Robotic Thymectomy for Myasthenia Gravis: Analysis of the Surgical and Neurological Outcomes After a 20 Years' Experience

Background: Evidence supporting robotic thymectomy for myasthenia gravis is generally based on small sample-size studies, heterogeneous in patient selection and in reporting outcomes. Therefore, this study was conducted to assess the surgical and neurological outcomes of robotic thymectomy in myasthenic patients and to identify prognostic factors associated with symptoms' remission through a large cohort of patients operated in a 20 years' period. Methods: A retrospective analysis of a prospectively maintained database was conducted for all patients undergoing robotic thymectomy for myasthenia gravis between 2002 and 2022. Myasthenia Gravis Foundation of America (MGFA) recommendations were used to report the neurological outcomes. Complete remission and overall improvement were evaluated using Cumulative Incidence Functions, while the effect of preoperative variables on the probability of remission was estimated with Cox models. Results: In total, 267 patients underwent robotic thymectomy. Median operative time was 135 min and there were 7 (2.6%) open conversions. Clinical follow-up (median 83 months) showed a 5-year probability of complete remission of 18% and of overall improvement of 84%. Complete remission was negatively associated with age (HR 0.97, 95% CI 0.95–0.99, p = 0.001) and preoperative use of pyridostigmine (HR 0.34, 95% CI 0.15–0.81, p = 0.014), while severe MGFA class did not reach significance (HR 0.55, 95% CI 0.3–1.01, p = 0.052). Instead, there was a benefit in patients operated on in later years (HR 1.11, 95% CI 1.04–1.18, p = 0.01). Comment: Robotic thymectomy is a safe procedure. Long-term neurological follow-up demonstrated an improvement in most patients, also in subgroups that historically showed worse outcomes.