Longitudinal patient-reported outcomes one year after uniportal versus multiportal thoracoscopic surgery for lung cancer

Longitudinal patient-reported outcomes one year after uniportal versus multiportal thoracoscopic surgery for lung cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Longitudinal patient-reported outcomes one year after uniportal versus multiportal thoracoscopic surgery for lung cancer Caiyang Liu, Ran Ran, Yadi Zhang, Yi Wang, Diego Gonzalez-Rivas, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7146106/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The debate over the superiority of uniportal video-assisted thoracoscopic surgery (VATS) (U-VATS) versus multiportal VATS (M-VATS) remains unresolved. Herein, we compared long-term patient-reported outcomes within one year after discharge. Methods We utilized data from a longitudinal prospective study on patients with lung cancer undergoing M-VATS and U-VATS. The covariates were balanced using propensity score matching (PSM). Longitudinal symptom severity and functional status were assessed monthly until one year post-discharge and compared between the groups. The outcomes were presented as the proportion of patients exhibiting clinically significant severe scores (≥ 7 points on 0–10 scales) in the Perioperative Symptom Assessment for Lung Surgery Scale. Results Among 1,000 patients included, 914 underwent U-VATS and 86 underwent M-VATS. After 1:2 PSM, 258 patients were matched with 172 patients in the U-VATS group and 86 in the M-VATS group. The U-VATS group reported less severe pain (relative risk = 2.87, 95% confidence interval: 1.12–7.37, p = 0.028) during the first year after discharge compared with the M-VATS group. However, no significant differences were observed between the groups regarding distress, shortness of breath, cough, fatigue, drowsiness, disturbed sleep, difficulty in walking, and activity limitation (all p˃0.05). The U-VATS group reported shorter operative time, length of stay, chest tube duration, and postoperative length of stay; less operative blood loss and total drainage; and lower 30- and 90-day complication rates after surgery than the M-VATS group (all p˂0.05). Conclusions Patients undergoing U-VATS may experience less severe pain during the first year after discharge compared with those undergoing M-VATS. Trial registration ChiCTR2000033016, 2020.05.18 Lun cancer Multiportal video-assisted thoracoscopic surgery Patient-reported outcomes Uniportal video-assisted thoracoscopic surgery Figures Figure 1 Figure 2 Figure 3 1. Background The use of video-assisted thoracoscopic surgery (VATS) has significantly advanced the approach to lung cancer surgery, offering less invasive alternatives to traditional thoracotomy. 1 VATS is linked to less postoperative pain, shorter hospitalization periods, and accelerated recovery, making it the preferred approach among most thoracic surgeons. 2 , 3 Among the variations of VATS, the uniportal VATS (U-VATS) and multiportal VATS (M-VATS) techniques have gained significant attention. Previous studies have shown that U-VATS offers somewhat better clinical results compared with M-VATS, such as postoperative hospitalization periods and the duration of chest tube drainage. 4 In addition, U-VATS, which utilizes a single incision, has been suggested to offer additional benefits, specifically in reducing postoperative pain and enhancing cosmetic outcomes, compared with M-VATS. 5 However, M-VATS provides better exposure and maneuverability. The debate over the optimal number of ports persists. Relying solely on traditional clinical outcomes might not provide a complete evaluation of surgical procedures. 6 While metrics like operative time, numbers of harvested lymph node (HLN), complication rates, and hospital length of stay (LOS) are important, they do not fully capture the patient's overall experience. Patient-reported outcomes (PROs), such as quality of life (QOL), are gaining recognition as critical measures for evaluating treatment effectiveness. 6 PROs can highlight differences in patient perceptions between procedures that may seem similar, providing valuable insights into what defines optimal surgical care. In thoracic surgery, the increasing importance of PROs emphasizes their role in symptom management and underscores their value in patient-centered care quality. 7 , 8 Incorporating PROs into clinical decision-making provides surgeons and patients with a more comprehensive understanding of treatment effectiveness. In 2022, we reported the PROs of these two surgical approaches within one month after discharge, addressing symptoms, functional status, and QOL. 9 However, existing research has largely focused on the early days following surgery, with a limited number of measurement time points. 10 – 13 There is a paucity of longitudinal data on long-term PROs following these approaches, particularly over the course of one year. Therefore, this study intended to address this gap by analyzing PROs one year after discharge in patients treated with U-VATS compared with those treated with M-VATS for lung cancer. We hypothesized that U-VATS may provide superior long-term PROs compared with M-VATS, thereby offering a more patient-centered approach to lung cancer surgery and facilitating shared decision-making. 2. Methods 2.1 Study Population Patient information was retrieved from an ongoing prospective cohort study (CN-PRO-Lung 3). The study received approval from the Ethics Committee for Medical Research and New Medical Technology at Sichuan Cancer Hospital, and all participants provided written informed consent. The inclusion criteria consisted of patients who underwent U-VATS or M-VATS within the CN-PRO-Lung 3 study between April 6, 2021, and June 30, 2024; those diagnosed with primary non-small cell lung cancer based on pathology; patients with a TNM stage from 0 to IIIA, as classified by the 8th edition of the TNM classification for lung cancer 14 ; and patients who underwent sub-lobectomy or lobectomy (including bilobectomy). The following criteria were used for exclusion: second surgery for lung cancer, VATS conversion to open surgery, sleeve lobectomy, more than one chest tube, preoperative neoadjuvant therapy, and incomplete data (lack of PRO data at baseline and any two subsequent time points or lack of pulmonary function test data). Figure 1 illustrates the flowchart for patient inclusion. 2.2 Surgical Procedures and Postoperative Care The decision to use U-VATS or M-VATS was based on the surgeon's professional judgment. Among the surgeons involved, all had more than eight years’ experiences of U-VATS and more than 10 years’ experience of M-VATS. In the current study cohort, one performed only U-VATS, another performed only M-VATS, and three used both approaches during the study period. Standard general anesthesia and unilateral lung ventilation were administered to all patients, and no nerve block was performed. In the case of U-VATS, a solitary incision, with a size of 3–4 cm, was performed in the 4th or 5th intercostal space, positioned between the anterior axillary line and the midaxillary line. In contrast, M-VATS required two to four incisions, each ranging from 0.5 to 4 cm. Taking the most common three-port VATS as an example, the observation port, with a size of 0.5-1 cm, was positioned in the 7th intercostal space along the midaxillary line; the working port, with a size of 2–4 cm, was located at the 3rd or 4th intercostal space along the anterior axillary line; and the assistant port, with a size of 0.5-1 cm, was placed in the 8th or 9th intercostal space along the posterior axillary line. In two-port and four-port VATS, the number and location of incisions were often adjusted based on this configuration. The choices of type of resection and type of lymphadenectomy were determined by the surgeons in accordance with the National Comprehensive Cancer Network Guidelines. 15 Upon completion of the procedure, a silicone drainage tube sized 20–30 Fr was generally introduced through the initial incision for U-VATS and through the lowest incision for M-VATS. After surgery, all patients were provided with standardized care. Early liquid diets were provided, with normal diets starting after bowel function was restored and gas was passed, and stool softeners could be used if necessary. Pain management was achieved through oral and/or intravenous analgesics. The urinary catheter usually was taken out within 24 hours following the surgery. Patients were required to begin early ambulation within 24 hours and engage in lung function exercises, such as deep breathing and blowing up a balloon. The drain was removed when the lung was fully expanded; the daily volume of drained fluid was less than 200 mL; there were no complications such as air leaks, chylothorax, or hemothorax. 2.3 Outcomes and Measures The primary outcome was a comparison of the proportion of patients with severe pain between the two groups during the first year after discharge. The secondary outcomes were assessments of the differences in distress, shortness of breath, cough, fatigue, drowsiness, disturbed sleep, difficulty in walking, activity limitation, and traditional clinical outcomes. PROs were conducted using the Chinese edition of the Perioperative Symptom Assessment for Lung Surgery (PSA-Lung), evaluating seven symptoms (pain, distress, shortness of breath, cough, fatigue, drowsiness, and disturbed sleep) and two functional aspects (difficulty in walking, and activity limitation). 16 Symptom severity and functional impairments were reported based on the proportion of patients exhibiting clinically significant severe scores, with severe defined as a score equal to or greater than 7 on a scale of 0-10. 9 , 17 The PSA-Lung scale’s reliability and validity for Chinese patients undergoing lung cancer surgery have been previously established by its development team. 16 , 18 Electronic questionnaires were primarily used to collect data on symptom severity and functional status, administered preoperatively, daily during postoperative hospitalization, daily within one month after discharge, weekly within 2–3 months after discharge, and monthly from 4 to 12 months afterward. For a few patients, data were gathered through paper questionnaires or telephone follow-ups involving a 24-hour recall. Additionally, traditional clinical outcomes were compared, including operative time, total drainage, operative blood loss, chest tube duration, stations of HLN, numbers of HLN, LOS, postoperative LOS, and 30- and 90-day complication rates after surgery. Patient demographic and clinical characteristic data were also acquired, and all information was recorded in the Electronic Data Capture System. 2.4 Statistical Analysis We analyzed the available PRO data recorded at the preoperative baseline, upon discharge, and monthly thereafter for up to one year. To balance the baseline characteristics, we performed propensity score matching (PSM) using a 1:2 caliper matching strategy based on the following variables: age, sex, Charlson Comorbidity Index (CCI), forced expiratory volume (FEV) 1%, body mass index (BMI), and TNM stage. An absolute standardized mean difference of less than 0.1 after matching was considered suggestive of good balance, and the differences in distances between patients were observed to be balanced following adjustment. Descriptive statistics were employed to summarize patients' demographic and clinical characteristics. For continuous variables, t-tests or Mann–Whitney U tests were conducted, while categorical variables were analyzed using either χ² test or Fisher’s exact test. To compare the proportions of patients experiencing severe symptoms and functional impairment between groups, generalized estimating equation models were utilized, treating time as a continuous variable. PSM was conducted using R, version 4.4.1 (R Core Team, Vienna, Austria), and the remaining analyses were carried out with SAS, version 9.4 (SAS Institute, Cary, NC, USA). Line charts were created with GraphPad Prism, version 8.0 (GraphPad Software, La Jolla, CA, USA). Statistical significance was defined as a two-sided p-value of < 0.05. 3. Results 3.1 Participant Characteristics Among the 2,252 patients in the CN-PRO-Lung 3 study, 1,000 were analyzed (Fig. 1 ). Prior to PSM, the cohort consisted of 914 patients treated with U-VATS and 86 with M-VATS. For the unmatched U-VATS and M-VATS groups, the median age was 53 years, with females making up more than 60% of the patients in both groups. No significant differences in age, sex, FEV1%, CCI, BMI, TNM stage, American Society of Anesthesiologists classification, pathological type, or type of resection were found between the groups. After 1:2 PSM, the U-VATS group had 172 patients matched with 86 patients from the M-VATS group. For the matched U-VATS and M-VATS groups, the median ages were 54 and 53 years, respectively, with females making up more than 70% of the patients in both groups. The comparison of baseline clinical data between the two groups still demonstrated no statistical significance, and the balance of covariates between the two groups was improved (Table 1 ). Table 1 Demographic and Clinical Characteristics Variables Unmatched cohort (n = 1000) 1:2 Propensity score matching (Caliper matching: n = 258) U-VATS (n = 914) M-VATS (n = 86) P U-VATS (n = 172) M-VATS (n = 86) P Age, median (range), y 53 (22–83) 53 (26–75) 0.841 54 (23–82) 53 (26–75) 0.963 Sex, No. (%) 0.429 0.999 Male 304 (33.3) 25 (29.1) 50 (29.1) 25 (29.1) Female 610 (66.7) 61 (70.9) 122 (70.9) 61 (70.9) BMI, median (range), kg/m 2 22.4 (15.4–38.8) 21.9 (15.2–31.1) 0.176 22.0 (15.4–30.9) 21.9 (15.2–31.1) 0.953 FEV1%, median (range), % 94.6 (30.0-159.7) 96.4 (30.0-136.7) 0.083 97.5 (30.0-135.9) 96.4 (30.0-136.7) 0.810 Comorbidity (CCI), No. (%) 0.336 0.813 No (0) 789 (86.3) 71 (82.6) 144 (83.7) 71 (82.6) Yes (≥ 1) 125 (13.7) 15 (17.4) 28 (16.3) 15 (17.4) TNM Stage, No. (%) 0.177 0.780 0-IA3 768 (84.0) 77 (89.5) 152 (88.4) 77 (89.5) IB-IIIA 146 (16.0) 9 (10.5) 20 (11.6) 9 (10.5) ASA classification, No. (%) 0.877 0.999 1 857 (93.8) 81 (94.2) 162 (94.2) 81 (94.2) > 1 57 (6.2) 5 (5.8) 10 (5.8) 5 (5.8) Pathological type, No. (%) 0.572 0.723 Adenocarcinoma 874 (95.6) 84 (97.7) 166 (96.5) 84 (97.7) Non-adenocarcinoma 40 (4.4) 2 (2.3) 6 (3.5) 2 (2.3) Type of resection, No. (%) 0.135 0.179 Sub-lobectomy 519 (56.8) 56 (65.1) 97 (56.4) 56 (65.1) Lobectomy 395 (43.2) 30 (34.9) 75 (43.6) 30 (34.9) Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CCI, Charlson Comorbidity Index; FEV1%, percentage of predicted forced expiratory volume in 1 second; M-VATS, multiportal video-assisted thoracoscopic surgery; U-VATS, uniportal video-assisted thoracoscopic surgery. 3.2 PROs At baseline, 100% of the questionnaires were completed, 80% on the discharge day, and 48.8–58.7% during the 12 months after discharge (Supplemental Table 1). At baseline, the proportions of severe symptoms and functional status showed no differences between the groups (Supplemental Table 2). Patients undergoing U-VATS experienced less severe pain both before (relative risk [RR] = 2.34, 95% confidence interval [CI]: 1.09–5.02, p = 0.028) (Fig. 2 ) and after PSM (RR = 2.87, 95% CI: 1.12–7.37, p = 0.028) (Fig. 3 ) during one year after discharge compared with patients undergoing M-VATS. However, statistical analysis revealed no significant differences in distress, shortness of breath, cough, fatigue, drowsiness, disturbed sleep, difficulty in walking, and activity limitation between the two groups (Table 2 ). Table 2 Proportion of Severe Symptom and Functioning Score Between U-VATS and M-VATS a Variables Unmatched cohort (n = 1000) 1:2 Propensity score matching (Caliper matching: n = 258) RR 95% CI P RR 95% CI P Pain 2.34 1.09–5.02 0.028 2.87 1.12–7.37 0.028 Cough 0.88 0.38-2.00 0.754 0.87 0.36–2.11 0.762 Shortness of breath 1.01 0.46–2.25 0.972 1.17 0.45–3.01 0.749 Disturbed sleep 0.88 0.46–1.70 0.709 0.67 0.31–1.44 0.305 Fatigue 1.23 0.51–2.92 0.645 0.61 0.22–1.68 0.336 Drowsiness 1.55 0.41–5.85 0.519 1.41 0.40–4.94 0.592 Distress 1.51 0.75–3.02 0.249 1.84 0.75–4.52 0.184 Activity limitation 1.39 0.58–3.36 0.460 1.67 0.57–4.85 0.349 Difficulty in walking 1.12 0.43–2.94 0.816 1.53 0.47–4.95 0.475 Abbreviations: M-VATS, multiportal video-assisted thoracoscopic surgery; U-VATS, uniportal video-assisted thoracoscopic surgery. a Severe score was defined as a score of ≥ 7 points for all items on 0–10 scales. 3.3 Traditional Clinical Outcomes The traditional clinical outcomes of the two groups showed no differences before and after PSM. In the matched cohort, patients undergoing U-VATS had less operative blood loss (p < 0.001) and total drainage (p < 0.001); shorter chest tube duration (p < 0.001), LOS (p < 0.001), postoperative LOS (p < 0.001), and operative time (p = 0.001); and lower 30-day (p = 0.001) and 90-day complication rates (p = 0.001) after surgery than patients undergoing M-VATS. No significant differences in the stations and numbers of HLN were observed between the two groups (Table 3 ) Table 3 Traditional Clinical Outcomes Between U-VATS and M-VATS Variables Unmatched cohort (n = 1000) 1:2 Propensity score matching (Caliper matching: n = 258) U-VATS (n = 914) M-VATS (n = 86) P U-VATS (n = 172) M-VATS (n = 86) P Operative time, median (range), min 75 (11–250) 95 (45–235) 0.001 73 (20–220) 95 (45–235) 0.001 Operative blood loss, median (range), mL 50 (5-500) 50 (20–200) < 0.001 50 (5-500) 50 (20–200) < 0.001 Total drainage, median (range), mL 340 (0-5060) 570 (80-2060) < 0.001 320 (20-2380) 570 (80-2060) < 0.001 Chest tube duration, median (range), days 2 (0–27) 3 (1–14) < 0.001 2 (0–11) 3 (1–14) < 0.001 Stations of harvested lymph nodes, median (range) 4 (0–9) 4 (0–7) 0.417 4 (0–8) 4 (0–7) 0.985 Numbers of harvested lymph nodes, median (range) 6 (0–32) 5 (0–22) 0.538 6 (0–26) 5 (0–22) 0.233 LOS, median (range), days 7 (3–38) 8 (3–18) < 0.001 7 (3–17) 8 (3–18) < 0.001 Postoperative LOS, median (range), days 4 (2–35) 5 (2–14) < 0.001 4 (2–11) 5 (2–14) < 0.001 30-day complication rate after surgery, n (%) 139 (15.2) 23 (26.7) 0.006 18 (10.5) 23 (26.7) 0.001 90-day complication rate after surgery, n (%) 146 (16.0) 24 (27.9) 0.005 19 (11.0) 24 (27.9) 0.001 Abbreviations: LOS, length of stay; M-VATS, multiportal video-assisted thoracoscopic surgery; U-VATS, uniportal video-assisted thoracoscopic surgery. 4. Discussion Minimally invasive thoracoscopic technology has undergone a period of rapid development and is now approaching maturity. 19 While U-VATS is gaining popularity globally, its advantages over M-VATS have not been definitively proven. This study focused on longitudinal PROs over a one-year period for lung cancer patients undergoing U-VATS and M-VATS. Our findings indicated that patients undergoing U-VATS experienced less severe pain with generally better clinical outcomes compared with those undergoing M-VATS. A central finding of our study was the significantly lower proportion of severe pain among U-VATS group patients than among M-VATS group patients throughout the one-year follow-up. This aligns with the growing body of literature suggesting that U-VATS is associated with reduced postoperative pain. 10 , 11 , 20 This reduction is attributed to a combination of factors. U-VATS minimizes muscular dissection, intercostal nerve injury, and parietal pleural injury compared with M-VATS. 10 , 11 , 20 Moreover, U-VATS is associated with a lower inflammatory response than M-VATS, which is believed to correlate with reduced postoperative pain. 21 While previous studies have demonstrated the advantage of U-VATS in reducing acute postoperative pain, to our knowledge, this study established this advantage is sustained over time. However, among the 13 time points, the present study only observed pain benefits at seven time points, which may result from the limited sample size or missing data. In our previous study, 9 patients who underwent U-VATS experienced significantly lower levels of pain, disturbed sleep, constipation, coughing, fatigue, and shortness of breath during the early postoperative period than those who underwent M-VATS. Additionally, patients who underwent U-VATS experienced less severe walking difficulties and a greater capacity to enjoy life compared with those who underwent M-VATS. However, apart from pain, the present study did not demonstrate significant differences in other symptoms or functional status one year post-discharge between the two groups. This suggests that the symptom and functional benefits associated with U-VATS may gradually diminish over time. Greater pain during the early postoperative period may lead to increased fatigue, shortness of breath, constipation, disturbed sleep, and walking impairment, suggesting a potential causal relationship or underlying connection among these symptoms. However, as pain becomes chronic, this relationship or connection may weaken. Another explanation could be the fact that the internal surgical manipulation required for lung resection is largely similar between the two approaches. 22 Thus, the overall impact on the lung parenchyma and subsequent symptoms might be comparable over a relatively long time. Moreover, the recovery of lung function is a significant contributor for the recovery of functional status, 23 , 24 and the alleviation of symptoms is likely more dependent on factors such as the extent of lung tissue resected, the existence of prior lung disease, and postoperative rehabilitation efforts, rather than the number of incisions made during surgery. 25 In addition to PROs, our study also examined traditional clinical outcomes. Consistent with the literature, 4 , 26 – 28 patients undergoing U-VATS had a significantly reduced blood loss, total drainage, chest tube duration, LOS, and overall rate of complications compared with those undergoing M-VATS. The stations and numbers of HLN were comparable between the two groups. These results indicated that U-VATS can be conducted with similarly favorable or even improved perioperative outcomes, while still maintaining safety and oncologic integrity. Interestingly, the U-VATS group had a significantly shorter operative time than the M-VATS group, which seems counterintuitive. Theoretically, a smaller incision makes surgery more challenging. In M-VATS, the camera and instruments can be strategically positioned across different ports to facilitate dissection and stapling, even at difficult angles. In contrast, U-VATS, with its single small incision and limited intercostal space, often leads to significant interference among the thoracoscope and instruments, which is considered a major disadvantage. As a result, U-VATS may result in longer operation times. 29 However, for surgeons with extensive experience and refined skills in U-VATS, interference between the thoracoscope and instruments is minimal, and may not even affect the procedure. In addition, U-VATS offers direct visualization similar to open thoracotomy, which improves hand-eye coordination and accelerates the procedure. This study had several advantages compared with previous research. Unlike most previous studies, it focused on long-term PROs following U-VATS versus M-VATS. Furthermore, unlike previous studies that have primarily concentrated on pain, this study focused on the seven most significant postoperative symptoms and two functions. Additionally, we used the proportion of patients with severe scores for between-group comparisons, which was more clinically relevant than the most common mean score. Moreover, our study had a large number of time points for collecting PRO data, which ensured that important PRO information was not overlooked. However, several limitations were present in this study. The study was conducted at a single center with a limited sample size, which limits the generalizability of the findings. The PSA-Lung scale has a smaller number of symptom items compared with other QOL scales and may not fully capture all aspects of postoperative QOL. Moreover, as a retrospective analysis, potential biases may still exist despite adjusting baseline information with the PSM method. Therefore, to substantiate these findings, future large-scale randomized prospective studies will be necessary. Conclusions In conclusion, patients undergoing U-VATS may experience reduced severe pain over the first year after discharge and improved traditional clinical outcomes compared with those undergoing M-VATS. These findings may influence surgical decision-making and encourage the adoption of U-VATS as a better method for lung cancer treatment. Abbreviations VATS video-assisted thoracoscopic surgery U- VATS uniportal video-assisted thoracoscopic surgery M- VATS multiportal video-assisted thoracoscopic surgery LOS length of stay HLN harvested lymph nodes PROs patient-reported outcomes QOL quality of life PSA-Lung Perioperative Symptom Assessment for Lung Surgery PSM propensity score matching CCI Charlson Comorbidity Index FEV forced expiratory volume BMI body mass index Declarations Ethics approval and consent to participate We confirm that this study was performed in compliance with relevant laws and institutional guidelines; received approval from the Ethics Committee for Medical Research and New Medical Technology of Sichuan Cancer Hospital on November 2, 2018 (SCCHEC-02-2018-043); and written informed consent was obtained from all participants prior to their involvement in the research. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This work was supported by Sichuan Science and Technology Program (2023YFH0075), the National Key R&D Plan for Intergovernmental Cooperation, the Ministry of Science and Technology of China (2022YFE0133100), and Sichuan Province Key Clinical Specialty Construction Project (no grant number). Authors' contributions C Y L : Writing – review & editing, Writing – original draft, Investigation, Formal analysis. R R : Writing – review & editing, Writing – original draft, Investigation, Formal analysis. Y D Z: Writing – review & editing, Writing – original draft, Investigation, Formal analysis. Y W: Writing – review & editing, Investigation. D G R: Writing – review & editing, Formal analysis. X W: Writing – review & editing, Investigation, Data curation. Q L S: Writing – review & editing, Conceptualization, Funding acquisition. Q L: Writing – review & editing, Conceptualization, Project administration. M J G: Writing – review & editing, Conceptualization, Data curation, Supervision. W D: Writing – review & editing, Conceptualization, Data curation, Supervision, Funding acquisition. All authors read and approved the final manuscript. Acknowledgements We thank Zhen Dai for her contribution to data analysis. We would like to acknowledge Editage (www.editage.com) support in manuscript preparation. References Wang Z, Pang L, Tang J, et al. Video-assisted thoracoscopic surgery versus muscle-sparing thoracotomy for non-small cell lung cancer: a systematic review and meta-analysis. BMC Surg. 2019;19:144. Swanson SJ, Herndon JE, D'Amico TA, et al. Video-assisted thoracic surgery lobectomy: Report of CALGB 39802—a prospective, multi-institution feasibility study. J Clin Oncol. 2007;25:4993–7. Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg. 2010;139:976–81. Xiang Z, Wu B, Zhang X, et al. Uniportal versus multiportal video-assisted thoracoscopic segmentectomy for non-small cell lung cancer: a systematic review and meta-analysis. Surg Today. 2023;53:293–305. Linlin W, Lihui G, Shiyuan SYR. Clinical applications of minimally invasive uniportal video-assisted thoracic surgery. J Cancer Res Clin Oncol. 2023;149:10235–9. Khullar OV, Fernandez FG. Patient-reported outcomes in thoracic surgery. Thorac Surg Clin. 2017;27:279–90. Dai W, Wang Y, Liao J, et al. Electronic patient-reported outcome-based symptom management versus usual care after lung cancer surgery: long-term results of a multicenter, randomized, controlled trial. J Clin Oncol. 2024;42:2126–31. Dai W, Feng W, Zhang Y, et al. Patient-reported outcome-based symptom management versus usual care after lung cancer surgery: a multicenter randomized controlled trial. J Clin Oncol. 2022;40:988–96. Dai W, Dai Z, Wei X, et al. Early patient-reported outcomes after uniportal vs multiportal thoracoscopic lobectomy. Ann Thorac Surg. 2022;114:1229–37. Dai F, Meng S, Mei L, et al. Single-port video-assisted thoracic surgery in the treatment of non-small cell lung cancer: a propensity-matched comparative analysis. J Thorac Dis. 2016;8:2872–8. Hirai K, Takeuchi S, Usuda J. Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: a retrospective comparative study of perioperative clinical outcomes. Eur J Cardiothorac Surg. 2016;49(Suppl 1):i37–41. Xu GW, Xie MR, Wu HR, et al. A prospective study examining the impact of uniportal video-assisted thoracic surgery on the short-term quality of life in patients with lung cancer. Thorac Cancer. 2020;11:612–8. Hao Z, Cai Y, Fu S, et al. [Comparison study of post-operative pain and short-term quality of life between uniportal and three portal video-assisted thoracic surgery for radical lung cancer resection]. Zhongguo Fei Ai Za Zhi. 2016;19:122–8. Goldstraw P, Chansky K, Crowley J, et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016;11:39–51. National Comprehensive Cancer Network. [NCCN Clinical Practice Guidelines in Non-small Cell Lung Cancer]. [Version: 11.2024]. October 15, 2024. https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450 Yu H, Lei C, Wei X, et al. Electronic symptom monitoring after lung cancer surgery: establishing a core set of patient-reported outcomes for surgical oncology care in a longitudinal cohort study. Int J Surg. 2024;42:2126–31. Swarm RA, Paice JA, Anghelescu DL, et al. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(8):977–1007. Su X, Huang Y, Gong R, et al. Undergoing lung surgery (PSA-Lung) was appropriate for symptom assessment after discharge. Qual Life Res. 2024;33:1807–18. Khan JA, Albalkhi I, Garatli S, et al. Recent advancements in minimally invasive surgery for early-stage non-small cell lung cancer: A narrative review. J Clin Med. 2024;13:3354. Ji C, Xiang Y, Pagliarulo V, et al. A multi-center retrospective study of single-port versus multi-port video-assisted thoracoscopic lobectomy and anatomic segmentectomy. J Thorac Dis. 2017;9:3711–8. Wan Q, Xue QS, Yu BW. Mechanisms and perioperative management of chronic postoperative pain. Chin J Pain Med. 2018;24:6. Dai W, Chang S, Pompili C, et al. Early postoperative patient-reported outcomes after thoracoscopic segmentectomy versus lobectomy for small-sized peripheral non-small-cell lung cancer. Ann Surg Oncol. 2022;29:547–56. Hockele LF, Sachet Affonso JV, Rossi D, et al. Pulmonary and functional rehabilitation improves functional capacity, pulmonary function and respiratory muscle strength in post COVID-19 patients: Pilot clinical trial. Int J Environ Res Public Health. 2022;19:14899. Sun HY. Effect of lung rehabilitation on lung function, exercise ability and quality of life in patients undergoing thoracoscopic radical resection of lung cancer. J Bengbu Med Coll. 2023;48:1286–90. Fuzhi Y, Dongfang T, Wentao F, et al. Rapid recovery of postoperative pulmonary function in patients with lung cancer and influencing factors. Front Oncol. 2022;12:927108. Yang Z, Shen Z, Zhou Q, et al. Single-incision versus multiport video-assisted thoracoscopic surgery in the treatment of lung cancer: a systematic review and meta-analysis. Acta Chir Belg. 2018;118:85–93. Yang X, Li M, Yang X, et al. Uniport versus multiport video-assisted thoracoscopic surgery in the perioperative treatment of patients with T1-3N0M0 non-small cell lung cancer: a systematic review and meta-analysis. J Thorac Dis. 2018;10:2186–95. Harris CG, James RS, Tian DH, et al. Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer. Ann Cardiothorac Surg. 2016;5:76–84. Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg. 2013;95:426–32. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx SupplementaryTable2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7146106","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489967186,"identity":"4f09f65d-d060-4eca-818b-67d04c2f992a","order_by":0,"name":"Caiyang Liu","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Caiyang","middleName":"","lastName":"Liu","suffix":""},{"id":489967187,"identity":"81f9da97-ae8a-4b72-8eff-d7f06521910e","order_by":1,"name":"Ran Ran","email":"","orcid":"","institution":"Sichuan Cancer Hospital \u0026 Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Ran","middleName":"","lastName":"Ran","suffix":""},{"id":489967188,"identity":"dad89a1b-947d-42e1-a62e-12034b7cdd5c","order_by":2,"name":"Yadi Zhang","email":"","orcid":"","institution":"Sichuan Cancer Hospital \u0026 Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Yadi","middleName":"","lastName":"Zhang","suffix":""},{"id":489967189,"identity":"1dd0197a-2307-4192-8376-74a94a1df260","order_by":3,"name":"Yi Wang","email":"","orcid":"","institution":"The First People's Hospital of Neijiang","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Wang","suffix":""},{"id":489967190,"identity":"ee77fe9b-60e0-4abd-a82f-83bc26422a3d","order_by":4,"name":"Diego Gonzalez-Rivas","email":"","orcid":"","institution":"Coruña University Hospital and Minimally Invasive Thoracic Surgery Unit (UCTMI)","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Gonzalez-Rivas","suffix":""},{"id":489967191,"identity":"140d26ef-9dc7-4e7c-8777-75eaf2c706fc","order_by":5,"name":"Xing Wei","email":"","orcid":"","institution":"Sichuan Cancer Hospital \u0026 Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Xing","middleName":"","lastName":"Wei","suffix":""},{"id":489967192,"identity":"f81d5dd8-a0f6-4b92-a6e8-ee6fccae4aec","order_by":6,"name":"Qiuling Shi","email":"","orcid":"","institution":"Sichuan Cancer Hospital \u0026 Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Qiuling","middleName":"","lastName":"Shi","suffix":""},{"id":489967193,"identity":"d949cb2f-f318-4f7c-94df-28e6850ee693","order_by":7,"name":"Qiang Li","email":"","orcid":"","institution":"Sichuan Cancer Hospital \u0026 Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Li","suffix":""},{"id":489967194,"identity":"1ad5fccc-5207-48fd-bbbb-5ad446725f4d","order_by":8,"name":"Mingjian Ge","email":"","orcid":"","institution":"The First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mingjian","middleName":"","lastName":"Ge","suffix":""},{"id":489967195,"identity":"f047a24f-c760-4a72-9b16-c8ebb47003a0","order_by":9,"name":"Wei Dai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIie3PMWsCMRjG8fcQdInX9YIUv0LkoB3aJl8lIXBdRApdHG96Xezux7ix3Q4OdEl768lBQZwLBy4KFhq7p3iblPwh2X48CYDPd4nlQQrA7qELpB1JWpHfu7DnXBKuCoyap1KEvfdldHjlw9tesWxg+slTB6FGIV2wWiGZJPTF6NHbPNELMM/aRViusCaslt2I3ER9zIOsIjEEKLXrYazcYH1kH+JE6DfmIquudn+Tyq7YrQAtGdgVZVc6J8JdhFab2WHOtP3LOL67Rq0zk8QgjZQuEpaPW7Y/cjGcmdH6C/lDtiq20EylcBFHdkKlLQ1A2xWfz+f7v/0AViJYhWhDD7AAAAAASUVORK5CYII=","orcid":"","institution":"Sichuan Cancer Hospital \u0026 Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China","correspondingAuthor":true,"prefix":"","firstName":"Wei","middleName":"","lastName":"Dai","suffix":""}],"badges":[],"createdAt":"2025-07-17 07:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7146106/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7146106/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87733187,"identity":"fcb18116-bab3-47b1-96d4-8ff74518fa79","added_by":"auto","created_at":"2025-07-28 11:55:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":698964,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of patient selection. (PRO, patient-reported outcome; U-VATS, uniportal video-assisted thoracoscopic surgery; M-VATS, multiportal video-assisted thoracoscopic surgery; NSCLC, non-small cell lung cancer)\u003c/p\u003e","description":"","filename":"OnlineFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7146106/v1/2b96690f4c328638f1d6cf1d.png"},{"id":87732023,"identity":"eeed70ac-33bc-4dab-90f6-788c7c555739","added_by":"auto","created_at":"2025-07-28 11:47:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":268950,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients with severe pain during the first year post-discharge before propensity score matching.\u003c/p\u003e","description":"","filename":"OnlineFig2.png","url":"https://assets-eu.researchsquare.com/files/rs-7146106/v1/f4fb5f79f85d9b64f4bb1961.png"},{"id":87732030,"identity":"8edd56b7-839f-406c-bdd8-3e04ff77962c","added_by":"auto","created_at":"2025-07-28 11:47:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":258974,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients with severe pain during the first year post-discharge after propensity score matching.\u003c/p\u003e","description":"","filename":"OnlineFig3.png","url":"https://assets-eu.researchsquare.com/files/rs-7146106/v1/c1bbf4cde56524090ce78c8f.png"},{"id":88255036,"identity":"c27882d1-de1f-494e-9c8e-0126f61fe28d","added_by":"auto","created_at":"2025-08-04 14:17:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2434169,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7146106/v1/b1eeac1a-d4c5-44d1-b441-03435f8a49b2.pdf"},{"id":87732027,"identity":"6eb38daf-7368-476d-816d-953235fdd966","added_by":"auto","created_at":"2025-07-28 11:47:40","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14370,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7146106/v1/d63032a8b045480a130d3911.docx"},{"id":87733189,"identity":"b07eb247-8062-4677-b812-3570b3dea4d3","added_by":"auto","created_at":"2025-07-28 11:55:40","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15305,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7146106/v1/8da914046755988d6ac628c4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Longitudinal patient-reported outcomes one year after uniportal versus multiportal thoracoscopic surgery for lung cancer","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe use of video-assisted thoracoscopic surgery (VATS) has significantly advanced the approach to lung cancer surgery, offering less invasive alternatives to traditional thoracotomy.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e VATS is linked to less postoperative pain, shorter hospitalization periods, and accelerated recovery, making it the preferred approach among most thoracic surgeons.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Among the variations of VATS, the uniportal VATS (U-VATS) and multiportal VATS (M-VATS) techniques have gained significant attention. Previous studies have shown that U-VATS offers somewhat better clinical results compared with M-VATS, such as postoperative hospitalization periods and the duration of chest tube drainage.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In addition, U-VATS, which utilizes a single incision, has been suggested to offer additional benefits, specifically in reducing postoperative pain and enhancing cosmetic outcomes, compared with M-VATS.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, M-VATS provides better exposure and maneuverability. The debate over the optimal number of ports persists.\u003c/p\u003e\u003cp\u003eRelying solely on traditional clinical outcomes might not provide a complete evaluation of surgical procedures.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e While metrics like operative time, numbers of harvested lymph node (HLN), complication rates, and hospital length of stay (LOS) are important, they do not fully capture the patient's overall experience. Patient-reported outcomes (PROs), such as quality of life (QOL), are gaining recognition as critical measures for evaluating treatment effectiveness.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e PROs can highlight differences in patient perceptions between procedures that may seem similar, providing valuable insights into what defines optimal surgical care. In thoracic surgery, the increasing importance of PROs emphasizes their role in symptom management and underscores their value in patient-centered care quality.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Incorporating PROs into clinical decision-making provides surgeons and patients with a more comprehensive understanding of treatment effectiveness.\u003c/p\u003e\u003cp\u003eIn 2022, we reported the PROs of these two surgical approaches within one month after discharge, addressing symptoms, functional status, and QOL.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, existing research has largely focused on the early days following surgery, with a limited number of measurement time points.\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e There is a paucity of longitudinal data on long-term PROs following these approaches, particularly over the course of one year. Therefore, this study intended to address this gap by analyzing PROs one year after discharge in patients treated with U-VATS compared with those treated with M-VATS for lung cancer. We hypothesized that U-VATS may provide superior long-term PROs compared with M-VATS, thereby offering a more patient-centered approach to lung cancer surgery and facilitating shared decision-making.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Population\u003c/h2\u003e\u003cp\u003ePatient information was retrieved from an ongoing prospective cohort study (CN-PRO-Lung 3). The study received approval from the Ethics Committee for Medical Research and New Medical Technology at Sichuan Cancer Hospital, and all participants provided written informed consent. The inclusion criteria consisted of patients who underwent U-VATS or M-VATS within the CN-PRO-Lung 3 study between April 6, 2021, and June 30, 2024; those diagnosed with primary non-small cell lung cancer based on pathology; patients with a TNM stage from 0 to IIIA, as classified by the 8th edition of the TNM classification for lung cancer\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e; and patients who underwent sub-lobectomy or lobectomy (including bilobectomy). The following criteria were used for exclusion: second surgery for lung cancer, VATS conversion to open surgery, sleeve lobectomy, more than one chest tube, preoperative neoadjuvant therapy, and incomplete data (lack of PRO data at baseline and any two subsequent time points or lack of pulmonary function test data). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the flowchart for patient inclusion.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Surgical Procedures and Postoperative Care\u003c/h2\u003e\u003cp\u003eThe decision to use U-VATS or M-VATS was based on the surgeon's professional judgment. Among the surgeons involved, all had more than eight years\u0026rsquo; experiences of U-VATS and more than 10 years\u0026rsquo; experience of M-VATS. In the current study cohort, one performed only U-VATS, another performed only M-VATS, and three used both approaches during the study period. Standard general anesthesia and unilateral lung ventilation were administered to all patients, and no nerve block was performed.\u003c/p\u003e\u003cp\u003eIn the case of U-VATS, a solitary incision, with a size of 3\u0026ndash;4 cm, was performed in the 4th or 5th intercostal space, positioned between the anterior axillary line and the midaxillary line. In contrast, M-VATS required two to four incisions, each ranging from 0.5 to 4 cm. Taking the most common three-port VATS as an example, the observation port, with a size of 0.5-1 cm, was positioned in the 7th intercostal space along the midaxillary line; the working port, with a size of 2\u0026ndash;4 cm, was located at the 3rd or 4th intercostal space along the anterior axillary line; and the assistant port, with a size of 0.5-1 cm, was placed in the 8th or 9th intercostal space along the posterior axillary line. In two-port and four-port VATS, the number and location of incisions were often adjusted based on this configuration. The choices of type of resection and type of lymphadenectomy were determined by the surgeons in accordance with the National Comprehensive Cancer Network Guidelines.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Upon completion of the procedure, a silicone drainage tube sized 20\u0026ndash;30 Fr was generally introduced through the initial incision for U-VATS and through the lowest incision for M-VATS.\u003c/p\u003e\u003cp\u003eAfter surgery, all patients were provided with standardized care. Early liquid diets were provided, with normal diets starting after bowel function was restored and gas was passed, and stool softeners could be used if necessary. Pain management was achieved through oral and/or intravenous analgesics. The urinary catheter usually was taken out within 24 hours following the surgery. Patients were required to begin early ambulation within 24 hours and engage in lung function exercises, such as deep breathing and blowing up a balloon. The drain was removed when the lung was fully expanded; the daily volume of drained fluid was less than 200 mL; there were no complications such as air leaks, chylothorax, or hemothorax.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Outcomes and Measures\u003c/h2\u003e\u003cp\u003eThe primary outcome was a comparison of the proportion of patients with severe pain between the two groups during the first year after discharge. The secondary outcomes were assessments of the differences in distress, shortness of breath, cough, fatigue, drowsiness, disturbed sleep, difficulty in walking, activity limitation, and traditional clinical outcomes.\u003c/p\u003e\u003cp\u003ePROs were conducted using the Chinese edition of the Perioperative Symptom Assessment for Lung Surgery (PSA-Lung), evaluating seven symptoms (pain, distress, shortness of breath, cough, fatigue, drowsiness, and disturbed sleep) and two functional aspects (difficulty in walking, and activity limitation).\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Symptom severity and functional impairments were reported based on the proportion of patients exhibiting clinically significant severe scores, with severe defined as a score equal to or greater than 7 on a scale of 0-10.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The PSA-Lung scale\u0026rsquo;s reliability and validity for Chinese patients undergoing lung cancer surgery have been previously established by its development team.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eElectronic questionnaires were primarily used to collect data on symptom severity and functional status, administered preoperatively, daily during postoperative hospitalization, daily within one month after discharge, weekly within 2\u0026ndash;3 months after discharge, and monthly from 4 to 12 months afterward. For a few patients, data were gathered through paper questionnaires or telephone follow-ups involving a 24-hour recall. Additionally, traditional clinical outcomes were compared, including operative time, total drainage, operative blood loss, chest tube duration, stations of HLN, numbers of HLN, LOS, postoperative LOS, and 30- and 90-day complication rates after surgery. Patient demographic and clinical characteristic data were also acquired, and all information was recorded in the Electronic Data Capture System.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eWe analyzed the available PRO data recorded at the preoperative baseline, upon discharge, and monthly thereafter for up to one year. To balance the baseline characteristics, we performed propensity score matching (PSM) using a 1:2 caliper matching strategy based on the following variables: age, sex, Charlson Comorbidity Index (CCI), forced expiratory volume (FEV) 1%, body mass index (BMI), and TNM stage. An absolute standardized mean difference of less than 0.1 after matching was considered suggestive of good balance, and the differences in distances between patients were observed to be balanced following adjustment.\u003c/p\u003e\u003cp\u003eDescriptive statistics were employed to summarize patients' demographic and clinical characteristics. For continuous variables, t-tests or Mann\u0026ndash;Whitney U tests were conducted, while categorical variables were analyzed using either χ\u0026sup2; test or Fisher\u0026rsquo;s exact test. To compare the proportions of patients experiencing severe symptoms and functional impairment between groups, generalized estimating equation models were utilized, treating time as a continuous variable.\u003c/p\u003e\u003cp\u003ePSM was conducted using R, version 4.4.1 (R Core Team, Vienna, Austria), and the remaining analyses were carried out with SAS, version 9.4 (SAS Institute, Cary, NC, USA). Line charts were created with GraphPad Prism, version 8.0 (GraphPad Software, La Jolla, CA, USA). Statistical significance was defined as a two-sided p-value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e\u003cp\u003eAmong the 2,252 patients in the CN-PRO-Lung 3 study, 1,000 were analyzed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Prior to PSM, the cohort consisted of 914 patients treated with U-VATS and 86 with M-VATS. For the unmatched U-VATS and M-VATS groups, the median age was 53 years, with females making up more than 60% of the patients in both groups. No significant differences in age, sex, FEV1%, CCI, BMI, TNM stage, American Society of Anesthesiologists classification, pathological type, or type of resection were found between the groups. After 1:2 PSM, the U-VATS group had 172 patients matched with 86 patients from the M-VATS group. For the matched U-VATS and M-VATS groups, the median ages were 54 and 53 years, respectively, with females making up more than 70% of the patients in both groups. The comparison of baseline clinical data between the two groups still demonstrated no statistical significance, and the balance of covariates between the two groups was improved (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eDemographic and Clinical Characteristics\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnmatched cohort\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1000)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e1:2 Propensity score matching\u003c/p\u003e\u003cp\u003e(Caliper matching: n\u0026thinsp;=\u0026thinsp;258)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eU-VATS (n\u0026thinsp;=\u0026thinsp;914)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM-VATS (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eU-VATS (n\u0026thinsp;=\u0026thinsp;172)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eM-VATS (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, median (range), y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (22\u0026ndash;83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (26\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.841\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54 (23\u0026ndash;82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53 (26\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.963\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.429\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e304 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e610 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61 (70.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e122 (70.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e61 (70.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI, median (range), kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.4 (15.4\u0026ndash;38.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.9 (15.2\u0026ndash;31.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.0 (15.4\u0026ndash;30.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.9 (15.2\u0026ndash;31.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.953\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1%, median (range), %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94.6 (30.0-159.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.4 (30.0-136.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e97.5 (30.0-135.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e96.4 (30.0-136.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.810\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidity (CCI), No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.336\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.813\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e789 (86.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (82.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e144 (83.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e71 (82.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes (\u0026ge;\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e125 (13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 (16.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTNM Stage, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.780\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0-IA3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e768 (84.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77 (89.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e152 (88.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e77 (89.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIB-IIIA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e146 (16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20 (11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9 (10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA classification, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e857 (93.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81 (94.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e162 (94.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e81 (94.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathological type, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.572\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.723\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdenocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e874 (95.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (97.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e166 (96.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e84 (97.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-adenocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of resection, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.179\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSub-lobectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e519 (56.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 (65.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e97 (56.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e56 (65.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLobectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e395 (43.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (34.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75 (43.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30 (34.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CCI, Charlson Comorbidity Index; FEV1%, percentage of predicted forced expiratory volume in 1 second; M-VATS, multiportal video-assisted thoracoscopic surgery; U-VATS, uniportal video-assisted thoracoscopic surgery.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 PROs\u003c/h2\u003e\u003cp\u003eAt baseline, 100% of the questionnaires were completed, 80% on the discharge day, and 48.8\u0026ndash;58.7% during the 12 months after discharge (Supplemental Table\u0026nbsp;1). At baseline, the proportions of severe symptoms and functional status showed no differences between the groups (Supplemental Table\u0026nbsp;2). Patients undergoing U-VATS experienced less severe pain both before (relative risk [RR]\u0026thinsp;=\u0026thinsp;2.34, 95% confidence interval [CI]: 1.09\u0026ndash;5.02, p\u0026thinsp;=\u0026thinsp;0.028) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and after PSM (RR\u0026thinsp;=\u0026thinsp;2.87, 95% CI: 1.12\u0026ndash;7.37, p\u0026thinsp;=\u0026thinsp;0.028) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) during one year after discharge compared with patients undergoing M-VATS. However, statistical analysis revealed no significant differences in distress, shortness of breath, cough, fatigue, drowsiness, disturbed sleep, difficulty in walking, and activity limitation between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProportion of Severe Symptom and Functioning Score Between U-VATS and M-VATS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnmatched cohort\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1000)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e1:2 Propensity score matching\u003c/p\u003e\u003cp\u003e(Caliper matching: n\u0026thinsp;=\u0026thinsp;258)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.09\u0026ndash;5.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.12\u0026ndash;7.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.38-2.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.754\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.36\u0026ndash;2.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.762\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShortness of breath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.46\u0026ndash;2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.972\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.45\u0026ndash;3.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.749\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisturbed sleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.46\u0026ndash;1.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.31\u0026ndash;1.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.305\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFatigue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.51\u0026ndash;2.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.645\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.22\u0026ndash;1.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.336\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrowsiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.41\u0026ndash;5.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.519\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.40\u0026ndash;4.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.592\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.75\u0026ndash;3.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.75\u0026ndash;4.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.184\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eActivity limitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.58\u0026ndash;3.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.460\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.57\u0026ndash;4.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.349\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDifficulty in walking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.43\u0026ndash;2.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.816\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.47\u0026ndash;4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.475\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eAbbreviations: M-VATS, multiportal video-assisted thoracoscopic surgery; U-VATS, uniportal video-assisted thoracoscopic surgery.\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eSevere score was defined as a score of \u0026ge;\u0026thinsp;7 points for all items on 0\u0026ndash;10 scales.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Traditional Clinical Outcomes\u003c/h2\u003e\u003cp\u003eThe traditional clinical outcomes of the two groups showed no differences before and after PSM. In the matched cohort, patients undergoing U-VATS had less operative blood loss (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and total drainage (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); shorter chest tube duration (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), LOS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), postoperative LOS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and operative time (p\u0026thinsp;=\u0026thinsp;0.001); and lower 30-day (p\u0026thinsp;=\u0026thinsp;0.001) and 90-day complication rates (p\u0026thinsp;=\u0026thinsp;0.001) after surgery than patients undergoing M-VATS. No significant differences in the stations and numbers of HLN were observed between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTraditional Clinical Outcomes Between U-VATS and M-VATS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnmatched cohort\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1000)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003e1:2 Propensity score matching\u003c/p\u003e\u003cp\u003e(Caliper matching: n\u0026thinsp;=\u0026thinsp;258)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eU-VATS (n\u0026thinsp;=\u0026thinsp;914)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM-VATS (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eU-VATS (n\u0026thinsp;=\u0026thinsp;172)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eM-VATS (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time, median (range), min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (11\u0026ndash;250)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95 (45\u0026ndash;235)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73 (20\u0026ndash;220)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95 (45\u0026ndash;235)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative blood loss, median (range), mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (5-500)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (20\u0026ndash;200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (5-500)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50 (20\u0026ndash;200)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal drainage, median (range), mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e340 (0-5060)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e570 (80-2060)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e320 (20-2380)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e570 (80-2060)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest tube duration, median (range), days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (1\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (0\u0026ndash;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 (1\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStations of harvested lymph nodes, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (0\u0026ndash;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (0\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.417\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (0\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 (0\u0026ndash;7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.985\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumbers of harvested lymph nodes, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (0\u0026ndash;32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (0\u0026ndash;22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.538\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (0\u0026ndash;26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5 (0\u0026ndash;22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.233\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLOS, median (range), days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (3\u0026ndash;38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (3\u0026ndash;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (3\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8 (3\u0026ndash;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative LOS, median (range), days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (2\u0026ndash;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (2\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (2\u0026ndash;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5 (2\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30-day complication rate after surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e139 (15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e90-day complication rate after surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e146 (16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (27.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 (11.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e24 (27.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eAbbreviations: LOS, length of stay; M-VATS, multiportal video-assisted thoracoscopic surgery; U-VATS, uniportal video-assisted thoracoscopic surgery.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eMinimally invasive thoracoscopic technology has undergone a period of rapid development and is now approaching maturity.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e While U-VATS is gaining popularity globally, its advantages over M-VATS have not been definitively proven. This study focused on longitudinal PROs over a one-year period for lung cancer patients undergoing U-VATS and M-VATS. Our findings indicated that patients undergoing U-VATS experienced less severe pain with generally better clinical outcomes compared with those undergoing M-VATS.\u003c/p\u003e\u003cp\u003eA central finding of our study was the significantly lower proportion of severe pain among U-VATS group patients than among M-VATS group patients throughout the one-year follow-up. This aligns with the growing body of literature suggesting that U-VATS is associated with reduced postoperative pain.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e This reduction is attributed to a combination of factors. U-VATS minimizes muscular dissection, intercostal nerve injury, and parietal pleural injury compared with M-VATS.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Moreover, U-VATS is associated with a lower inflammatory response than M-VATS, which is believed to correlate with reduced postoperative pain.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e While previous studies have demonstrated the advantage of U-VATS in reducing acute postoperative pain, to our knowledge, this study established this advantage is sustained over time. However, among the 13 time points, the present study only observed pain benefits at seven time points, which may result from the limited sample size or missing data. In our previous study,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e patients who underwent U-VATS experienced significantly lower levels of pain, disturbed sleep, constipation, coughing, fatigue, and shortness of breath during the early postoperative period than those who underwent M-VATS. Additionally, patients who underwent U-VATS experienced less severe walking difficulties and a greater capacity to enjoy life compared with those who underwent M-VATS. However, apart from pain, the present study did not demonstrate significant differences in other symptoms or functional status one year post-discharge between the two groups. This suggests that the symptom and functional benefits associated with U-VATS may gradually diminish over time. Greater pain during the early postoperative period may lead to increased fatigue, shortness of breath, constipation, disturbed sleep, and walking impairment, suggesting a potential causal relationship or underlying connection among these symptoms. However, as pain becomes chronic, this relationship or connection may weaken. Another explanation could be the fact that the internal surgical manipulation required for lung resection is largely similar between the two approaches.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Thus, the overall impact on the lung parenchyma and subsequent symptoms might be comparable over a relatively long time. Moreover, the recovery of lung function is a significant contributor for the recovery of functional status,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and the alleviation of symptoms is likely more dependent on factors such as the extent of lung tissue resected, the existence of prior lung disease, and postoperative rehabilitation efforts, rather than the number of incisions made during surgery.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn addition to PROs, our study also examined traditional clinical outcomes. Consistent with the literature,\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e patients undergoing U-VATS had a significantly reduced blood loss, total drainage, chest tube duration, LOS, and overall rate of complications compared with those undergoing M-VATS. The stations and numbers of HLN were comparable between the two groups. These results indicated that U-VATS can be conducted with similarly favorable or even improved perioperative outcomes, while still maintaining safety and oncologic integrity. Interestingly, the U-VATS group had a significantly shorter operative time than the M-VATS group, which seems counterintuitive. Theoretically, a smaller incision makes surgery more challenging. In M-VATS, the camera and instruments can be strategically positioned across different ports to facilitate dissection and stapling, even at difficult angles. In contrast, U-VATS, with its single small incision and limited intercostal space, often leads to significant interference among the thoracoscope and instruments, which is considered a major disadvantage. As a result, U-VATS may result in longer operation times.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e However, for surgeons with extensive experience and refined skills in U-VATS, interference between the thoracoscope and instruments is minimal, and may not even affect the procedure. In addition, U-VATS offers direct visualization similar to open thoracotomy, which improves hand-eye coordination and accelerates the procedure.\u003c/p\u003e\u003cp\u003eThis study had several advantages compared with previous research. Unlike most previous studies, it focused on long-term PROs following U-VATS versus M-VATS. Furthermore, unlike previous studies that have primarily concentrated on pain, this study focused on the seven most significant postoperative symptoms and two functions. Additionally, we used the proportion of patients with severe scores for between-group comparisons, which was more clinically relevant than the most common mean score. Moreover, our study had a large number of time points for collecting PRO data, which ensured that important PRO information was not overlooked. However, several limitations were present in this study. The study was conducted at a single center with a limited sample size, which limits the generalizability of the findings. The PSA-Lung scale has a smaller number of symptom items compared with other QOL scales and may not fully capture all aspects of postoperative QOL. Moreover, as a retrospective analysis, potential biases may still exist despite adjusting baseline information with the PSM method. Therefore, to substantiate these findings, future large-scale randomized prospective studies will be necessary.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, patients undergoing U-VATS may experience reduced severe pain over the first year after discharge and improved traditional clinical outcomes compared with those undergoing M-VATS. These findings may influence surgical decision-making and encourage the adoption of U-VATS as a better method for lung cancer treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVATS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003evideo-assisted thoracoscopic surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eU- VATS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003euniportal video-assisted thoracoscopic surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eM- VATS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emultiportal video-assisted thoracoscopic surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLOS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003elength of stay\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHLN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eharvested lymph nodes\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePROs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epatient-reported outcomes\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003equality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSA-Lung\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePerioperative Symptom Assessment for Lung Surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epropensity score matching\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCharlson Comorbidity Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFEV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eforced expiratory volume\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebody mass index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm that this study was performed in compliance with relevant laws and institutional guidelines; received approval from the Ethics Committee for Medical Research and New Medical Technology of Sichuan Cancer Hospital on November 2, 2018 (SCCHEC-02-2018-043); and written informed consent was obtained from all participants prior to their involvement in the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Sichuan Science and Technology Program (2023YFH0075), the National Key R\u0026amp;D Plan for Intergovernmental Cooperation, the Ministry of Science and Technology of China (2022YFE0133100), and Sichuan Province Key Clinical Specialty Construction Project (no grant number).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC Y L\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Writing \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Investigation, Formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR R\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Writing \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Investigation, Formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eY D Z:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Writing \u0026ndash; original draft, Investigation, Formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eY W:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Investigation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD G R:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Formal analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eX W:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Investigation, Data curation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQ L S:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Conceptualization, Funding acquisition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQ L:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Conceptualization, Project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM J G:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Conceptualization, Data curation, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eW D:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; review \u0026amp; editing, Conceptualization, Data curation, Supervision, Funding acquisition.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Zhen Dai for her contribution to data analysis. We would like to acknowledge Editage (www.editage.com) support in manuscript preparation.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang Z, Pang L, Tang J, et al. Video-assisted thoracoscopic surgery versus muscle-sparing thoracotomy for non-small cell lung cancer: a systematic review and meta-analysis. BMC Surg. 2019;19:144.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwanson SJ, Herndon JE, D'Amico TA, et al. Video-assisted thoracic surgery lobectomy: Report of CALGB 39802\u0026mdash;a prospective, multi-institution feasibility study. J Clin Oncol. 2007;25:4993\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScott WJ, Allen MS, Darling G, et al. Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial. J Thorac Cardiovasc Surg. 2010;139:976\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXiang Z, Wu B, Zhang X, et al. Uniportal versus multiportal video-assisted thoracoscopic segmentectomy for non-small cell lung cancer: a systematic review and meta-analysis. Surg Today. 2023;53:293\u0026ndash;305.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLinlin W, Lihui G, Shiyuan SYR. Clinical applications of minimally invasive uniportal video-assisted thoracic surgery. J Cancer Res Clin Oncol. 2023;149:10235\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhullar OV, Fernandez FG. Patient-reported outcomes in thoracic surgery. Thorac Surg Clin. 2017;27:279\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai W, Wang Y, Liao J, et al. Electronic patient-reported outcome-based symptom management versus usual care after lung cancer surgery: long-term results of a multicenter, randomized, controlled trial. J Clin Oncol. 2024;42:2126\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai W, Feng W, Zhang Y, et al. Patient-reported outcome-based symptom management versus usual care after lung cancer surgery: a multicenter randomized controlled trial. J Clin Oncol. 2022;40:988\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai W, Dai Z, Wei X, et al. Early patient-reported outcomes after uniportal vs multiportal thoracoscopic lobectomy. Ann Thorac Surg. 2022;114:1229\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai F, Meng S, Mei L, et al. Single-port video-assisted thoracic surgery in the treatment of non-small cell lung cancer: a propensity-matched comparative analysis. J Thorac Dis. 2016;8:2872\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHirai K, Takeuchi S, Usuda J. Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: a retrospective comparative study of perioperative clinical outcomes. Eur J Cardiothorac Surg. 2016;49(Suppl 1):i37\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu GW, Xie MR, Wu HR, et al. A prospective study examining the impact of uniportal video-assisted thoracic surgery on the short-term quality of life in patients with lung cancer. Thorac Cancer. 2020;11:612\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHao Z, Cai Y, Fu S, et al. [Comparison study of post-operative pain and short-term quality of life between uniportal and three portal video-assisted thoracic surgery for radical lung cancer resection]. Zhongguo Fei Ai Za Zhi. 2016;19:122\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoldstraw P, Chansky K, Crowley J, et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016;11:39\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Comprehensive Cancer Network. [NCCN Clinical Practice Guidelines in Non-small Cell Lung Cancer]. [Version: 11.2024]. October 15, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nccn.org/guidelines/guidelines-detail?category=1\u0026amp;id=1450\u003c/span\u003e\u003cspan address=\"https://www.nccn.org/guidelines/guidelines-detail?category=1\u0026amp;id=1450\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu H, Lei C, Wei X, et al. Electronic symptom monitoring after lung cancer surgery: establishing a core set of patient-reported outcomes for surgical oncology care in a longitudinal cohort study. Int J Surg. 2024;42:2126\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwarm RA, Paice JA, Anghelescu DL, et al. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019;17(8):977\u0026ndash;1007.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSu X, Huang Y, Gong R, et al. Undergoing lung surgery (PSA-Lung) was appropriate for symptom assessment after discharge. Qual Life Res. 2024;33:1807\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan JA, Albalkhi I, Garatli S, et al. Recent advancements in minimally invasive surgery for early-stage non-small cell lung cancer: A narrative review. J Clin Med. 2024;13:3354.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJi C, Xiang Y, Pagliarulo V, et al. A multi-center retrospective study of single-port versus multi-port video-assisted thoracoscopic lobectomy and anatomic segmentectomy. J Thorac Dis. 2017;9:3711\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWan Q, Xue QS, Yu BW. Mechanisms and perioperative management of chronic postoperative pain. Chin J Pain Med. 2018;24:6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai W, Chang S, Pompili C, et al. Early postoperative patient-reported outcomes after thoracoscopic segmentectomy versus lobectomy for small-sized peripheral non-small-cell lung cancer. Ann Surg Oncol. 2022;29:547\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHockele LF, Sachet Affonso JV, Rossi D, et al. Pulmonary and functional rehabilitation improves functional capacity, pulmonary function and respiratory muscle strength in post COVID-19 patients: Pilot clinical trial. Int J Environ Res Public Health. 2022;19:14899.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSun HY. Effect of lung rehabilitation on lung function, exercise ability and quality of life in patients undergoing thoracoscopic radical resection of lung cancer. J Bengbu Med Coll. 2023;48:1286\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFuzhi Y, Dongfang T, Wentao F, et al. Rapid recovery of postoperative pulmonary function in patients with lung cancer and influencing factors. Front Oncol. 2022;12:927108.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang Z, Shen Z, Zhou Q, et al. Single-incision versus multiport video-assisted thoracoscopic surgery in the treatment of lung cancer: a systematic review and meta-analysis. Acta Chir Belg. 2018;118:85\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang X, Li M, Yang X, et al. Uniport versus multiport video-assisted thoracoscopic surgery in the perioperative treatment of patients with T1-3N0M0 non-small cell lung cancer: a systematic review and meta-analysis. J Thorac Dis. 2018;10:2186\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarris CG, James RS, Tian DH, et al. Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer. Ann Cardiothorac Surg. 2016;5:76\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg. 2013;95:426\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lun cancer, Multiportal video-assisted thoracoscopic surgery, Patient-reported outcomes, Uniportal video-assisted thoracoscopic surgery","lastPublishedDoi":"10.21203/rs.3.rs-7146106/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7146106/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe debate over the superiority of uniportal video-assisted thoracoscopic surgery (VATS) (U-VATS) versus multiportal VATS (M-VATS) remains unresolved. Herein, we compared long-term patient-reported outcomes within one year after discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe utilized data from a longitudinal prospective study on patients with lung cancer undergoing M-VATS and U-VATS. The covariates were balanced using propensity score matching (PSM). Longitudinal symptom severity and functional status were assessed monthly until one year post-discharge and compared between the groups. The outcomes were presented as the proportion of patients exhibiting clinically significant severe scores (≥ 7 points on 0–10 scales) in the Perioperative Symptom Assessment for Lung Surgery Scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 1,000 patients included, 914 underwent U-VATS and 86 underwent M-VATS. After 1:2 PSM, 258 patients were matched with 172 patients in the U-VATS group and 86 in the M-VATS group. The U-VATS group reported less severe pain (relative risk = 2.87, 95% confidence interval: 1.12–7.37, p = 0.028) during the first year after discharge compared with the M-VATS group. However, no significant differences were observed between the groups regarding distress, shortness of breath, cough, fatigue, drowsiness, disturbed sleep, difficulty in walking, and activity limitation (all p˃0.05). The U-VATS group reported shorter operative time, length of stay, chest tube duration, and postoperative length of stay; less operative blood loss and total drainage; and lower 30- and 90-day complication rates after surgery than the M-VATS group (all p˂0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients undergoing U-VATS may experience less severe pain during the first year after discharge compared with those undergoing M-VATS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration \u003c/strong\u003eChiCTR2000033016, 2020.05.18\u003c/p\u003e","manuscriptTitle":"Longitudinal patient-reported outcomes one year after uniportal versus multiportal thoracoscopic surgery for lung cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 11:47:35","doi":"10.21203/rs.3.rs-7146106/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e466457-827d-408a-9a61-98d8f9b88554","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T14:09:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 11:47:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7146106","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7146106","identity":"rs-7146106","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}