Experts debate benefits and costs of robotic lung transplantation

The expanding use of robotic technology in lung transplantation came under scrutiny at today's 46th Annual Meeting and Scientific Sessions of the International Society for Heart and Lung Transplantation (ISHLT), where experts debated whether its clinical benefits justify the cost and complexity.

The debate featured Stephanie Chang, MD, a Thoracic and Transplant Surgeon at NYU Langone Health, arguing in favor of robotics, and Hermann Reichenspurner, MD, PhD, a retired Surgeon and pioneer in minimally invasive cardiothoracic surgery, presenting the counterpoint.

Robotic-assisted thoracic surgery may expand patient pool

Dr. Chang highlighted the potential of robotic-assisted surgery to improve recovery and expand access to transplantation.
"Robotic, minimally invasive approaches can reduce the physiologic stress of transplantation compared with traditional, large access incisions," she said.

Dr. Chang noted that in lung transplantation, robotic techniques offer:

• smaller incisions and improved visualization
• less bleeding and fewer hemodynamic shifts
• potential reductions in kidney injury, pain, and hospital stays.

"As robotic techniques become faster and more widely adopted, more frail and older patients may become candidates for transplant," she said.

In contrast, Dr. Reichenspurner emphasized that current evidence does not demonstrate superior patient outcomes with robotic approaches compared to established minimally invasive techniques.

"There is not a single comparative study showing a significant advantage of robotic systems in terms of survival, morbidity, or length of stay," he said. "Outcomes are comparable, but not better."

Dr. Reichenspurner, who has performed approximately 450 heart transplants and is a past president of ISHLT, was an early adopter of robotic and minimally invasive cardiac surgery in the late 1990s. He stressed that his position reflects experience, not resistance to innovation.

"This is not about being conservative," he said. "It is about determining whether the added cost and complexity are justified by measurable benefit."

Do expenses justify use?

He pointed to several limitations of robotic systems, including:

• high upfront and maintenance costs
• limited patient access to centers offering robotic capabilities
• lack of randomized controlled trials to support international guideline adoption.

Dr. Reichenspurner also raised concerns that robotics may sometimes function more as a competitive marketing tool than a clinically necessary advancement. At the same time, Dr. Reichenspurner acknowledged specific advantages of robotic systems, including for surgical training.

"Surgical robots are more accurately described as tele-manipulators, surgeon-controlled systems that enhance precision but do not operate independently," he said. "With these systems, both the trainee and the instructor can operate simultaneously, which is a clear benefit for education."

The discussion also highlighted important distinctions in how robotics is applied across medical specialties. While robotic systems are widely used in thoracic procedures and fields such as urology and gynecology, their role in heart transplantation remains extremely limited.

"To date, robotic heart transplantation is essentially nonexistent," Dr. Reichenspurner noted. "For cardiac transplantation, a large incision is still required anyway, which limits the use of robotics."

The need for controlled, randomized trials

While both speakers agreed that the use of robotics in lung transplantation is likely to grow, particularly in centers that already use the technology for other thoracic procedures, widespread adoption will likely depend on stronger clinical evidence.

"For the use of robotics to become part of formal guidelines, we need randomized trials comparing its outcomes to minimally invasive surgery," said Dr. Reichenspurner.

The annual meeting and scientific sessions of the ISHLT are being held from 22–25 April at the Metro Toronto Convention Centre in Toronto, ON, Canada.