Will the Future of Health Care Lead to the End of the Robotic Golden Years?

Abstract

It has been almost 12 years since the US Food and Drug Administration approved the da Vinci robotic surgical system. Since its introduction, robotic assisted laparoscopic procedures have expanded into almost all areas of urology, with robotic prostatectomy being the most prominent. In 2010, national estimates showed that 69–85% of all radical prostatectomy cases were performed robotically [1]. This rapid diffusion of robotic technology into current surgical practice is quite striking. The reasons behind its broad acceptance in prostate cancer are unclear, specifically in light of the significant costs associated with this technique and the lack of its clear superiority compared with conventional approaches: radical retropubic prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP). In early comparative studies, advantages with robotic assisted laparoscopic prostatectomy (RALP) were limited to perioperative factors such as blood loss, transfusion rates, inpatient hospital stay, length of catheterization, and surgical complications [2,3]. The advent of RALP pushed surgeons to modify the open approach to compete as a comparable minimally invasive strategy. Consequently, relative benefits of RALP to RRP have narrowed over time, now with perioperative advantages limited to blood loss and transfusion rates. However, at centers such as ours with very high-volume surgeons, the difference in transfusion rates is no longer significant. Furthermore, techniques such as using a 10-cm incision and reducing the length of stay to approximately 24 h has allowed RRP to compete with the rising popularity of RALP. Recently, Ficarra et al. performed an updated comparative review of prostatectomy approaches and showed that RALP may allow for an earlier return of both potency and continence over RRP [4,5].