The impact of robotic surgery on the surgical management of prostate cancer in the USA

Objective: To describe the surgeon characteristics associated with robot-assisted radical prostatectomy (RARP) adoption and determine the possible impact of this adoption on practice patterns and cost.

Patients and methods: A retrospective cohort study with a weighted sample size of 489,369 men who underwent non-RARP (i.e., open or laparoscopic RP) or RARP in the USA from 2003 to 2010 was performed. We evaluated predictors for RARP adoption, defined as performing >50% of annual RP using the robotic approach. Additionally, we identified the resulting changes in prostate cancer surgery practice patterns and expenditures.

Results: From 2003 to 2010, RARP adoption increased from 0.7% to 42% of surgeons performing RP. High-volume surgeons, defined as performing >24 RPs annually, had statically significantly higher odds of adopting RARP throughout the study period. From 2005 to 2007, adoption was more common among surgeons at teaching (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.7-3.4), intermediate- (200-399 beds; OR 5.96, 95% CI 1.3-26.5) and large-sized hospitals (≥ 400 beds; OR 6.1, 95% CI 1.4-25.8); after 2007, adoption was more common among surgeons at urban hospitals (OR 3.3, 95% CI 1.7-6.4). RARP adoption was generally associated with increased RP volume, greatest for high-volume surgeons and least for low-volume surgeons (<5 RPs annually). The annual number of surgeons performing RP decreased from about 10,000 to 8200, with the proportion of cases performed by high-volume surgeons increasing from 10% to 45%. RARP was more costly, disproportionally contributing to the 40% increase in annual prostate cancer surgery expenditures. RARP costs generally decreased plateauing at slightly over $10,000, while non-RARP costs increased to nearly $9000 by the end of the study.

Conclusion: There was widespread RARP adoption in the USA between 2003 and 2010, particularly among high-volume surgeons. The diffusion of RARP was associated with a centralisation of care and an increased economic burden for prostate cancer surgery.