Uptake and accessibility of surgical robotics in England

Predicting Surgical Difficulty in Rectal Cancer Surgery: A Systematic Review of Artificial Intelligence Models Applied to Pre-Operative MRI

Introduction: Following the rapid advances in minimally invasive surgery, there are a multitude of surgical modalities available for resecting rectal cancers. Robotic resections represent the current pinnacle of surgical approaches. Currently, decisions on the surgical modality depend on local resources and the expertise of the surgical team. Given limited access to robotic surgery, developing tools based on pre-operative data that can predict the difficulty of surgery would streamline the efficient utilisation of resources. This systematic review aims to appraise the existing literature on artificial intelligence (AI)-driven preoperative MRI analysis for surgical difficulty prediction to identify knowledge gaps and promising models warranting further clinical evaluation. Methods: A systematic review and narrative synthesis were undertaken in accordance with PRISMA and SWiM guidelines. Systematic searches were performed on Medline, Embase, and the CENTRAL Trials register. Studies published between 2012 and 2024 were included where AI was applied to preoperative MRI imaging of adult rectal cancer patients undergoing surgeries, of any approach, for the purpose of stratifying surgical difficulty. Data were extracted according to a pre-specified protocol to capture study characteristics and AI design; the objectives and performance outcome metrics were summarised. Results: Systematic database searches returned 568 articles, 40 ultimately included in this review. AI to support preoperative difficulty assessments were identified across eight domains (direct surgical difficulty grading, extramural vascular invasion (EMVI), lymph node metastasis (LNM), lymphovascular invasion (LVI), perineural invasion (PNI), T staging, and the requirement for multiple linear stapler firings. For each, at least one model was identified with very good performance (AUC scores of >0.80), with several showing excellent performance considerably above this threshold. Conclusions: AI tools applied to preoperative rectal MRI to support preoperative difficulty assessment for rectal cancer surgeries are emerging, with the progressing development and strong performance of many promising models. These warrant further clinical evaluation, which can aid personalised surgical approaches and ensure the adequate utilisation of limited resources.

Evaluation of current and emerging endoluminal robotic platforms using the IDEAL framework

BACKGROUND

Robotic-assisted endoluminal systems are rapidly evolving within the field of minimally invasive surgery. The IDEAL framework (Idea, Development, Exploration, Assessment, and Surveillance) can be used to evaluate novel technologies. This review provides a summary of current and emerging endoluminal systems using the IDEAL framework.

METHODS

A scoping review was conducted to include all existing and developing robotic-assisted endoluminal systems. Data was collected via virtual interviews, questionnaires, biomedical databases, company websites, and peer-reviewed articles. Key metrics were reported, enabling the assignment of each system to an IDEAL stage.

RESULTS

The review identified 17 distinct systems from 16 companies. Nine systems received regulatory approval in their respective countries. Our evaluation showed that two systems were at the pre-IDEAL Stage 0. Seven systems were in the Idea stage (Stage 1), six systems were in the Development stage (Stage 2) and two systems completed Stage 3. No system underwent long-term study evaluation (Stage 4).

CONCLUSIONS

There is a gap in long-term clinical data of robotic-assisted endoluminal systems, indicated by the absence of systems at Stage 4. Collaborative efforts amongst the medical community, regulatory bodies, and industry specialists are vital to ensure the delivery of evidence-based medicine in the discipline of robotics.

Determining the learning curve of minimally invasive antireflux surgery: systematic review, meta-analysis, and meta-regression

The rapid uptake of minimally invasive antireflux surgery has led to interest in learning curves for this procedure. This study ascertains the learning curve in laparoscopic and robotic-assisted antireflux surgery. A systematic review of the literature pertaining to learning curves in minimally invasive fundoplication with or without hiatal hernia repair was performed using PubMed, Medline, Embase, Web of Science, and Cochrane Library databases. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase. Twenty-five studies met the eligibility criteria. A meta-regression analysis was performed to quantitatively investigate the trend of number of cases required to achieve surgical proficiency from 1996 to present day. Using a mixed-effects negative binomial regression model, the predicted learning curve for laparoscopic and robotic-assisted antireflux surgery was found to be 24.7 and 31.1 cases, respectively. The meta-analysis determined that surgeons in their learning phase may experience a moderately increased rate of conversion to open procedure (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.28, 4.64), as well as a slightly increased rate of intraoperative complications (OR 1.60; 95% CI 1.08, 2.38), postoperative complications (OR 1.98; 95% CI 1.36, 2.87), and needing reintervention (OR 1.64; 95% CI 1.16, 2.34). This study provides an insight into the expected caseload to be competent in performing antireflux surgery. The discrepancy between outcomes during and after the learning curve for antireflux surgery suggests a need for close proctorship for learning surgeons.

Opinion, uptake and current practice of robot-assisted upper gastrointestinal and oesophagogastric surgery in the UK: AUGIS national survey results

INTRODUCTION

The uptake of upper gastrointestinal (GI) robotic surgery in the United Kingdom (UK), and Europe more widely, is expanding rapidly. This study aims to present a current snapshot of the practice and opinions of the upper GI community with reference to robotic surgery, with an emphasis on tertiary cancer (oesophagogastric) resection centres.

METHODS

An electronic survey was circulated to the UK upper GI surgical community via national mailing lists, social media and at an open-invitation conference on robotic upper GI surgery in January 2023. The survey included questions on surgeons' current practice or planned adoption (if any) of robotics at individual and unit level, and their opinions on robotic upper GI surgery in general. Priority ranking and Likert-scale response options were used.

RESULTS

In total, 81 respondents from 43 hospitals were included. Thirty-four resectional centres responded, including 30 of 31 (97%) recognised upper GI cancer centres in England. Respondents reported performing robotic surgery in 21 of 34 (61.8%) resectional centres, with a median of 65 procedures per centre performed at the time of the survey (range 0-500, interquartile range 93.75). Every centre without a robotic programme expressed a desire or had active plans to implement one. Respondents ranked surgeon ergonomics as the most important reason for pursuing robotics, followed by improvements in patient outcomes and oncological efficacy.

CONCLUSIONS

Robotic upper GI practice is nascent but rapidly growing in the UK with plans for uptake in almost all tertiary centres. There is growing opinion that this is likely to become the predominant surgical approach in future with benefits to both patients and surgeons. This snapshot offers a point of reference to all stakeholders in upper GI surgery.

Exploring the Role of Intracorporeal Ultrasound in Partial Nephrectomies: A Systematic Review

Renal cell carcinoma accounts for the sixth most common cancer in the United Kingdom. With the increasing application of cross-sectional imaging, the frequency of incidental renal masses has increased over time. Laparoscopic and robot-assisted partial nephrectomy has become the standard of care in the management of size and stage-appropriate renal masses. The objective of this systematic review was to analyse the surgical outcomes when intracorporeal ultrasound was utilised as an adjunct in partial nephrectomy. A comprehensive search in PubMed and Google Scholar was performed in July 2024 for publications in the English language. The primary endpoint was to evaluate the role of intracorporeal ultrasound as an adjunct in robotic partial nephrectomies and its impact on tumour clearance. After identifying 609 records, 52 records were screened and 44 records were sought for retrieval. Eight publications were included in this systematic review comprising 765 patients. Seven of the eight studies reported outcomes from single centres. The mean percentage of negative surgical margins was 97.6% (range = 92.1-100%). The use of intracorporeal ultrasound as an adjunct in partial nephrectomy for T1 renal cell cancer has proven to improve the rates of negative surgical margins thereby reducing the incidence of local recurrence and distant metastasis.

Recent Advances in Robotic Surgery for Urologic Tumors

This review discusses recent advances in robotic surgery for urologic tumors, focusing on three key areas: robotic systems, assistive technologies, and artificial intelligence. The Da Vinci SP system has enhanced the minimally invasive nature of robotic surgeries, while the Senhance system offers advantages such as tactile feedback and eye-tracking capabilities. Technologies like 3D reconstruction combined with augmented reality and fluorescence imaging aid surgeons in precisely identifying the anatomical relationships between tumors and surrounding structures, improving surgical efficiency and outcomes. Additionally, the development of artificial intelligence lays the groundwork for automated robotics. As these technologies continue to evolve, we are entering an era of minimally invasive, precise, and intelligent robotic surgery.

Role of Robotic-Assisted Surgery in Public Health: Its Advantages and Challenges

The modern hospital setting is closely related to engineering and technology. In a hospital, modern equipment is abundant in every department, including the operating room, intensive care unit, and laboratories. Thus, the quality of treatment provided in hospitals and technology advancements are closely tied. Robotic systems are used to support and improve the accuracy and agility of human surgeons during medical procedures. This surgical approach is commonly referred to as robotic surgery or robotic-assisted surgery (RAS). These systems are not entirely autonomous; they are managed by skilled surgeons who carry out procedures with improved accuracy and minimized invasiveness using a console and specialized instruments. Because RAS offers increased surgical precision, less discomfort after surgery, shorter hospital stays, and faster recovery time, all of which improve patient outcomes and lessen the strain on healthcare resources, it plays a critical role in public health. Its minimally invasive technique benefits patients and the healthcare system by lowering problems, reducing the requirement for blood transfusions, and reducing the danger of infections related to medical care. Furthermore, the possibility of remote surgery via robotic systems can increase access to specialized care, reducing regional differences and advancing fairness in public health. In this review article, we will be covering how RAS has its role in public health.

Robotic pyeloplasty: Technological global panacea or geo-surgical nightmare?

To the Editor, Pelvi-ureteric junction obstruction (PUJO) is a well-recognised clinical entity characterised by functionally significant impairment of drainage of urine at the level of the pelvi-ureteric junction due to extrinsic or intrinsic obstruction and is encountered both by adult and paediatric urologists alike. Management of PUJO has been surgical historically, and the gold standard has been an open Anderson-Hynes dismembered pyeloplasty [...].

Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England

BACKGROUND

Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity.

METHODS

Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis.

RESULTS

A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS.

CONCLUSIONS

MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.

Robotic and laparoscopic gynaecological surgery: a prospective multicentre observational cohort study and economic evaluation in England

OBJECTIVE

To compare the health-related quality of life and cost-effectiveness of robot-assisted laparoscopic surgery (RALS) versus conventional 'straight stick' laparoscopic surgery (CLS) in women undergoing hysterectomy as part of their treatment for either suspected or proven gynaecological malignancy.

DESIGN

Multicentre prospective observational cohort study.

SETTING

Patients aged 16+ undergoing hysterectomy as part of their treatment for gynaecological malignancy at 12 National Health Service (NHS) cancer units and centres in England between August 2017 and February 2020.

PARTICIPANTS

275 patients recruited with 159 RALS, 73 CLS eligible for analysis.

OUTCOME MEASURES

Primary outcome was the European Organisation for Research and Treatment of Cancer Quality of Life measure (EORTC). Secondary outcomes included EuroQol-5 Dimension (EQ-5D-5L) utility, 6-minute walk test (6MWT), NHS costs using pounds sterling (£) 2018-2019 prices and cost-effectiveness. The cost-effectiveness evaluation compared EQ-5D-5L quality adjusted life years and costs between RALS and CLS.

RESULTS

No difference identified between RALS and CLS for EORTC, EQ-5D-5L utility and 6MWT. RALS had unadjusted mean cost difference of £556 (95% CI -£314 to £1315) versus CLS and mean quality adjusted life year (QALY) difference of 0.0024 (95% CI -0.00051 to 0.0057), non-parametric incremental cost-effectiveness ratio of £231 667per QALY. For the adjusted cost-effectiveness analysis, RALS dominated CLS with a mean cost difference of -£188 (95% CI -£1321 to £827) and QALY difference of 0.0024 (95% CI -0.0008 to 0.0057).

CONCLUSIONS

Findings suggest that RALS versus CLS in women undergoing hysterectomy (after adjusting for differences in morbidity) is cost-effective with lower costs and QALYs. Results are highly sensitive to the usage of robotic hardware with higher usage increasing the probability of cost-effectiveness. Non-inferiority randomised controlled trial would be of benefit to decision-makers to provide further evidence on the cost-effectiveness of RALS versus CLS but may not be practical due to surgical preferences of surgeons and the extensive roll out of RALS.

Utilising an accelerated Delphi process to develop consensus on the requirement and components of a pre-procedural core robotic surgery curriculum

Robot-assisted surgery (RAS) continues to grow globally. Despite this, in the UK and Ireland, it is estimated that over 70% of surgical trainees across all specialities have no access to robot-assisted surgical training (RAST). This study aimed to provide educational stakeholders guidance on a pre-procedural core robotic surgery curriculum (PPCRC) from the perspective of the end user; the surgical trainee. The study was conducted in four Phases: P1: a steering group was formed to review current literature and summarise the evidence, P2: Pan-Specialty Trainee Panel Virtual Classroom Discussion, P3: Accelerated Delphi Process and P4: Formulation of Recommendations. Forty-three surgeons in training representing all surgical specialties and training levels contributed to the three round Delphi process. Additions to the second- and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥ 80% agreement. There was 100% response from all three rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of > 0.8. There was 97.7% agreement that a standardised PPCRC would be advantageous to training and that, independent of speciality, there should be a common approach (95.5% agreement). Consensus was reached in multiple areas: 1. Experience and Exposure, 2. Access and context, 3. Curriculum Components, 4 Target Groups and Delivery, 5. Objective Metrics, Benchmarking and Assessment. Using the Delphi methodology, we achieved multispecialty consensus among trainees to develop and reach content validation for the requirements and components of a PPCRC. This guidance will benefit from further validation following implementation.

Nurses' perceptions and experiences of robotic assisted surgery (RAS): An integrative review

AIM

To identify and review published literature on the perceptions and experience of nurses working with RAS.

BACKGROUND

Robotic assisted surgery (RAS) is rapidly becoming accepted as the elite modality for surgery since its introduction in the 1980 s, more recently there has been a rising trend of use with several specialities operating using this technology. The role of nurses in perioperative care has been described as maintaining the momentum of the patient's journey. Patients undergoing RAS require nursing care throughout their journey, therefore knowledge of nurses' experiences and perceptions of RAS is important to identifying nurse education and development needs.

DESIGN

Integrative literature review DATABASE SOURCES: Databases searched for peer reviewed studies included CINAHL, Academic Search Complete, EMBASE, Scopus, ADA Psycinfo, Medline.

REVIEW METHODS

A comprehensive database search was conducted following PRISMA guidelines. Six databases were searched with 523 screened for eligibility. Ten studies were included in the review seven qualitative and three quantitative.

RESULTS

Ten studies were identified, critically appraised and synthesised using thematic analysis. All studies were conducted with nurses in the perioperative environment. Key findings were that nurses education regarding RAS is limited with more emphasis placed on surgeon education and training. There was evidence that nurses experienced a lack of education, training and information as barriers to their role which subsequently raised their stress levels.

CONCLUSION

Evidence suggests a clear need for education and training for nurses working with RAS. In addition, nurses working with RAS provide care preoperatively, intraoperatively, postoperatively and post discharge in the community. However, no research has been conducted with nurses outside of the perioperative environment. Further research is required to understand the experiences and perceptions of nurses working with RAS patients in all care settings to identify their education and development needs.

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer

Importance

The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.

Objectives

To compare the cost-effectiveness of iRARC with that of ORC.

Design, Setting, and Participants

This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.

Interventions

Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169).

Main Outcomes and Measures

Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.

Results

A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.

Conclusions and Relevance

In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT03049410.

The Availability, Cost, Limitations, Learning Curve and Future of Robotic Systems in Urology and Prostate Cancer Surgery

Robot-assisted surgical systems (RASS) have revolutionised the management of many urological conditions over the last two decades with robot-assisted radical prostatectomy (RARP) now being considered by many to be the preferred surgical approach. Intuitive Surgical has dominated the market during this time period with successive iterations of the da Vinci model. The expiration of patents has opened the RASS market and several new contenders have become available or are currently in development. This comprehensive narrative review aims to explore the merits of each robotic system as well as the evidence and barriers to their use. The newly developed RASS have increased the versality of robotic surgical systems to a wider range of settings through advancement in technology. The increased competition may result in an overall reduction in cost, broadening the accessibility of RASS. Learning curves and training remain a barrier to their use, but the situation appears to be improving through dedicated training programmes. Outcomes for RARP have been well investigated and tend to support improved early functional outcomes. Overall, the rapid developments in the field of robot-assisted surgery indicate the beginning of a promising new era to further enhance urological surgery.

The Atlantic divide: contrasting surgical robotics training in the USA, UK and Ireland

The uptake of robotic surgery is rapidly increasing worldwide across surgical specialties. However, there is currently a much higher use of robotic surgery in the United States of America (USA) compared to the United Kingdom (UK) and Ireland. Reduced exposure to robotic surgery in training may lead to longer learning curves and worse patient outcomes. We aimed to identify whether any difference exists in exposure to robotic surgery during general surgical training between trainees in the USA, UK and Ireland. Over a 15-week period from September 2021, a survey was distributed through the professional networks of the research team. Participants were USA, UK or Irish trainees who were part of a formal general surgical training curriculum. 116 survey responses were received. US trainees (n = 34) had all had robotic simulator experience, compared to only 37.93% of UK (n = 58) and 75.00% of Irish (n = 24) trainees (p <  0.00001). 91.18% of US trainees had performed 15 or more cases as the console surgeon, compared to only 3.44% of UK and 16.67% of Irish trainees (p <  0.00001). Fifty UK trainees (86.21%) and 22 Irish trainees (91.67%) compared to 12 US trainees (35.29%) do not think they have had adequate robotics training (p <  0.00001). Surgical trainees in the USA have had significantly more exposure to training in robotic surgery than their UK and Irish counterparts.

Embracing robotic surgery in low- and middle-income countries: Potential benefits, challenges, and scope in the future

Robotic surgery has applications in many medical specialties, including urology, general surgery, and surgical oncology. In the context of a widespread resource and personnel shortage in Low- and Middle-Income Countries (LMICs), the use of robotics in surgery may help to reduce physician burnout, surgical site infections, and hospital stays. However, a lack of haptic feedback and potential socioeconomic factors such as high implementation costs and a lack of trained personnel may limit its accessibility and application. Specific improvements focused on improved financial and technical support to LMICs can help improve access and have the potential to transform the surgical experience for both surgeons and patients in LMICs. This review focuses on the evolution of robotic surgery, with an emphasis on challenges and recommendations to facilitate wider implementation and improved patient outcomes.

Environmental sustainability in robotic and laparoscopic surgery: systematic review

BACKGROUND

Minimally invasive surgical (MIS) techniques are considered the gold standard of surgical interventions, but they have a high environmental cost. With global temperatures rising and unmet surgical needs persisting, this review investigates the carbon and material footprint of MIS and summarizes strategies to make MIS greener.

METHODS

The MEDLINE, Embase, and Web of Science databases were interrogated between 1974 and July 2021. The search strategy encompassed surgical setting, waste, carbon footprint, environmental sustainability, and MIS. Two investigators independently performed abstract/full-text reviews. An analysis of disability-adjusted life years (DALYs) averted per ton of carbon dioxide equivalents (CO2e) or waste produced was generated.

RESULTS

From the 2456 abstracts identified, 16 studies were selected reporting on 5203 MIS procedures. Greenhouse gas (GHG) emissions ranged from 6 kg to 814 kg CO2e per case. Carbon footprint hotspots included production of disposables and anaesthetics. The material footprint of MIS ranged from 0.25 kg to 14.3 kg per case. Waste-reduction strategies included repackaging disposables, limiting open and unused instruments, and educational interventions. Robotic procedures result in 43.5 per cent higher GHG emissions, 24 per cent higher waste production, fewer DALYs averted per ton of CO2, and less waste than laparoscopic alternatives.

CONCLUSION

The increased environmental impact of robotic surgery may not sufficiently offset the clinical benefit. Utilizing alternative surgical approaches, reusable equipment, repackaging, surgeon preference cards, and increasing staff awareness on open and unused equipment and desflurane avoidance can reduce GHG emissions and waste.

The role of the bedside assistant in robot-assisted surgery: A critical synthesis

INTRODUCTION

Robot-assisted surgery has grown exponentially since its inception and first approval in the United States in the year 2000. The surgeon operating with the assistance of the robot sits remotely to the patient and another practitioner assists at the bedside. The role of the bedside assistant and the training that is required to undertake this role are understudied topics.

AIM

To explore the functions, training and professional development of the bedside assistant in robot-assisted surgery and propose the necessary foundations for the safe enactment of the role in the United Kingdom.

METHODS

Through critical interpretative synthesis, relevant literature was systematically searched and analysed to inform integration of evidence.

RESULTS

Seventy-three studies were retrieved from the literature, across several health care disciplines and surgical specialities. These were critically analysed to inform a theoretically sound account grounded on evidence.

CONCLUSION

The role, functions and skills of the bedside assistant in robot-assisted surgery vary across contexts. These were analysed and critically synthetised to produce several keys to the success of bedside assistants in robot-assisted surgery in the context of the United Kingdom and of its national regulations.

Cost-effectiveness of Robotic-Assisted Radical Prostatectomy for Localized Prostate Cancer in the UK

IMPORTANCE

The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in surgical equipment costs due to their shared use by different clinical specialties necessitate an updated cost-effectiveness analysis in a centralized, largely government-funded health care system such as the UK National Health Service (NHS).

OBJECTIVE

To compare robotic-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) and laparoscopic-assisted radical prostatectomy (LRP) using contemporary data on clinical outcomes, costs, and surgical volumes in the UK.

DESIGN, SETTING, AND PARTICIPANTS

This economic analysis used a Markov model developed to compare the cost-effectiveness of RARP, LRP, and ORP to treat localized prostate cancer. The model was constructed from the perspective of the UK NHS. The model simulated 65-year-old men who underwent radical prostatectomy for localized prostate cancer and were followed up for a 10-year period. Data were analyzed from May 1, 2020, to July 31, 2021.

EXPOSURES

Robotic-assisted radical prostatectomy, LRP, and ORP.

MAIN OUTCOMES AND MEASURES

Quality-adjusted life-years (QALYs), costs (direct medical costs and costs outside the NHS), and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared with LRP, RARP cost £1785 (US $2350) less and had 0.24 more QALYs gained; thus, RARP was a dominant option compared with LRP. Compared with ORP, RARP had 0.12 more QALYs gained but cost £526 (US $693) more during the 10-year time frame, resulting in an ICER of £4293 (US $5653)/QALY. Because the ICER was below the £30 000 (US $39 503) willingness-to-pay threshold, RARP was more cost-effective than ORP in the UK. The most sensitive variable influencing the cost-effectiveness of RARP was the lower risk of biochemical recurrence (BCR). Scenario analysis indicated RARP would remain more cost-effective than ORP as long as the BCR hazard ratios comparing RARP vs ORP were less than 0.99.

CONCLUSIONS AND RELEVANCE

These findings suggest that in the UK, RARP has an ICER lower than the willingness-to-pay threshold and thus is likely a cost-effective surgical treatment option for patients with localized prostate cancer compared with ORP and LRP. The results were mainly driven by the lower risk of BCR for RARP. These findings may differ in other health care settings where different thresholds and costs may apply.

The Ethical Digital Surgeon

This viewpoint explores the ethical and regulatory consequences of the digital transformation of the operating room. Surgical robotics is undergoing significant change and future advances will center around the capture and use of data. The consequences of creating this surgical data pipeline must be understood and digital surgical systems must prioritize the safeguarding of patient data. Moreover, data protection laws and frameworks must adapt to the changing nature of surgical data. Finally, digital surgeons must understand changing data legislation and best practice on data governance to act as guardians not only for their own but also for their patients’ data.