Nipple‑Sparing Mastectomy: Robotic vs Conventional vs Endoscopic with Immediate Prosthetic Reconstruction

Comparison of robotic, conventional, and endoscopic nipple-sparing mastectomy with immediate prosthetic breast reconstruction for breast cancer: A systematic review and meta-analysis

Introduction: The Challenge of Breast Cancer Treatment

Breast cancer is a leading cause of cancer-related illness worldwide. Traditional mastectomy techniques remove the nipple-areola complex (NAC) along with breast tissue, often resulting in significant scarring and emotional impact. Nipple-sparing mastectomy (NSM) preserves the skin envelope and NAC while removing cancerous tissue, offering both oncologic safety and improved cosmetic outcomes. When combined with immediate prosthetic breast reconstruction (IPBR), NSM aims to minimize visible scars and maintain quality of life without compromising cancer control.

Three Approaches to NSM

1. Conventional NSM (CNSM)

   • Technique: Direct incisions around the breast.

   • Advantages: Shortest operating time and hospital stay; lower initial cost.

   • Drawbacks: Larger visible scars; higher rates of severe complications such as NAC necrosis.

2. Endoscopic-Assisted NSM (ENSM)

   • Technique: Small incisions and endoscopic visualization.

   • Advantages: Smallest incisions, leading to minimal scarring and high patient satisfaction.

   • Drawbacks: Longer surgery time; slightly increased resource use.

3. Robotic NSM (RNSM)

   • Technique: Robotic arms provide enhanced precision through small ports.

   • Advantages: Lowest rates of overall and severe complications, reduced NAC necrosis, and fewer cancer recurrences.

   • Drawbacks: Longest operating time; highest equipment and training costs.

Key Findings from the Comparative Analysis

A systematic review and network meta-analysis of ten studies encompassing 1,525 patients (504 RNSM, 771 CNSM, 250 ENSM) provides the first head-to-head comparison of these three techniques with IPBR.

• Incision Length:
  ENSM achieved the shortest scars, reducing incision length by an average of 5.6 cm compared to CNSM. RNSM also trended toward shorter incisions but did not reach statistical significance.

• Operating Time:
  CNSM remained the most time-efficient. ENSM and RNSM extended surgery by roughly one hour compared to CNSM, reflecting the additional procedural complexity.

• Blood Loss & Hospital Stay:
  All three approaches showed similar blood loss and length of hospital stay. RNSM ranked best for minimizing intraoperative bleeding, while CNSM had a slight edge in discharge times.

• Complication Rates:

  • Overall complications: RNSM reduced risk by about 27% versus CNSM.

  • Serious (Grade 3) complications: RNSM cut risk by 63%.

  • NAC necrosis: RNSM virtually eliminated severe necrosis events.
    ENSM’s safety profile fell between RNSM and CNSM.

• Cancer Control:

  • Positive margins: No significant differences among the three techniques.

  • Recurrence: RNSM showed the lowest recurrence rate—a 94% reduction compared to CNSM—while ENSM also trended lower.

Practical Implications for Researchers and Clinicians

• Choosing the Right Technique:

  • CNSM is efficient and widely accessible, making it a solid choice where resources or specialized training are limited.

  • ENSM offers superior cosmetic results with minimal scarring, ideal for patients prioritizing appearance and willing to accept longer surgery.

  • RNSM delivers the best safety and cancer-control outcomes, suitable for high-risk patients when institutional expertise and technology permit.

• Balancing Cost and Benefit:
  Robotic platforms require significant investment and a learning curve. Health systems should consider long-term savings from fewer complications against upfront costs.

• Guiding Future Research:
  Larger, multicenter randomized trials with standardized reporting—covering implant placement methods and adjuvant therapies—are needed. Long-term follow-up will clarify whether the early benefits of minimally invasive approaches persist over time.

Novel Contributions

This analysis uniquely ranks CNSM, ENSM, and RNSM across multiple outcomes using a Bayesian network framework. It highlights that minimally invasive techniques—particularly robotic—can improve complication rates and reduce recurrence without sacrificing safety, while endoscopic methods maximize cosmetic benefits.

Conclusion: Toward Personalized NSM

Minimally invasive NSM techniques are transforming breast cancer surgery. Conventional NSM remains a reliable, cost-effective option. Endoscopic NSM delivers the best cosmetic results, and robotic NSM offers the greatest reductions in complications and recurrence. By matching each approach to patient priorities—whether efficiency, appearance, or safety—clinicians can deliver truly personalized care. Future high-quality trials will be key to refining these strategies and ensuring access to the most effective treatments.

引言：乳腺癌治疗的挑战

乳腺癌是全球主要的癌症相关疾病之一。传统乳房切除术通常会同时切除乳头—乳晕复合体（NAC）及乳房组织，常导致明显瘢痕以及较大的心理负担。保留乳头切除术（NSM）在切除癌变组织的同时保留皮肤包膜及NAC，既保证了肿瘤安全，又改善了术后美容效果。当NSM与即时义乳重建（IPBR）结合时，可最大限度减少可见瘢痕，并在不牺牲癌症控制的前提下维持患者生活质量。

三种NSM实施方式

1. 常规保留乳头切除术（CNSM）

   • 技术要点：在乳房周围进行传统切口。

   • 优点：手术时间最短，住院时间最短；初期费用较低。

   • 缺点：切口更大，瘢痕更明显；严重并发症（如NAC坏死）发生率较高。

2. 内镜辅助保留乳头切除术（ENSM）

   • 技术要点：通过小切口结合内镜可视化操作。

   • 优点：切口最小，瘢痕最少，患者满意度高。

   • 缺点：手术时间较长；资源消耗略有增加。

3. 机器人辅助保留乳头切除术（RNSM）

   • 技术要点：利用机器人机械臂通过小孔精准操作。

   • 优点：总体及严重并发症发生率最低，NAC坏死率降低，癌症复发率较低。

   • 缺点：手术时间最长；设备及培训成本最高。

比较分析的主要发现

本研究系统回顾并基于网络荟萃分析了 10 项共计 1,525 名患者（504 例 RNSM、771 例 CNSM、250 例 ENSM），首次直观比较了三种术式在联合即时义乳重建下的疗效差异。

• 切口长度
  ENSM 的平均切口最短，比 CNSM 平均减少 5.6 厘米。RNSM 在切口长度上也呈缩短趋势，但未达统计学显著性。

• 手术时间
  CNSM 最为省时；ENSM 和 RNSM 较 CNSM 各延长约 1 小时，反映出内镜或机器人操作的额外复杂性。

• 失血量及住院时长
  三种术式在术中失血量及住院时间上相近。RNSM 在减少术中失血方面表现最佳，而 CNSM 在患者出院时间上略占优势。

• 并发症发生率

  • 总体并发症：RNSM 相较于 CNSM 风险降低约 27%。

  • 严重（3 级）并发症：RNSM 风险降低 63%。

  • NAC 坏死：RNSM 几乎消除了严重坏死事件；ENSM 的安全性介于 RNSM 与 CNSM 之间。

• 癌症控制

  • 阳性切缘：三者差异无统计学显著性。

  • 复发率：RNSM 复发率最低，相较于 CNSM 下降 94%；ENSM 也呈下降趋势。

对研究者与临床医师的实践启示

• 术式选择

  • CNSM：效率高、技术普及度广，适合资源或专业培训有限的环境。

  • ENSM：切口小、外观美观，适合重视术后美容且能接受手术时间延长的患者。

  • RNSM：并发症率及复发率最低，适合高危患者及具备相应技术和设备的机构。

• 成本与效益平衡
  机器人平台虽需高额投资及培训，但长期来看并发症减少所节省的成本或可抵消部分前期支出。

• 未来研究方向
  亟需更大规模、多中心的随机对照试验，采用标准化报告（如义乳放置方法、辅助治疗方案），并进行长期随访，以验证微创技术的持续获益。

独创性贡献

本研究首次采用贝叶斯网络框架，对 CNSM、ENSM 与 RNSM 在多项临床结局指标上进行综合排名，凸显微创技术（尤其是机器人技术）在提升并发症率及降低复发率方面的潜力，同时表明内镜技术在最大化美容效果方面的优势。

结论：迈向个体化的NSM

微创保留乳头切除术正推动乳腺癌手术的个体化发展。常规NSM依旧是可靠且具成本效益的选项；内镜NSM在美容效果上无出其右；机器人NSM则在并发症率及复发风险控制方面表现最佳。通过根据患者需求（效率、外观或安全性）选择术式，临床医师能够提供真正个体化的治疗。未来高质量研究将助力优化策略、扩大患者受益。

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Reference:

Na An, Wenjuan Wang, Dandan Dai, Fei Yuan, Yufeng Zhang

Comparison of robotic, conventional, and endoscopic nipple-sparing mastectomy with immediate prosthetic breast reconstruction for breast cancer: A systematic review and meta-analysis.

Biomol Biomed [Internet]. 2025 Apr. 21 [cited 2025 Jul. 24];

Available from: https://www.bjbms.org/ojs/index.php/bjbms/article/view/11687

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