Robot-Assisted Resection of Mediastinal Tumors in Pediatric Patients: A Systematic Review

Introduction: Mediastinal tumors in children are rare and heterogeneous, and their surgical management is challenging due to limited working space and proximity to critical structures. While thoracoscopy has expanded, technical limitations persist in complex mediastinal dissections. Robot-assisted surgery may address these limitations, but its role in pediatric mediastinal tumor resection is not well defined. This systematic review aims to synthesize the available evidence on robot-assisted resection of mediastinal tumors in children, focusing on patient selection, technical feasibility, perioperative outcomes, and available oncologic results. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (CRD420251245437). PubMed/MEDLINE, Web of Science, Scopus, and the Cochrane Library were searched up to 1 December 2025. Eligible studies included pediatric patients (0-18 years) undergoing robot-assisted resection of mediastinal tumors. Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers. Due to heterogeneity and lack of comparative data, a qualitative narrative synthesis was undertaken. Results: Fifteen studies were included, comprising retrospective case series and case reports, including 215 children, 149 (69.3%) of whom were derived from a single retrospective study. The most frequent indications were localized neurogenic tumors, predominantly in the posterior mediastinum. Robot-assisted surgery was consistently performed with curative intent. The da Vinci platform was used in all cases, with reproducible port-placement strategies adapted to tumor location and patient size. Conversion to open surgery occurred in 11 (5.1%) cases, mainly due to bleeding or limited exposure, with no emergency conversions reported. Reported perioperative complications were uncommon, although complication reporting was heterogeneous across studies. No perioperative deaths were reported. Two disease-related deaths occurred during follow-up in patients with recurrent Ewing sarcoma. Long-term oncologic outcomes could not be adequately assessed because of heterogeneous reporting and limited follow-up. Conclusions: Robot-assisted resection of mediastinal tumors in children appears feasible in carefully selected cases treated at experienced centers. Current evidence mainly supports its use for localized tumors with favorable anatomy, particularly in the posterior mediastinum, while long-term oncologic adequacy remains insufficiently defined.