Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs. open thoracotomy and video-assisted thoracic surgery (VATS) for NSCLC is limited.Patients >65 years old with stage I-IIIA NSCLC treated with RAS, VATS or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched by age, sex, stage, and extent of resection. We used propensity score methods to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs.In our matched study cohort of 2, 766 resected NSCLC patients, RAS was associated with lower complication rates (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.42-0.79) compared to open thoracotomy, and similar complication rates (OR: 1.02; 95% CI: 0.76-1.37) compared to VATS. RAS patients were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR: 1.28; 95% CI: 0.94-1.74) or VATS (OR: 0.88; 95% CI: 0.66-1.18). There was no significant difference in overall survival after RAS vs. open thoracotomy (hazard ratio [HR]: 0.81, 95% CI: 0.63-1.04) or VATS (HR: 0.91; 95% CI: 0.70-1.18). Costs were similar for RAS ($54,702) vs. open thoracotomy ($57,104; p=0.08), and higher compared to VATS ($48,729; p=0.02).RAS leads to improved operative outcomes compared to open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.