Editorial Comment for Rebuck et al.

S ince approval by the United States Food and Drug Administration in 2000, robot-assisted laparoscopic surgery has gained wide acceptance by urologists and is now the most commonly performed surgical technique for clinically localized prostate cancer. Robot-assisted radical prostatectomy (RARP) provides advantages of less blood loss and shorter hospital stay when compared with retropubic radical prostatectomy (RRP) and better visual clarity and more precise manipulation of surgical instruments when compared with laparoscopic radical prostatectomy (LRP). Despite these advantages of RARP, though, critics point to the high cost as well as the lack of clear evidence of superiority in oncologic and functional outcomes when compared with other surgical techniques. ¹

Bolenz and associates ² recently reported that among RARP, LRP, and RRP, RARP has the highest cost. This study indicated that surgical supplies and operating room (OR) costs were the main reason for the high cost for RARP. Moreover, routine maintenance contracts increased the cost by $2698/patient in centers that performed an average of 126 cases/year. Given this backdrop, it is clear that RARP must meet the economic demands as well as improved surgical outcomes to justify the preferred use of surgical robots in men undergoing radical prostatectomy.

In this article, Rebuck and colleagues demonstrated that the overall cost of RARP can be reduced by carefully analyzing the OR setup and use and modifying the components of OR processes. As a result, the authors were able to reduce the total cost of RARP by 18.1% ($11,806 to $9,258). Notwithstanding this cost reduction, this article still demonstrates the excessively high cost of RARP when compared with RRP and LRP, because it has been reported that the cost of LRP is ∼$5000. ^2,3

The authors are to be commended for attempting to decrease the high cost of RARP. This study clearly demonstrates that OR setup and flow of work can be optimized to increase efficiency and decrease cost of RARP. Even after the optimization, however, the cost of RARP still remained high when compared with LRP and RRP. This said, the inherent advantages of RARP—better vision and ergonomics—should not be overlooked. It is the responsibility of the surgeons to translate these mechanical advantages of a surgical robot into tangible improvement in oncologic and quality of life outcomes for patients with prostate cancer. Only then, the inherently higher cost of RARP may be justified.