The evolving use of robotic surgery: a population-based analysis

Introduction: Robotic surgery has rapidly been integrated into the Canadian health care system despite limited evidence demonstrating its clinical benefit. Our objectives were to describe secular trends and patient- and system-level determinants of the receipt of robotic rather than open or laparoscopic surgery. Methods: This population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent 1 of the 4 commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy or partial nephrectomy. For each procedure, patients were categorized on the basis of surgical approach: robotic versus open or laparoscopic. Multivariable regression models characterized the trend of robotic surgery use and the association of patient and systems characteristics with the surgical approach received. Results: A total 24 741 patients had radical prostatectomy, 75 473 total hysterectomy, 18 252 thoracic lobectomy and 4608 partial nephrectomy. After adjusting for age, sex, comorbidities, disease stage (if applicable), socioeconomic status, rurality, teaching hospital status, physician volume and years in practice the overall rate of robotic surgery increased by 24% annually in Ontario: 13% increase in robotic radical prostatectomy, 9% in robotic total hysterectomy, 26% for thoracic lobectomy and 26% for partial nephrectomy. There were some variations in the association between patient- or system-level characteristics and the receipt of robotic surgery between the different procedures. Generally, across all procedures, patients with a lower comorbidity burden and earlier disease stage (when applicable) were more likely to receive robotic surgery than open or laparoscopic surgery. In addition, high-volume, early- to midcareer surgeons at teaching hospitals were more likely to provide robotic surgery. Conclusion: Use of robotic surgery has substantially increased in Ontario and is offered selectively. Further study of the real-world clinical outcomes and health care costs of this shift in practice is needed.