World Largest Single Surgeon’s Experience of Robotic Resection of Pulmonary and Bronchial Carcinoid Tumors

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Snyder, Nikolaos Pachos, Robert J. Cerfolio This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9075983/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Apr, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Carcinoid tumors of the lung/bronchus are relatively rare. Methods: This is a consecutive (non-selected) series from a validated prospective database of patients from one surgeon. Results: From July, 1996 to March 2026 one thoracic surgeon (RJC) performed 19,425 operations and 243 patients (1.3%) had a carcinoid tumor. Starting February 2009, we started robotic surgery and have performed 3,100 robotic operations as of March 2026, of which 134 (4.3%) patients had a carcinoid tumor resected robotically. Eighty-one patients (60%) underwent lobectomy, 17 (13%) had a sleeve resection of the airway and 9 (7%) had bi-lobectomy. The median operative time was 118 minutes and the median actual blood loss of 20 mL (10 – 50). There were no major intraoperative complications, and no patients required blood transfusion or conversion to open thoracotomy. Median length of stay was one day and 83% of patients went home on post-operative day one. All patients had an R0 resection. The median lymph node yield was 27. There was one 30- and 90-day mortality (0.7%). Five-year overall survival was 95%, with median follow-up of 80 months. Patient and family satisfaction was 98%. Conclusion: This is the largest single surgeon’s experience performing robotic resection for pulmonary carcinoid tumors. It shows that a robotic platform offers outstanding short and long-term outcomes, even for complex operations such as sleeve resection and bi-lobectomy. Patients and their families also enjoy an outstanding experience with high satisfaction that requires only one night stay in the hospital. carcinoid tumor pulmonary carcinoid robotic surgery minimally invasive surgery Figures Figure 1 Introduction Bronchopulmonary carcinoid tumors account for only 1% of thoracic malignancies, with only less than two cases per 100,000 people annually [ 1 ]. Pulmonary carcinoids usually occur at age 30–60, but they also represent the predominant primary pulmonary malignancy in pediatric and young adult populations. Pulmonary carcinoids are neuroendocrine tumors arising from Kulchitsky cells and comprise 25–30% of all carcinoid tumors [ 1 ]. Pulmonary carcinoids span a broad spectrum of pathologic subtypes and clinical behavior. Typical carcinoids are the most common pulmonary carcinoid; they are typically well differentiated, follow a relatively slow clinical course, and are associated with excellent long-term outcomes after complete resection [ 2 ]. Atypical carcinoids are intermediate grade, aggressive tumors accounting for 10–27% of pulmonary carcinoids [ 3 , 4 ]. Most lymph node metastases and more advanced disease occur in individuals with atypical carcinoid tumors. Patients often present with hemoptysis or pneumonia if they have bronchial tumors obstructing significant parts of the lung. Many of these patients are diagnosed with asthma during childhood as they often experience dyspnea and wheezing. Patients with lung nodules can be asymptomatic, and present only for the incidental finding from imaging performed for other reasons. A small subset of these patients presents with carcinoid syndrome, characterized by bronchospasm, flushing, diarrhea, and right-heart failure due to physiological changes mediated by serotonin release from carcinoid tumors. Diagnosis relies on CT scan and bronchoscopy, as well as endobronchial ultrasound for lymph node staging in some patients. Surgery is the mainstay of treatment. Minimally invasive approaches, especially robotic lung resection, offer a highly effective and muscle-sparing option with low morbidity and mortality. In this study we report outcomes from 134 consecutive patients who underwent robotic resection for bronchial or pulmonary carcinoid tumors performed by a single surgeon. To our knowledge, this represents the largest reported experience of robotic resection for pulmonary carcinoid tumors performed by an individual surgeon. Methods Data Source We reviewed a prospectively maintained database of consecutive patients treated surgically by a sole surgeon (R.J.C.) at two academic institutions. The primary outcomes included completeness of resection (R0), number of lymph node stations sampled, total lymph node yield, hospital course, postoperative complications, readmission, mortality, and patient satisfaction. Secondary outcomes were operative time, ICU admission, and length of stay. Patient satisfaction was measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Institutional Review Board (IRB) approval was obtained from the University of Alabama at Birmingham (No. 030403013) and New York University Langone Health (i26-00209). Surgical Technique All resections were performed using a completely portal robotic approach with four robotic arms, as previously described [ 5 ] and in some patients later in our series using the SP robot [ 6 ]. For the Xi or DaVinci 5 robotic platform (Intuitive Surgical, Sunnyvale, CA, USA), access to the pleural cavity was achieved through an 8-mm trocar positioned anteriorly along the mid-axillary line at the level of the eighth rib as previously described [ 7 ] and the SP was placed subcostal [ 6 ]. The types of resections performed included pulmonary wedge resection, segmentectomy, lobectomy, bi-lobectomy, sleeve resection, bronchoplasty and other pulmonary resections. Statistical Analysis A nalyses were conducted using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). Baseline demographics, clinical characteristics, and perioperative outcomes were summarized using descriptive measures. Overall survival was evaluated with Kaplan–Meier survival analysis, with time calculated from the date of surgery until death or last known vital status. Results From July 1996 to March 2026, a total of 19,425 thoracic procedures were performed by a sole surgeon (RJC). During this period, 243 patients underwent resection for carcinoid tumors of the lung and/or bronchus. Our robotic program began in February 2009, after which robotic pulmonary resection was offered to all eligible patients. From February 2009 through March 2026, 134 consecutive, unselected patients underwent robotic resection for carcinoid tumors. Within this group, 83 patients were female, median age was 61 years (range 7–83), and median body mass index was 27 kg/m² (range 17–57). Additional baseline characteristics are described in Table 1 . Table 1 Patient characteristics (n = 134). Age – median (range) 61 (7–83) Female sex – n (%) 83 (62) White race – n (%) 111 (83) BMI – median (range) 27 (17–57) Smoking status at time of surgery – n (%) Never smoker 66 (54) Current smoker 10 (8) Former smoker 50 (37) Pack-year history – median (range) 12.5 (0.5–110) Months since smoking cessation – median (range) 72 (1–600) Preoperative FEV1 – median (range) 87 (31–146) Preoperative DLCO – median (range) 85 (33–131) HTN – n (%) 40 (33) DM – n (%) 14 (11) CAD – n (%) 11 (9) COPD – n (%) 8 (7) Pulmonary hypertension – n (%) 3 (3) Preoperative anticoagulation – n (%) 0 (0) Site of primary cancer – n (%) Bronchus 28 (20.9) Lung 106 (79.1) Tumor size (cm) – median (range) 2 (0.8–10.1) Preoperative Stage (Eighth Edition) – n (%) IA1 27 (20.1) IA2 48 (35.8) IA3 9 (6.7) IB 25 (18.6) IIA 6 (2.9) IIB 10 (7.5) IIIA 9 (6.7) IIIB 1 (0.7) IVA 2 (1.5) Most patients presented with early-stage disease and preserved pulmonary function. The majority of tumors were parenchymal (106 patients, 79.1%), with a median tumor diameter of 2 cm (range 0.8–10.1) on preoperative imaging. The overall burden of major cardiopulmonary comorbidity was low. All procedures were completed robotically, without conversions to thoracotomy. The median operative duration was 118 minutes (range 62–239). No intraoperative complications or blood transfusions occurred. Postoperative complications were infrequent, and none were classified as Clavien–Dindo grade IIIb or higher. Reoperation was required in two patients (1.5%), including one segmentectomy and one wedge resection. The median hospital length of stay was one day (range 1–7 days), and 83% of patients were discharged on postoperative day one. Pathology demonstrated typical carcinoid in 82% of patients. Margin-negative (R0) resection was achieved in all of our patients. Frozen sections in the operating room demonstrated negative margins in all patients. Margins on final pathology were indeterminate in four patients; however, none of these patients have recurred to date (median follow-up 28 months). Thirty- and 90-day readmission and mortality rates were each 0.7%. Perioperative, postoperative, and oncologic outcomes are described in Table 2 . Table 2 Perioperative, Postoperative, and Oncologic Outcomes (n = 134) Procedure – n (%) Lobectomy 81 (60.4) Segmentectomy 19 (14.2) Wedge resection 4 (3) Bi-lobectomy 9 (6.7) Sleeve resection 17 (12.7) Other 4 (3) Approach – n (%) Robotic 134 (100) Conversion to thoracotomy 0 (0) Operative time, min (range) 118 (62–239) Lymph node yield, n (range) 27 (12–55) Actual blood loss, cc (range) 20 (10–50) Blood transfusion required – n (%) 0 (0) Intraoperative complications – n (%) 0 (0) Postoperative complications – n (%) Pneumothorax requiring chest tube 2 (1.5) Pleural effusion requiring chest tube 3 (2.2) Flash pulmonary edema 1 (0.7) Chylothorax 2 (1.5) Empyema 0 (0) Bronchial stricture 1 (0.7) Atrial fibrillation 2 (1.5) Pericarditis 1 (0.7) Surgical site infection 1 (0.7) ICU admission 2 (1.5) Tumor type – n (%) Typical carcinoid 110 (82.1) Atypical carcinoid 16 (11.9) Other 8 (6) Final pathologic stage (lung masses, eighth edition) – n (%) IA1 27 (20.1) IA2 48 (35.8) IA3 9 (6.7) IB 25 (18.6) IIA 6 (2.9) IIB 10 (7.5) IIIA 9 (6.7) IIIB 1 (0.7) IVA 2 (1.5) N stage N0 122 (91%) N1 3 (2.2%) N2 6 (4.5%) R0 resection 134 (100) Length of stay – median (range) 1 (1–7) Discharged with chest tube 1 (0.7) Reoperation required – n (%) 2 (1.5) 30-day readmission – n (%) 1 (0.7) 30-day mortality – n (%) 1 (0.7) 90-day mortality – n (%) 1 (0.7) 1-year mortality – n (%) 1 (0.7) 3-year mortality – n (%) 4 (2.9) 5-year mortality – n (%) 7 (5.2) Follow-up was obtained in 119 (97%) patients with a median of 80.5 months. The overall survival is illustrated in Fig. 1 A. Survival outcomes did not differ significantly according to pathologic stage (log-rank p = 0.95), histologic subtype (log-rank p = 0.16), or nodal status (N0 vs N+, p = 0.43) (Figs. 1 B– 1 D). Discussion Carcinoid tumors represent a relatively uncommon subset of pulmonary malignancies. Our institution receives referrals from across the world, resulting in a substantial clinical experience with these tumors. The World Health Organization classifies typical carcinoids are categorized as low-grade neuroendocrine tumors with fewer mitoses and no necrosis and atypical carcinoids as intermediate-grade in terms of mitotic index and focal necrosis. [ 8 ]. These pathologic differences are associated with important prognostic implications, with typical carcinoids demonstrating favorable long-term survival of 88–93% at 5 years, while atypical carcinoids exhibits more aggressive biological behavior with survival rates at 10 years ranging from 20–70% depending on stage [ 9 ]. Our findings, however, are different as shown in the survival curve, Fig. 3. We had 24 patients with non-typical carcinoid and nine of them had nodal metastases. Six patients had N2 disease and 3 had N1 level disease. All these patients are alive to date. This finding may be secondary to the aggressive lymph node resection that we routinely performed robotically since these patients do not respond well to currently available adjuvant chemotherapy or immunotherapy options. Surgical resection of carcinoid tumors should include a complete ipsilateral lymph node dissection. Nodal metastases are not rare, ranging from 10% in typical carcinoids to 75% in atypical carcinoids, with lymph node involvement being an independent predictor or poorer survival [ 3 , 10 ]. As an example, aggressive management of enlarged malignant subcarinal lymph nodes was performed in a patient with evident N2 nodal involvement who underwent a right lower lobectomy with bronchial sleeve reconstruction, reconnecting the right middle lobe bronchus to the bronchus intermedius. The operative steps are illustrated in the accompanying video vignette (Video 1). Robotic resection presents an excellent approach for these patients in terms of safety, efficacy, survival, patient morbidity and cosmetics as well as patient satisfaction and recovery [ 11 ]. Patients with bronchopulmonary carcinoids tend to be younger than those with other lung malignancies [ 3 ] as shown in our study. The predominance of centrally located tumors amenable to bronchoscopic visualization is consistent with the literature, where 50–80% of carcinoids present as endobronchial lesions. 4 Preoperative bronchoscopic assessment is critical for surgical planning, particularly in determining the feasibility of parenchyma-sparing procedures such as sleeves of the airway. 4 Prior studies examining the surgical treatment of bronchopulmonary carcinoids have primarily described outcomes following open techniques such as thoracotomy or via VATS [ 4 ]. Data on robotic resection remains limited and underrepresented in literature. Zirafa in 2025 reported on 45 patients [ 13 ]. This is the second largest robotic series in literature. It was from a multi-surgeon experience and had similar results to ours, except their patients underwent more wedge resection, less segmentectomy and a longer median length of stay of five days compared to our series. A minority of patients experienced postoperative complications. Two developed pneumothorax, three developed pleural effusions and all were identified early through close postoperative monitoring and were managed successfully without long-term sequelae. Only one patient required admission to the ICU postoperatively (a 39-year-old male who had flash pulmonary edema of unknown etiology) and recovered. Since 2019 all patients have had a one-day length of stay. We had one 30 and/or 90-day mortality which occurred in a patient who underwent a routine robotic right middle lobectomy for a 6 cm typical carcinoid and went home on POD1. The patient had a cardiac arrest at home and returned to our emergency room, had a normal CXR and then suffered refractory multi-focal ventricular arrhythmias and went into pulseless electrical activity and died on POD3. There are several interesting findings in our study. We report a higher mortality rate in the typical carcinoid patients (n = 110) compared to the non-atypical (n = 24). This finding may be consistent with published literature that demonstrates that in patients with typical carcinoids, deaths from non-cancer causes exceed cancer-specific deaths after 1–3 years post-diagnosis, given the indolent biology of these tumors [ 9 ]. Long-term survivors with typical carcinoids are at increased risk of cardiovascular mortality and age-related comorbidities [ 13 ]. There are several important limitations to our study. Our findings may not be scalable because of our large surgical experience (19,425 operations and over 3100 robotic operations) by the sole surgeon in this study. Second, longer follow-up (10–15 years) may be needed to fully assess oncologic outcomes and or death specific data. Third, the care team gains important experience over time. It is difficult to control for these factors. A strength of this study is that it uses a consecutive case series drawn from a validated single-surgeon database in which all variables were systematically recorded. Additionally, no patients were excluded for a robotic platform because of tumor size, patient body habitus or comorbidity, or operative complexity. This consecutive single-surgeon series demonstrates that robotic resection for pulmonary carcinoid tumors is safe and effective, with excellent perioperative outcomes, high long-term survival, and short length of stay. Even complex procedures such as sleeve resections and bi-lobectomies can be performed robotically with high patient and family satisfaction. Declarations Author Contributions CAS and NP performed data curation, statistical analyses, methodological development, validation, and preparation of figures, and drafted the manuscript. CAS, NP, and RJC reviewed and revised the manuscript critically for intellectual content. RJC was responsible for study conception, project management, provision of resources, and supervision of the research. Funding None. Conflict of Interest Dr. Cerfolio reports equity in Fruit Street, Informed Inc., and NovaNav; intellectual property related to Tego; and consulting and advisory roles with Informed Inc., NovaNav, various Publishers, Commend Corporation, Thoraguard (Centese), Intuitive Surgical, and Johnson & Johnson; serves as CEO and President of Rolo-7, C⁴, and Coop-Lor-Corporation. The other authors have no disclosures. Ethics approval Ethical approval for this investigation was granted by the Institutional Review Boards of the University of Alabama at Birmingham (No. 030403013) and New York University Langone Health (i26-00209). Because of the retrospective design, the requirement for individual patient consent was waived. All procedures were conducted in compliance with institutional research standards and internationally accepted ethical principles governing human subject research. Data Availability The datasets analyzed during the present study may be shared by the corresponding author upon reasonable request and subject to institutional authorization. Acknowledgments: None References Petrella F, Cara A, Cassina EM, et al. Pulmonary Carcinoids: Diagnostic and Therapeutic Approach. Cancers (Basel). 2025;17(17):2748. Published 2025 Aug 23. doi:10.3390/cancers17172748 Pinchot SN, Holen K, Sippel RS, Chen H. Carcinoid tumors. Oncologist. 2008;13(12):1255-1269. doi:10.1634/theoncologist.2008-0207 Sen T, Dotsu Y, Corbett V, et al. Pulmonary neuroendocrine neoplasms: the molecular landscape, therapeutic challenges, and diagnosis and management strategies. Lancet Oncol . 2025;26(1):e13-e33. doi:10.1016/S1470-2045(24)00374-7 Bertolaccini L, Caffarena G, Spada F, et al. Survival outcomes and prognostic factors in surgically resected lung carcinoids: A 25-year retrospective analysis. Eur J Surg Oncol . 2025;51(10):110366. doi:10.1016/j.ejso.2025.110366 Cerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg . 2011;142(4):740-746. doi:10.1016/j.jtcvs.2011.07.022 Zervos M, Park BJ, Marshall MB, et al. Robotic-assisted single-port system for pulmonary lobectomy: A prospective feasibility study. J Thorac Cardiovasc Surg . 2025;170(1):54-60.e1. doi:10.1016/j.jtcvs.2025.04.004 Cerfolio RJ, Bryant AS, Minnich DJ. Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology. J Thorac Cardiovasc Surg . 2012;143(5):1138-1143. doi:10.1016/j.jtcvs.2011.12.021 Demetri G, Elias A, Gershenson D, et al. NCCN Small-Cell Lung Cancer Practice Guidelines. The National Comprehensive Cancer Network. Oncology (Williston Park) . 1996;10(11 Suppl):179-194. Hallet J, Rousseau M, Wakeam E, et al. Contemporary Incidence and Survival of Lung Neuroendocrine Neoplasms. JAMA Netw Open . 2025;8(10):e2535125. Published 2025 Oct 1. doi:10.1001/jamanetworkopen.2025.35125 Kneuertz PJ, Kamel MK, Stiles BM, et al. Incidence and Prognostic Significance of Carcinoid Lymph Node Metastases. Ann Thorac Surg . 2018;106(4):981-988. doi:10.1016/j.athoracsur.2018.05.044 Kent MS, Hartwig MG, Vallières E, et al. Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases. Ann Surg . 2023;277(6):1002-1009. doi:10.1097/SLA.0000000000005820 Zirafa CC, Manfredini B, Romano G, et al. Surgical Management of Pulmonary Typical Carcinoids: A Single-Centre Experience Comparing Anatomical and Non-Anatomical Resections. J Clin Med. 2025;14(15):5488. Published 2025 Aug 4. doi:10.3390/jcm14155488 Xing H, Wu C, Zhang D, Zhang X. Competing risk analysis of cardiovascular-specific mortality in typical carcinoid neoplasms of the lung: A SEER database analysis. Medicine (Baltimore) . 2023;102(40):e35104. doi:10.1097/MD.0000000000035104 Additional Declarations Competing interest reported. Dr. Cerfolio reports equity in Fruit Street, Informed Inc., and NovaNav; intellectual property related to Tego; and consulting and advisory roles with Informed Inc., NovaNav, various Publishers, Commend Corporation, Thoraguard (Centese), Intuitive Surgical, and Johnson & Johnson; serves as CEO and President of Rolo-7, C⁴, and Coop-Lor-Corporation. The other authors have no disclosures. Supplementary Files Video1.mp4 Cite Share Download PDF Status: Published Journal Publication published 25 Apr, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 30 Mar, 2026 Reviews received at journal 29 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers invited by journal 15 Mar, 2026 Editor assigned by journal 10 Mar, 2026 Submission checks completed at journal 09 Mar, 2026 First submitted to journal 09 Mar, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9075983","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":607060536,"identity":"3536e244-d105-42c5-9f80-85d4cb6e53ee","order_by":0,"name":"Caroline A. Snyder","email":"","orcid":"","institution":"NYU Grossman School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"A.","lastName":"Snyder","suffix":""},{"id":607060545,"identity":"2cc3781e-108e-4cb1-a63c-ab7751de7646","order_by":1,"name":"Nikolaos Pachos","email":"data:image/png;base64,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","orcid":"","institution":"NYU Langone Health","correspondingAuthor":true,"prefix":"","firstName":"Nikolaos","middleName":"","lastName":"Pachos","suffix":""},{"id":607060546,"identity":"9cf1faf4-9021-4375-80f5-646ebe10937a","order_by":2,"name":"Robert J. Cerfolio","email":"","orcid":"","institution":"NYU Langone Health","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"J.","lastName":"Cerfolio","suffix":""}],"badges":[],"createdAt":"2026-03-09 18:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9075983/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9075983/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-026-03432-3","type":"published","date":"2026-04-25T15:58:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104879012,"identity":"6cd5aa4a-e621-4bd3-98d3-a6685f5b525c","added_by":"auto","created_at":"2026-03-18 08:59:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":213685,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier Survival Analysis. (A) \u003c/strong\u003eEntire cohort of 134 patients with overall survival 94.8%. \u003cstrong\u003e(B)\u003c/strong\u003eSurvival by pathologic stage (log-rank p = 0.95). \u003cstrong\u003e(C)\u003c/strong\u003e Survival by histologic subtype (typical vs. non-typical, where non-typical includes atypical carcinoids and other neuroendocrine tumors (log-rank p = 0.95). \u003cstrong\u003e(D)\u003c/strong\u003eSurvival by nodal status (N0 vs. N+, where N+ includes N1 and N2 disease) (log-rank p=0.43). Shaded areas represent 95% confidence intervals.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-9075983/v1/67bb13f755854487456462de.png"},{"id":107928553,"identity":"d7fdd761-bae8-4bd5-a187-1810c7df73b6","added_by":"auto","created_at":"2026-04-27 16:11:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":441324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9075983/v1/b98f9a11-fd7a-41af-93c2-a4e44eb0451b.pdf"},{"id":104878866,"identity":"a97eee41-e12b-48a5-bf6c-b9a1d940a503","added_by":"auto","created_at":"2026-03-18 08:58:50","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":56071880,"visible":true,"origin":"","legend":"","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-9075983/v1/2f88f104d538647ef7e9392a.mp4"}],"financialInterests":"Competing interest reported. Dr. Cerfolio reports equity in Fruit Street, Informed Inc., and NovaNav; intellectual property related to Tego; and consulting and advisory roles with Informed Inc., NovaNav, various Publishers, Commend Corporation, Thoraguard (Centese), Intuitive Surgical, and Johnson \u0026 Johnson; serves as CEO and President of Rolo-7, C⁴, and Coop-Lor-Corporation. The other authors have no disclosures.","formattedTitle":"World Largest Single Surgeon’s Experience of Robotic Resection of Pulmonary and Bronchial Carcinoid Tumors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBronchopulmonary carcinoid tumors account for only 1% of thoracic malignancies, with only less than two cases per 100,000 people annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pulmonary carcinoids usually occur at age 30\u0026ndash;60, but they also represent the predominant primary pulmonary malignancy in pediatric and young adult populations. Pulmonary carcinoids are neuroendocrine tumors arising from Kulchitsky cells and comprise 25\u0026ndash;30% of all carcinoid tumors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pulmonary carcinoids span a broad spectrum of pathologic subtypes and clinical behavior. Typical carcinoids are the most common pulmonary carcinoid; they are typically well differentiated, follow a relatively slow clinical course, and are associated with excellent long-term outcomes after complete resection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Atypical carcinoids are intermediate grade, aggressive tumors accounting for 10\u0026ndash;27% of pulmonary carcinoids [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most lymph node metastases and more advanced disease occur in individuals with atypical carcinoid tumors.\u003c/p\u003e \u003cp\u003ePatients often present with hemoptysis or pneumonia if they have bronchial tumors obstructing significant parts of the lung. Many of these patients are diagnosed with asthma during childhood as they often experience dyspnea and wheezing. Patients with lung nodules can be asymptomatic, and present only for the incidental finding from imaging performed for other reasons. A small subset of these patients presents with carcinoid syndrome, characterized by bronchospasm, flushing, diarrhea, and right-heart failure due to physiological changes mediated by serotonin release from carcinoid tumors. Diagnosis relies on CT scan and bronchoscopy, as well as endobronchial ultrasound for lymph node staging in some patients. Surgery is the mainstay of treatment.\u003c/p\u003e \u003cp\u003eMinimally invasive approaches, especially robotic lung resection, offer a highly effective and muscle-sparing option with low morbidity and mortality. In this study we report outcomes from 134 consecutive patients who underwent robotic resection for bronchial or pulmonary carcinoid tumors performed by a single surgeon. To our knowledge, this represents the largest reported experience of robotic resection for pulmonary carcinoid tumors performed by an individual surgeon.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cp\u003e We reviewed a prospectively maintained database of consecutive patients treated surgically by a sole surgeon (R.J.C.) at two academic institutions. The primary outcomes included completeness of resection (R0), number of lymph node stations sampled, total lymph node yield, hospital course, postoperative complications, readmission, mortality, and patient satisfaction. Secondary outcomes were operative time, ICU admission, and length of stay. Patient satisfaction was measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Institutional Review Board (IRB) approval was obtained from the University of Alabama at Birmingham (No. 030403013) and New York University Langone Health (i26-00209).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Technique\u003c/h3\u003e\n\u003cp\u003eAll resections were performed using a completely portal robotic approach with four robotic arms, as previously described [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and in some patients later in our series using the SP robot [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. For the Xi or DaVinci 5 robotic platform (Intuitive Surgical, Sunnyvale, CA, USA), access to the pleural cavity was achieved through an 8-mm trocar positioned anteriorly along the mid-axillary line at the level of the eighth rib as previously described [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and the SP was placed subcostal [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The types of resections performed included pulmonary wedge resection, segmentectomy, lobectomy, bi-lobectomy, sleeve resection, bronchoplasty and other pulmonary resections.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003e \u003cb\u003eA\u003c/b\u003enalyses were conducted using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). Baseline demographics, clinical characteristics, and perioperative outcomes were summarized using descriptive measures. Overall survival was evaluated with Kaplan\u0026ndash;Meier survival analysis, with time calculated from the date of surgery until death or last known vital status.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFrom July 1996 to March 2026, a total of 19,425 thoracic procedures were performed by a sole surgeon (RJC). During this period, 243 patients underwent resection for carcinoid tumors of the lung and/or bronchus. Our robotic program began in February 2009, after which robotic pulmonary resection was offered to all eligible patients. From February 2009 through March 2026, 134 consecutive, unselected patients underwent robotic resection for carcinoid tumors. Within this group, 83 patients were female, median age was 61 years (range 7\u0026ndash;83), and median body mass index was 27 kg/m\u0026sup2; (range 17\u0026ndash;57). Additional baseline characteristics are described in 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\u003ePatient characteristics (n\u0026thinsp;=\u0026thinsp;134).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge \u0026ndash; median (range)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (7\u0026ndash;83)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale sex \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite race \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI \u0026ndash; median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (17\u0026ndash;57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking status at time of surgery \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack-year history \u0026ndash; median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.5 (0.5\u0026ndash;110)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonths since smoking cessation \u0026ndash; median\u003c/p\u003e \u003cp\u003e(range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (1\u0026ndash;600)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative FEV1 \u0026ndash; median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (31\u0026ndash;146)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative DLCO \u0026ndash; median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (33\u0026ndash;131)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAD \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary hypertension \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative anticoagulation \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of primary cancer \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (20.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (79.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size (cm) \u0026ndash; median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.8\u0026ndash;10.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Stage (Eighth Edition) \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (20.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (35.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\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\u003eMost patients presented with early-stage disease and preserved pulmonary function. The majority of tumors were parenchymal (106 patients, 79.1%), with a median tumor diameter of 2 cm (range 0.8\u0026ndash;10.1) on preoperative imaging. The overall burden of major cardiopulmonary comorbidity was low. All procedures were completed robotically, without conversions to thoracotomy. The median operative duration was 118 minutes (range 62\u0026ndash;239). No intraoperative complications or blood transfusions occurred. Postoperative complications were infrequent, and none were classified as Clavien\u0026ndash;Dindo grade IIIb or higher. Reoperation was required in two patients (1.5%), including one segmentectomy and one wedge resection. The median hospital length of stay was one day (range 1\u0026ndash;7 days), and 83% of patients were discharged on postoperative day one.\u003c/p\u003e \u003cp\u003ePathology demonstrated typical carcinoid in 82% of patients. Margin-negative (R0) resection was achieved in all of our patients. Frozen sections in the operating room demonstrated negative margins in all patients. Margins on final pathology were indeterminate in four patients; however, none of these patients have recurred to date (median follow-up 28 months). Thirty- and 90-day readmission and mortality rates were each 0.7%. Perioperative, postoperative, and oncologic outcomes are described in 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\u003ePerioperative, Postoperative, and Oncologic Outcomes (n\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure \u0026ndash; n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (60.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmentectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (14.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWedge resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBi-lobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleeve resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, min (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (62\u0026ndash;239)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph node yield, n (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (12\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActual blood loss, cc (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion required \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative complications \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complications \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumothorax requiring chest tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion requiring chest tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlash pulmonary edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChylothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpyema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchial stricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericarditis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor type \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypical carcinoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (82.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtypical carcinoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (11.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal pathologic stage (lung masses, eighth edition) \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (20.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (35.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIA3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122 (91%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0 resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay \u0026ndash; median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarged with chest tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation required \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day readmission \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day mortality \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90-day mortality \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1-year mortality \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3-year mortality \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-year mortality \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5.2)\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\u003eFollow-up was obtained in 119 (97%) patients with a median of 80.5 months. The overall survival is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA. Survival outcomes did not differ significantly according to pathologic stage (log-rank p\u0026thinsp;=\u0026thinsp;0.95), histologic subtype (log-rank p\u0026thinsp;=\u0026thinsp;0.16), or nodal status (N0 vs N+, p\u0026thinsp;=\u0026thinsp;0.43) (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB\u0026ndash;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCarcinoid tumors represent a relatively uncommon subset of pulmonary malignancies. Our institution receives referrals from across the world, resulting in a substantial clinical experience with these tumors. The World Health Organization classifies typical carcinoids are categorized as low-grade neuroendocrine tumors with fewer mitoses and no necrosis and atypical carcinoids as intermediate-grade in terms of mitotic index and focal necrosis. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These pathologic differences are associated with important prognostic implications, with typical carcinoids demonstrating favorable long-term survival of 88\u0026ndash;93% at 5 years, while atypical carcinoids exhibits more aggressive biological behavior with survival rates at 10 years ranging from 20\u0026ndash;70% depending on stage [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings, however, are different as shown in the survival curve, Fig.\u0026nbsp;3. We had 24 patients with non-typical carcinoid and nine of them had nodal metastases. Six patients had N2 disease and 3 had N1 level disease. All these patients are alive to date. This finding may be secondary to the aggressive lymph node resection that we routinely performed robotically since these patients do not respond well to currently available adjuvant chemotherapy or immunotherapy options. Surgical resection of carcinoid tumors should include a complete ipsilateral lymph node dissection. Nodal metastases are not rare, ranging from 10% in typical carcinoids to 75% in atypical carcinoids, with lymph node involvement being an independent predictor or poorer survival [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As an example, aggressive management of enlarged malignant subcarinal lymph nodes was performed in a patient with evident N2 nodal involvement who underwent a right lower lobectomy with bronchial sleeve reconstruction, reconnecting the right middle lobe bronchus to the bronchus intermedius. The operative steps are illustrated in the accompanying video vignette (Video 1).\u003c/p\u003e \u003cp\u003eRobotic resection presents an excellent approach for these patients in terms of safety, efficacy, survival, patient morbidity and cosmetics as well as patient satisfaction and recovery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patients with bronchopulmonary carcinoids tend to be younger than those with other lung malignancies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] as shown in our study. The predominance of centrally located tumors amenable to bronchoscopic visualization is consistent with the literature, where 50\u0026ndash;80% of carcinoids present as endobronchial lesions.\u003csup\u003e4\u003c/sup\u003e Preoperative bronchoscopic assessment is critical for surgical planning, particularly in determining the feasibility of parenchyma-sparing procedures such as sleeves of the airway.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrior studies examining the surgical treatment of bronchopulmonary carcinoids have primarily described outcomes following open techniques such as thoracotomy or via VATS [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Data on robotic resection remains limited and underrepresented in literature. Zirafa in 2025 reported on 45 patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This is the second largest robotic series in literature. It was from a multi-surgeon experience and had similar results to ours, except their patients underwent more wedge resection, less segmentectomy and a longer median length of stay of five days compared to our series.\u003c/p\u003e \u003cp\u003eA minority of patients experienced postoperative complications. Two developed pneumothorax, three developed pleural effusions and all were identified early through close postoperative monitoring and were managed successfully without long-term sequelae. Only one patient required admission to the ICU postoperatively (a 39-year-old male who had flash pulmonary edema of unknown etiology) and recovered. Since 2019 all patients have had a one-day length of stay. We had one 30 and/or 90-day mortality which occurred in a patient who underwent a routine robotic right middle lobectomy for a 6 cm typical carcinoid and went home on POD1. The patient had a cardiac arrest at home and returned to our emergency room, had a normal CXR and then suffered refractory multi-focal ventricular arrhythmias and went into pulseless electrical activity and died on POD3.\u003c/p\u003e \u003cp\u003eThere are several interesting findings in our study. We report a higher mortality rate in the typical carcinoid patients (n\u0026thinsp;=\u0026thinsp;110) compared to the non-atypical (n\u0026thinsp;=\u0026thinsp;24). This finding may be consistent with published literature that demonstrates that in patients with typical carcinoids, deaths from non-cancer causes exceed cancer-specific deaths after 1\u0026ndash;3 years post-diagnosis, given the indolent biology of these tumors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Long-term survivors with typical carcinoids are at increased risk of cardiovascular mortality and age-related comorbidities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several important limitations to our study. Our findings may not be scalable because of our large surgical experience (19,425 operations and over 3100 robotic operations) by the sole surgeon in this study. Second, longer follow-up (10\u0026ndash;15 years) may be needed to fully assess oncologic outcomes and or death specific data. Third, the care team gains important experience over time. It is difficult to control for these factors. A strength of this study is that it uses a consecutive case series drawn from a validated single-surgeon database in which all variables were systematically recorded. Additionally, no patients were excluded for a robotic platform because of tumor size, patient body habitus or comorbidity, or operative complexity.\u003c/p\u003e \u003cp\u003eThis consecutive single-surgeon series demonstrates that robotic resection for pulmonary carcinoid tumors is safe and effective, with excellent perioperative outcomes, high long-term survival, and short length of stay. Even complex procedures such as sleeve resections and bi-lobectomies can be performed robotically with high patient and family satisfaction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eCAS and NP performed data curation, statistical analyses, methodological development, validation, and preparation of figures, and drafted the manuscript.\u003cbr\u003e\u0026nbsp;CAS, NP, and RJC reviewed and revised the manuscript critically for intellectual content.\u003cbr\u003e\u0026nbsp;RJC was responsible for study conception, project management, provision of resources, and supervision of the research.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003eConflict of Interest\u003c/p\u003e\n\u003cp\u003eDr. Cerfolio reports equity in Fruit Street, Informed Inc., and NovaNav; intellectual property related to Tego; and consulting and advisory roles with Informed Inc., NovaNav, various Publishers, Commend Corporation,\u0026nbsp;Thoraguard (Centese),\u0026nbsp;Intuitive Surgical, and Johnson \u0026amp; Johnson; serves as CEO and President of Rolo-7, C⁴, and Coop-Lor-Corporation.\u0026nbsp;The other authors have no disclosures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eEthical approval for this investigation was granted by the Institutional Review\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eBoards of the\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eUniversity of Alabama at Birmingham (No. 030403013) and New York University Langone Health (i26-00209). Because of the retrospective design, the requirement for individual patient consent was waived. All procedures were conducted in compliance with institutional research standards and internationally accepted ethical principles governing human subject research.\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the present study may be shared by the corresponding author upon reasonable request and subject to institutional authorization.\u003c/p\u003e\n\u003cp\u003eAcknowledgments:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePetrella F, Cara A, Cassina EM, et al. Pulmonary Carcinoids: Diagnostic and Therapeutic Approach. Cancers (Basel). 2025;17(17):2748. Published 2025 Aug 23. doi:10.3390/cancers17172748\u003c/li\u003e\n \u003cli\u003ePinchot SN, Holen K, Sippel RS, Chen H. Carcinoid tumors. Oncologist. 2008;13(12):1255-1269. doi:10.1634/theoncologist.2008-0207\u003c/li\u003e\n \u003cli\u003eSen T, Dotsu Y, Corbett V, et al. Pulmonary neuroendocrine neoplasms: the molecular landscape, therapeutic challenges, and diagnosis and management strategies. \u003cem\u003eLancet Oncol\u003c/em\u003e. 2025;26(1):e13-e33. doi:10.1016/S1470-2045(24)00374-7\u003c/li\u003e\n \u003cli\u003eBertolaccini L, Caffarena G, Spada F, et al. Survival outcomes and prognostic factors in surgically resected lung carcinoids: A 25-year retrospective analysis. \u003cem\u003eEur J Surg Oncol\u003c/em\u003e. 2025;51(10):110366. doi:10.1016/j.ejso.2025.110366\u003c/li\u003e\n \u003cli\u003eCerfolio RJ, Bryant AS, Skylizard L, Minnich DJ. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 2011;142(4):740-746. doi:10.1016/j.jtcvs.2011.07.022\u003c/li\u003e\n \u003cli\u003eZervos M, Park BJ, Marshall MB, et al. Robotic-assisted single-port system for pulmonary lobectomy: A prospective feasibility study. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 2025;170(1):54-60.e1. doi:10.1016/j.jtcvs.2025.04.004\u003c/li\u003e\n \u003cli\u003eCerfolio RJ, Bryant AS, Minnich DJ. Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 2012;143(5):1138-1143. doi:10.1016/j.jtcvs.2011.12.021\u003c/li\u003e\n \u003cli\u003eDemetri G, Elias A, Gershenson D, et al. NCCN Small-Cell Lung Cancer Practice Guidelines. The National Comprehensive Cancer Network. \u003cem\u003eOncology (Williston Park)\u003c/em\u003e. 1996;10(11 Suppl):179-194.\u003c/li\u003e\n \u003cli\u003eHallet J, Rousseau M, Wakeam E, et al. Contemporary Incidence and Survival of Lung Neuroendocrine Neoplasms. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2025;8(10):e2535125. Published 2025 Oct 1. doi:10.1001/jamanetworkopen.2025.35125\u003c/li\u003e\n \u003cli\u003eKneuertz PJ, Kamel MK, Stiles BM, et al. Incidence and Prognostic Significance of Carcinoid Lymph Node Metastases. \u003cem\u003eAnn Thorac Surg\u003c/em\u003e. 2018;106(4):981-988. doi:10.1016/j.athoracsur.2018.05.044\u003c/li\u003e\n \u003cli\u003eKent MS, Hartwig MG, Valli\u0026egrave;res E, et al. Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases. \u003cem\u003eAnn Surg\u003c/em\u003e. 2023;277(6):1002-1009. doi:10.1097/SLA.0000000000005820\u003c/li\u003e\n \u003cli\u003eZirafa CC, Manfredini B, Romano G, et al. Surgical Management of Pulmonary Typical Carcinoids: A Single-Centre Experience Comparing Anatomical and Non-Anatomical Resections. J Clin Med. 2025;14(15):5488. Published 2025 Aug 4. doi:10.3390/jcm14155488\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eXing H, Wu C, Zhang D, Zhang X. Competing risk analysis of cardiovascular-specific mortality in typical carcinoid neoplasms of the lung: A SEER database analysis. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 2023;102(40):e35104. doi:10.1097/MD.0000000000035104\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"carcinoid tumor, pulmonary carcinoid, robotic surgery, minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-9075983/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9075983/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eCarcinoid tumors of the lung/bronchus are relatively rare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis is a consecutive (non-selected) series from a validated prospective database of patients from one surgeon.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFrom July, 1996 to March 2026 one thoracic surgeon (RJC) performed 19,425 operations and 243 patients (1.3%) had a carcinoid tumor. Starting February 2009, we started robotic surgery and have performed 3,100 robotic operations as of March 2026, of which 134 (4.3%) patients had a carcinoid tumor resected robotically. Eighty-one patients (60%) underwent lobectomy, 17 (13%) had a sleeve resection of the airway and 9 (7%) had bi-lobectomy. The median operative time was 118 minutes and the median actual blood loss of 20 mL (10 – 50). There were no major intraoperative complications, and no patients required blood transfusion or conversion to open thoracotomy. Median length of stay was one day and 83% of patients went home on post-operative day one. All patients had an R0 resection. The median lymph node yield was 27. There was one 30- and 90-day mortality (0.7%). Five-year overall survival was 95%, with median follow-up of 80 months. Patient and family satisfaction was 98%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis is the largest single surgeon’s experience performing robotic resection for pulmonary carcinoid tumors. It shows that a robotic platform offers outstanding short and long-term outcomes, even for complex operations such as sleeve resection and bi-lobectomy. Patients and their families also enjoy an outstanding experience with high satisfaction that requires only one night stay in the hospital.\u003c/p\u003e","manuscriptTitle":"World Largest Single Surgeon’s Experience of Robotic Resection of Pulmonary and Bronchial Carcinoid Tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:57:38","doi":"10.21203/rs.3.rs-9075983/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T21:54:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-29T17:41:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T13:07:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199969043892452490059131573591578841393","date":"2026-03-17T23:57:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19165364471085694075898279468634353321","date":"2026-03-17T23:25:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165873188910848191194557702872340011227","date":"2026-03-16T07:34:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-15T23:03:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T14:18:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T03:42:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2026-03-09T17:53:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7319fe22-38af-403d-b858-ceb1355293ab","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:08:29+00:00","versionOfRecord":{"articleIdentity":"rs-9075983","link":"https://doi.org/10.1007/s11701-026-03432-3","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-04-25 15:58:52","publishedOnDateReadable":"April 25th, 2026"},"versionCreatedAt":"2026-03-18 08:57:38","video":"","vorDoi":"10.1007/s11701-026-03432-3","vorDoiUrl":"https://doi.org/10.1007/s11701-026-03432-3","workflowStages":[]},"version":"v1","identity":"rs-9075983","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9075983","identity":"rs-9075983","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}