thymoma (Masaoka I and II) were operated on by median sternotomy
(108 patients) or the robotic approach (56 patients). Duration of surgery, amount of blood loss, complications, duration of chest drainage,
postoperative hospital stay, oncological results and total costs were retrospectively evaluated. Data were analysed also after propensity
score matching.
RESULTS: Compared to the trans-sternal group, robotic thymectomy had significantly longer average operative times (P < 0.001) but less
intraoperative blood loss (P = 0.01), less perioperative complications (P = 0.03), shorter time to chest drainage removal and hospital dis-
charge (P < 0.001). The median expense for the trans-sternal approach was significantly higher than the cost of the robotic procedure
(P < 0.001), mainly due to longer hospitalization. From an oncological point of view, there were no differences in thymoma recurrence, al-
though follow-up of the trans-sternal group was significantly longer (P < 0.001). Data were confirmed after propensity score matching.
CONCLUSIONS: Robotic thymectomy for early-stage thymoma is a technically safe and feasible procedure with low complication rate
and shorter hospital stay compared to the trans-sternal approach. Cost analysis revealed lower expenses for the robotic procedure due to
the reduced hospital stay. The oncological outcomes seemed comparable, but longer follow-up is needed.
Keywords: Thymoma • Surgery • Early stage • Robot • Trans-sternal thymectomy

INTRODUCTION
Thymomas are rare neoplasms, representing 0.2–1.5% of all
malignancies, but are the most common tumours of the medias-
tinum [1]. Surgery is the cornerstone of treatment, particularly for
early-stage disease, and completeness of resection with adequate
safety margins is the main prognostic factor [2].
Different surgical approaches have been described to perform
thymectomy, but to date, sternotomy still represents the gold
standard. Minimally invasive approaches seem to be promising al-
ternatives to open techniques and, in the last 2 decades, have
been slowly adopted in the surgery of malignant tumours of the
mediastinal district. The main downsides are the supposed
†Presented at the 31st Annual Meeting of the European Association for Cardio-
Thoracic Surgery, Vienna, Austria, 7–10 October 2017.
‡The first two authors contributed equally to this work.
THORACIC
increased risk of local recurrence (due to reduced safety margins
after minimally invasive resection) and the possible rupture of the
capsule with implantation of the tumour during endoscopic ma-
nipulations. Furthermore, the lack of long-term oncological results,
the learning curve required to perform this operation safely and
the relative rarity of these tumours are additional reasons that
slow down the diffusion of the video-assisted thoracic surgery
(VATS) resection [3–5]. The introduction of robotic-assisted tech-
nologies in the late 1990s provided a technical advancement able
to overcome the limitations of conventional thoracoscopy: the
three-dimensional vision system and the articulated instruments of
the daVinci Surgical Robotic System (Intuitive Surgical, Inc.,
Sunnyvale, CA, USA) allow for an ‘open-like’ intervention with a
minimally invasive access. The application of robotic technology
has been tested in a variety of thoracic surgery procedures, with a
prevalent application for mediastinal diseases, where the robotic
system seems to provide the best advantages [6, 7].

C The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V
580 G. Marulli et al. / European Journal of Cardio-Thoracic Surgery
The aim of the study was to evaluate the surgical and onco-
logical results after robotic thymectomy (RATS) for early-stage
thymoma, compared with a population of patients operated on
through a median sternotomy.
MATERIALS AND METHODS
We retrospectively reviewed the medical records of 278 patients
with a thymic tumour who underwent surgical resection in the
Unit of Thoracic Surgery of the University of Padova, from June
1982 to December 2016. Exclusion criteria were thymic neoplas-
tic diseases other than thymoma, advanced stage disease (Stage
III or IV according to Masaoka), incomplete resection (R1 or R2)
and surgical resection other than trans-sternal or robotic tech-
nique. One hundred and sixty-four patients who met the inclu-
sion criteria (Stage I or II thymoma completely surgically resected
using either the trans-sternal or the robotic approach) were
selected for the study. The institutional review board approved
this study.
All patients signed a detailed consent form in which they were
informed about the possible complications of thymoma resection
by the robotic approach and the lack of long-term data.
Information on patient demographics, presence of associated
myasthenia gravis (MG), tumour characteristics, stage, intraopera-
tive and postoperative data (e.g. complications, need for open
conversion or additional ports or accesses, operative time, day of
drain removal and length of hospital stay), total cost of operation
and postoperative stay and administration of adjuvant treatment
were collected.
The Masaoka staging system [8] was used to assess the patho-
logical stage, and the new World Health Organization classifica-
tion was used to define the histology [9].
Preoperative assessments included an evaluation of pulmonary
and cardiac functions together with a total body computed tom-
ography or magnetic resonance imaging. Preferred radiological
characteristics to be eligible for RATS were the following: location
of the tumour in the anterior mediastinum; distinct fat plane be-
tween the tumour and surrounding structures; unilateral tumour
predominance; tumour encapsulation; existence of residual, nor-
mal-appearing thymic tissue and no mass compression effect.
Although the tumour size was not considered a strict selection
criterion for the robotic approach, a tumour diameter <_5 cm was
preferred. Exclusion criteria for robotic surgery were radiological
evidence of invasion of the surrounding structures (e.g. pericar-
dium, lung, nerves or large vessels), the presence of adhesions
(e.g. previous thoracic surgery or pleuritis), the inability to per-
form single-lung ventilation and a body mass index >35 kg/m2.
All patients completed the follow-up (the last follow-up was
May 2017) with a periodic clinical evaluation. Chest and abdom-
inal computed tomographic scans were required every 6 months
during the first 2 years after surgery and then every year.
Robotic surgical technique
The side of surgical access was based on the presence of unilat-
eral tumour predominance. The RATS surgical technique from
either the left or the right side has been described previously
[10, 11]. We emphasize some technical tips and pitfalls.
A monopolar cautery spatula was used routinely for dissection,
focusing on avoiding thermal injury particularly when operating
close to the phrenic nerves. Carbon dioxide insufflation of
6–10 mmHg was applied during the procedure to increase the
size of the mediastinal space. All surgeons involved in the pro-
cedure adopted a ‘no-touch technique’ with an en bloc resection
of the thymus and perithymic fat tissue. During the application of
this technique, the thymoma was never touched, and normal
thymic tissue and perithymic fat were used for grasping and for
traction, so as to avoid direct manipulation of the tumour, capsu-
lar damage and potential seeding. All thymic and perithymic fat
was dissected together with thymoma with safe surgical margins,
in agreement with the International Thymic Malignancy Interest
Group (ITMIG) criteria [12]. In case of myasthenic patients,
particular attention was posed on the removal of all the media-
stinal fat.
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Cost analysis
We analysed both the operation and the hospital stay costs.
According to the data of the Ministry of Economy, the average
daily cost for a hospital in Italy is 674e per patient. Regarding the
cost of the operation, because the fixed cost of the surgical the-
atre, the healthcare personal cost and the anaesthetics cost could
be considered equal in both operations, we considered only the
expense for specific materials used in each operation. Performing
a trans-sternal thymectomy requires the use of stainless steel
wires for the closure of the sternotomy, and these cost around
150e per patient (data from the centre’s finance group).
Conversely, for a RATS, at least the following instruments are
needed (cost in parenthesis): CADIERE forceps (4509e),
monopolar cautery spatula (4501e) and Robotic 100 clips applier
(4723e). However, due to the fact that these instruments can be
used for 10 operations, for a single operation, the overall price
should be divided by 10, resulting in 1373e per patient.
Statistical analysis
Continuous data are expressed as mean and standard deviation,
whereas categorical variables are expressed as counts and per-
centages. The normality of the quantitative variable distribution
was verified by the Shapiro–Wilk test. At first step, the statistical
analyses were performed to compare the characteristics of the
trans-sternal thymectomy (TST) and RATS groups. The Student’s
t-test for unpaired data or Wilcoxon’s summed rank test were
used, as appropriate, to evaluate differences between means.
At second step, the propensity score matching was based on
5 variables [age at surgery, Masaoka stage, World Health
Organization (WHO) histological classification, tumour dimension
and MG] that resulted significantly associated with the surgical
group at logistic regression analysis. The matching process used
the nearest neighbour method. To take into account a possible se-
lection bias due to surgery period, the matched patients were
compared using generalized linear models adjusting for year of
surgery. A P-value <0.05 was considered to indicate statistical sig-
nificance. Statistical analyses and matching were performed using
R packages from the Comprehensive R Archive Network.
RESULTS
Of the 164 patients selected for this study, 108 (66%) patients
underwent TST and 56 (34%) patients RATS. The baseline patient
 G. Marulli et al. / European Journal of Cardio-Thoracic Surgery 581

and tumour characteristics in the 2 groups are presented in Table 1.
Compared with the TST group, the RATS group was characterized
by a younger age, a higher percentage of MG, a lower diameter of
the tumour and a higher proportion of Masaoka Stage II thymoma.
The surgical outcome in the RATS and TST groups are pre-
sented in Table 2. In the RATS group, 6 patients were approached
from the right thoracic cavity and 50 patients from the left side.
No intraoperative or perioperative mortality was recorded for
both groups. Two (3%) patients in the minimally invasive group
needed open conversion, in 1 case because of the dimension of
the specimen and difficult dissection (myasthenic patient with
abundant mediastinal fat) and in the other because of suspicions
of pericardial infiltration. In 1 patient, a cervicotomy was per-
formed to complete the dissection of the thymus in the neck.
Regardless of the surgical approach, all patients had an R0 re-
section, and there were no intraoperative deaths.
In the RATS group, the median operative time (skin-to-skin,
comprehensive of operative time at the console, docking, speci-
men removal and undocking) was 132.5 min [interquartile range
(IQR) 115.0–170.0 min], and in the TST group, it was significantly
shorter (median 115.0 min, IQR 90.0–137.5 min; P < 0.001).
The robotic group had significantly less intraoperative blood
loss [when the cut-off is set at 100 ml (P = 0.02), while the signifi-
cance was lost at a cut-off of 200 ml (P = 0.13)] and earlier chest
drain removal and hospital discharge.
The overall incidence of perioperative complications was
higher in the TST group than in the RATS group (15% vs 4%;
P = 0.03); however, no significant difference was reached for

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Table 1: Demographic and pathological data in the 2 groups (overall and after matching)

Robotic group TST group P-value Robotic group TST group P-value
(n = 56) (n = 108) (n = 41) (n = 41)

Age (years), (mean ± SD) 55.82 ± 12.01 59.44 ± 10.85 0.05 58.24 ± 10.97 57.66 ± 10.30 0.88a
Male, n (%) 25 (45) 49 (45.4) 1.00 18 (49.9) 19 (46.3) 0.98a
Female, n (%) 31 (55) 59 (54.6) 23 (56.1) 22 (53.7)
Myasthenia gravis, n (%) 30 (54) 31 (28.7) 0.002 19 (46.3) 15 (36.6) 0.38a
Masaoka stage, n (%) 0.07 0.09a
I 11 (20) 36 (33.3) 8 (19.5) 9 (22.0)
II 45 (80) 72 (66.7) 33 (80.5) 32 (78.0)
WHO type, n (%) 0.08 0.47a
A 4 (7) 18 (17) 3 (7) 4 (10)
AB 12 (21) 37 (34) 10 (24) 9 (22)
B1 18 (32) 26 (24) 14 (34) 13 (31)
B2 15 (27) 20 (18) 10 (25) 10 (25)
B3 7 (13) 7 (7) 4 (10) 5 (12)
Dimension (cm), mean ± SD 43.25 ± 18.43 76.17 ± 31.82 <0.001 50.36 ± 15.54 54.49 ± 21.53 0.05a

a
Adjusted to year of surgery.
SD: standard deviation; TST: trans-sternal thymectomy; WHO: World Health Organization.

THORACIC
Table 2: Operative and postoperative data (overall and after matching)

Robotic group TST group P-value Robotic group TST group P-value
(n = 56) (n = 108) (n = 41) (n = 41)

Operative time (min), median (IQR) 132.5 (115–170) 115 (90–137) <0.001 125 (115–160) 120 (95–135) 0.45a
Open conversion, n (%) 2 (3) 1 (2)
Intraoperative blood loss (ml), n (%)
>_50 3 (5) 21 (19) 0.01 3 (7) 9 (22) 0.99a
>_100 2 (3) 17 (16) 0.02
>_200 2 (3) 11 (10) 0.13
Postoperative complications, n (%)
Overall 2 (4) 16 (15) 0.03 2 (5) 3 (7) 0.50a
Major 2 (4) 7 (6) 0.72
Drain removal (days), median (IQR) 2 (1–2) 4 (4–5) <0.001 2 (1–2) 4 (3–5) 0.16a
Length of hospital stay (days), median (IQR) 3 (3–4) 6 (5–7) <0.001 3 (3–4) 6 (5–6) 0.04a
Total costs (e), median (IQR) 3395 (3395–4069) 4194 (3520–4868) <0.001 3395 (3395–4069) 4194 (3520–4868) <0.001a
Adjuvant radiotherapy, n (%) 25 (45) 39 (36) 0.30 15 (36) 18 (44) 0.50a
Length of follow-up (months), median (IQR) 30.9 (8.5–67.8) 90.7 (46.8–149.5) <0.001 28.3 (18.2–61.4) 88.3 (61.6–116.4) 0.04a
Recurrence, n (%) 1 (2) 2 (2) 1.0 1 (2) 0 (0) na

a
Adjusted to year of surgery and tumour dimension.
IQR: interquartile range; na: not applicable; TST: trans-sternal thymectomy.
582 G. Marulli et al. / European Journal of Cardio-Thoracic Surgery
major complications (P = 0.72). Seven patients in the TST group
had the following major complications: 3 respiratory failures, 2
myasthenic crisis, 1 sternal dehiscence and 1 cardiac arrest. Two
patients in the RATS group presented with each one of the fol-
lowing complications: myasthenic crisis and haemothorax, which
required surgical treatment.
The median expense for a TST and consequent hospital stay
was e4194 (IQR e3520–e4868), which was significantly higher
than the cost for a RATS (e3395, IQR e3395–e4069, P < 0.001).
Sixty-four patients received postoperative radiotherapy, 25
(45%) in the robotic group and 39 (36%) in the trans-sternal
group, with no significant difference between groups (P = 0.30).
Two (2%) patients in the TST group had a thymoma recur-
rence, whereas in the robotic group, 1 (2%) patient experienced
pleural recurrence 32 months after the initial operation. This dif-
ference was not statistically significant (P = 1.00). However, the
median duration of the follow-up was significantly different be-
tween the 2 groups (P < 0.001), with a median length of
90.7 months (IQR 46.8–149.5 months) in the median sternotomy
group, compared to a median length of 30.9 months (IQR 8.5–
67.8 months) in the other. During follow-up, 27 patients died in
the TST group, all but 1 of non-thymoma-related causes, whereas
there was only 1 death in the RATS group because of leukaemia.
The 5-year survival rate was 98% vs 95% (P = 0.10) for robotic vs
trans-sternal, respectively (Fig. 1).
After propensity score matching, 41 patients from the TST
group were compared with 41 patients from the RATS group.
Patient baseline characteristics and pathological data were similar
in the 2 groups, except for tumour dimension (Table 1). There
were no statistically significant differences between the 2 groups
in terms of operative time, intraoperative blood losses and
postoperative complications (Table 2). RATS, however, still
showed a significantly shorter duration of hospital stay (P = 0.04).
Follow-up duration was confirmed to be longer for the TST
group (median = 88.3 vs 28.3 months, P = 0.04) with no difference
in terms of recurrence rate.
DISCUSSION
Thymectomy is the cornerstone in the treatment of early-stage
thymoma. Different approaches have been described to perform
this operation, either open or minimally invasive approaches. TST
is still considered to be the gold standard due to its technical
Figure 1: Overall survival in the 2 groups. TST: trans-sternal thymectomy.
advantages and the plentiful literature confirming the superiority
of oncological results. As in other surgical fields, minimally inva-
sive techniques for performing thymectomy have gained atten-
tion in recent years for their capability to assure the complete
removal of the tumour, without the disadvantages of the open
techniques. Nevertheless, surgical and oncological issues are still
matter of debate.
In the present study, we compared TST with RATS, both from
the surgical and oncological point of view, using a propensity
score matching to make the 2 populations comparable.
From the surgical point of view, minimally invasive thymec-
tomy, particularly through the VATS approach, has always been
considered a challenging operation requiring a long learning
curve to perform this operation safely. Nevertheless, several
groups have published their experiences, demonstrating good
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surgical results after robotic/thoracoscopic thymoma resection
and, when compared to open approaches, significantly less
blood loss and shorter postoperative stay in the minimally inva-
sive group [4, 13–17].
Only a few authors have compared TST with RATS [15, 18–21].
Cakar et al. [18] published the 1st series comparing RATS with
TST, showing a better clinical outcome with a lower rate of com-
plications and reduced postoperative stay in the robotic group.
Balduyck et al. [19] compared the 2 approaches using quality-of-
life assessment questionnaires showing a better postoperative re-
covery in patients who underwent robotic surgery. Other authors
corroborated the previous findings, describing a reduced blood
loss and hospital stay in robotic compared to trans-sternal series
[15, 20–21]. Nonetheless, in these studies, the population was
heterogeneous (patients with thymoma and/or MG, various
stages of disease), and the analysis focused only on surgical as-
pects. On the contrary, in this study, we restricted the analysis
only on early-stage thymoma, excluding Stage III tumours be-
cause, although technically feasible through the robotic ap-
proach, the resection of adjacent structures should still be
considered experimental. Moreover, in comparison with an open
approach, such as trans-sternal technique, it could represent a
potential bias in terms of both surgical results and oncological
outcome.
Our data confirm all the benefits of a minimally invasive pro-
cedure previously described. First, reduced blood loss with the
robotic approach, and only 3 patients presented an intraopera-
tive blood loss of >50 ml. Regarding the postoperative complica-
tions, the number of patients that experienced at least 1
complication was also lower in the robotic group (4% vs 15%),
with a total of only 2 complications represented by a case of
myasthenic crisis and a case of haemothorax.
Additionally, the day of drain removal occurred earlier with
consequently shorter lengths of hospital stay. With just 3 inci-
sions in the 3rd and 5th intercostal spaces in addition to a lower
complication rate, it was possible to discharge the patients ear-
lier without significant pain. Although a specific quality-of-life
assessment has not been performed, these findings corroborated
the results published by Balduyck et al. [19], showing a better
postoperative recovery in patients who underwent robotic
surgery.
When comparing open and minimally invasive techniques,
one of the main issues is the prolonged operative time of the lat-
ter. The skin-to-skin time of a RATS in the current series had a
median duration of 132.5 min, which is about 20 min longer than
the median time for a TST. There can be different explanations
for this finding: firstly, in our analysis, the docking time was
 G. Marulli et al. / European Journal of Cardio-Thoracic Surgery
included in the total account of the time. As shown by Bodner
et al. [6], there are important differences when evaluating the
time for the setting up of the robot, for the surgeon working at
the console and the skin-to-skin time. Indeed, the long time for
the robot set-up represents a bias when comparing the robotic
approach with the standard sternotomy, making it difficult to
compare the 2 techniques. In addition, this bias can be deter-
mined by the steep learning curve of the robotic technique and,
therefore, it is inversely proportional to the surgeon’s experience.
Indeed, different authors have found a reduction of the opera-
tive time with an increasing number of operations performed
[21, 22].
Nevertheless, several surgeons have been reluctant to use
these surgical approaches for thymoma because of the possible
oncological concerns related to rupture of the capsule with im-
plantation of the tumour during endoscopic manipulations and
the supposed increased risk of local recurrence (due to reduced
safety margins after minimally invasive resection). Furthermore,
the lack of long-term oncological results (the longest mean fol-
low-up is 62 months as reported by Liu et al. [23]) and the relative
rarity of these tumours are additional reasons that slowed down
the spread of thoracoscopic resection for early-stage thymomas
[3–5].
Recently, Friedant et al. [17] performed a systematic review
and meta-analysis of the current literature regarding minimally
invasive (VATS and robotic) versus open thymectomy for thymic
malignancies. Data showed no significant differences in the R0
resection rate and loco-regional recurrence in patients with
Masaoka Stages I and II tumours in the 2 groups.
In the current series, only 2 patients presented a pleural recur-
rence in the trans-sternal group and 1 patient in the robotic
group, 32 months after the initial surgery. The recurrence rate in
the 2 groups showed no statistically significant differences, and
the results were confirmed also after matching; however, this re-
sult might represent a false negative (or type II error), given the
fact there was only 1 event. Moreover, thymomas are low-grade
tumours with an indolent clinical course and late recurrences
(>60 months as reported by Kimura et al. [24]); therefore, a fol-
low-up of at least 10 years is required. Nevertheless, with a me-
dian follow-up time of 30 months and the longest duration of the
follow-up of 180 months, we can state that the RATS also appears
to be safe in the mid-term follow-up from an oncological point
of view.
Another important issue is the dimension of the tumour. The
size of thymoma appropriate for robotic resection is still a matter
of debate. The majority of the literature deals with lesions <5 cm
[5, 14]. Although a large tumour size may not be considered an
absolute contraindication, it may interfere with the thoracoscopic
procedure, causing the manipulation to be more difficult with
increased chance of an open conversion, or it may prolong the
operative time [14]. On the contrary, trans-sternal operation has
no dimensional limitation. Indeed, in the current series, the mean
diameter of thymomas in patients operated through a robotic
approach was 43.25 ± 18.43 mm, which was significantly lower
than the diameter of thymomas of the other group
(76.17 ± 31.82 mm, P < 0.001). Because of this, tumor dimension
might represent an important bias when comparing the two
techniques. However, after matching the patients also for the
tumor dimension, there were no significant differences in the
final result with only blood losses losing significance. On the con-
trary, the reduction in terms of hospital stay and the oncological
outcomes were confirmed.
583
Finally, one of the main criticisms directed at robotic surgery is
the high cost. To date, no author performed a direct cost com-
parison of the 2 techniques. Augustin et al. [25] performed an
evaluation of the procedural costs for a RATS compared with the
standard VATS approach, showing that the robotic approach was
91% more expensive than its counterpart.
The cost for the DaVinci robot is variable between 1 000 000e
and 2 500 000e. In addition to this, the average costs for the an-
nual maintenance are around 100 000e/175 000e. However,
these fee could be divided among the different surgical units
other than the thoracic surgical unit that use the robotic system,
such as urology and gynaecology: this ‘shared’ use of the DaVinci
robot allows for the division of the initial and running costs.
Apart from the initial cost of the DaVinci system, the extra costs
are mainly related to disposables. Performing a RATS requires an
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additional cost of about 1223e, compared to a median sternot-
omy. This amount was calculated by deducting the price of the
stainless steel wires needed for the closure of the sternotomy
(150e) from the price of the surgical robotic instruments (1373e)
that are necessary for the intervention. Because the other costs of
the operation (e.g. for the healthcare personal or for the anaes-
thesia) could be considered equal, we did not take them into
consideration. However, an accurate cost analysis cannot be re-
stricted just to the expense for the operation. In fact, another im-
portant element that should be taken into consideration is the
duration of the hospitalization. According to the data of the
Italian Ministry of Economy, the average daily cost for a hospital
stay in Italy is around 674e. This amount is calculated taking into
consideration the following elements: healthcare personal costs,
board and lodging costs, drugs costs and non-healthcare per-
sonal costs. Because the RATS with the DaVinci system permits a
reduced hospital stay, a significant saving is possible. With a me-
dian hospital stay of 3 days, the hospitalization is 3 days shorter
than the recovery needed after a TST, with a reduced expense of
2022e per patient. Moreover, the indirect costs of the operation
should also be considered. These can be defined as the lack of
productivity due to the disease, which can affect the patient but
also the relatives. The thymectomy performed with the DaVinci
system allows for a faster recovery, with reduced postoperative
pain and disabilities.
THORACIC
Limitations
The present study has some limitations, in particular the low
number of patients, the non-randomized and retrospective fash-
ion. In addition, the follow-up is still inadequate in allowing for a
definitive conclusion regarding the oncological outcome.
Anyway, the propensity score matching enabled us to over-
come some intrinsic bias and make the 2 populations more com-
parable, confirming the encouraging results of the robotic
technique especially from a surgical point of view.
CONCLUSION
In conclusion, although the ‘pure’ operation cost for a RATS is
sensibly higher than that for conventional sternotomy, this ex-
pense is compensated by a reduced postoperative hospital stay
and a faster recovery.
Conflict of interest: none declared.
584 G. Marulli et al. / European Journal of Cardio-Thoracic Surgery
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