Why pay more for robot in breast surgery: literature review and analysis of costs

Introduction

The advent of robotic technology has marked a new era across various surgical specialties, offering enhanced precision, improved ergonomics, and the potential for better patient outcomes. One of its more recent applications is robot-assisted nipple-sparing mastectomy (R-NSM), in the field of breast surgery. Since its first reported use in 2014, R-NSM has gained international interest, with numerous surgical teams adopting and refining the technique (1-5).

In R-NSM, surgeons rely on robotic arms and 3D visualization systems to perform the dissection, enabling the incision to be placed away from the breast, avoiding visible scarring. This technique provides enhanced visualization, and improves surgeon comfort compared to other minimally invasive techniques such as endoscopic-assisted nipple-sparing mastectomy (E-NSM) (6-8). Access is typically achieved via an axillary or lateral chest incision, through which the dissection planes are expanded using CO₂ insufflation. Once docked, the robot assists in a dissection similar to that of conventional NSM (C-NSM), particularly aiding in delicate areas like the nipple and inner quadrants. Reconstruction, usually implant-based, follows using the same incision, although autologous flap reconstructions have also been reported (1,2,9,10).

The learning curve for R-NSM varies with surgeon experience. Initial studies noted reduced operative time after just a few cases, with more recent data suggesting 20–30 procedures may be needed to reach proficiency (11-13). In the randomized controlled trial, R-NSM added about 1 hour and 18 minutes of operative time compared to C-NSM. This benchmark, reflecting surgeons without prior robotic experience, will be used as a reference in our cost evaluations, even if other reports, such as from Lai et al., suggest shorter time differences with broader surgeon and OR team experience (6,14).

Patient selection remains critical for optimal outcomes. Ideal candidates are those with smaller, non-ptotic breasts, early-stage cancer without nipple or skin involvement, and clinically negative axillary nodes. These features minimize risk and operative time during the learning curve. Even if the indication can be extended to patients with larger breasts after gaining proficiency, patients needing nipple repositioning or excess skin removal, common in larger or ptotic breasts, are less suited to R-NSM.

Regarding safety, pilot studies and a randomized trial have confirmed R-NSM’s non-inferiority to C-NSM, showing similar complication rates. A multi-center pooled analysis of 292 R-NSM and 463 C-NSM cases reported fewer complications in the robotic group, especially less nipple necrosis and grade III events, likely due to reduced tissue trauma and smaller incisions (9,14-18). These findings support its role in preserving both function and aesthetics.

Cosmetic outcomes and quality of life also favor R-NSM. By minimizing scarring and preserving tissue integrity, R-NSM has been associated with higher patient satisfaction and improved psychosocial outcomes. These benefits persist even at a long-term 12-month follow-up (14,16,17). Further studies are warranted to assess the potential for additional procedures such as fat grafting or implant adjustment.

Current oncological evidence, including a randomized trial and meta-analyses, indicates that R-NSM is oncologically safe, with comparable disease-free and overall survival rates to C-NSM (14,16,17,19,20). However, long-term data and large-scale studies are still needed to confirm these findings.

Regulatory status varies globally: both the Multiport and Single-Port (SP) Da Vinci systems are CE-marked in Europe and widely approved in Asia, while the U.S. FDA has not granted approval outside of clinical trials (19-21). Ongoing prospective trials in the U.S. are evaluating safety, conversion rates, and oncologic outcomes (19,20,22,23). Initial studies have already demonstrated the absence of residual breast tissue after R-NSM, which further supports its oncological adequacy (24,25). International collaboration will be key in solidifying the long-term safety profile of this technique.

Although R-NSM remains early in its adoption, its evidence base is substantive, including a randomized controlled trial in addition to multiple observational studies and meta-analyses, more than is available for many other mastectomy techniques.

Meanwhile, the financial implications of adopting robotic systems, including R-NSM, have sparked considerable debate (21,26). The high costs of acquisition and maintenance, combined with limited reimbursement for mastectomy procedures, raise concerns about its economic viability (22,27), and may vary considerably across different healthcare systems.

The primary aim of this study is to contribute to the literature by transparently reporting our institutional experience and real-world cost data on robotic mastectomy, as one of the most active referral centers for minimally invasive breast surgery in Europe. Given the limited number of detailed, transparent reports on real-world costs in breast surgery, sharing institutional experiences is essential to enable future comparisons and cumulative analyses.

Our intent is not to propose a universal model of economic sustainability or to stage a contest over which technique is less costly, but rather to provide transparent cost data on R-NSM relative to C-NSM, that remains the global standard of care. We present this article in accordance with the Narrative Review reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-351/rc).

Methods

This narrative review was conducted to evaluate the clinical, technical, and economic aspects of R-NSM in comparison to C-NSM, with a particular focus on cost components and institutional experience.

A literature search was performed using PubMed and Google Scholar, covering publications up to March 31, 2025. The search strategy included a combination of Medical Subject Headings (MeSH) and free-text terms, using keywords such as: “Robotic Nipple-Sparing Mastectomy”, “Robot-assisted Breast Surgery”, “R-NSM”, “Conventional NSM”, “Surgical outcomes”, “Oncological safety”, “Cost analysis”, and “Healthcare economics”.

No language restrictions were applied. Relevant studies in English and Italian were included. To supplement the literature review, we also consulted publicly available national and regional price lists and procurement registries in Italy to obtain real-world cost data for surgical materials and hospital resource usage (28).

Study selection was performed independently by three authors, with disagreements resolved through discussion with a fourth author and a senior reviewer. All authors contributed to the data synthesis, literature review, or cost breakdown analysis based on their clinical or research expertise.

A summary of the search strategy and inclusion criteria is provided in Table 1, along with the databases consulted and search terms applied.

Artificial intelligence assistance (ChatGPT, GPT-4, OpenAI) was used for limited support in language rephrasing, clarity enhancement, and formatting improvements during manuscript preparation.

Economic considerations—why pay more for robot

The integration of robotic systems into surgeries such as R-NSM has prompted intense discussion over their financial sustainability (21,26). The substantial investment required for system purchase and upkeep, combined with limited reimbursement for mastectomy procedures, continues to raise doubts about the cost-effectiveness of R-NSM in routine clinical practice (22,27).

While robotic technology introduces precision and efficiency to surgery, these advantages come at a greater financial cost compared to traditional methods (29,30). In the context of breast surgery, particularly R-NSM, these costs may be offset by other considerations.

Reduced need for secondary procedures (complications management, 2-step reconstruction)

One key argument in favor of R-NSM is its potential to reduce complications such as skin and nipple necrosis, which can occur in up to 30% of C-NSM cases according to some series (31,32). R-NSM may lower these rates due to less traumatized skin flaps and shorter incisions (14-17,33). Robotic precision minimizes tissue traction and trauma, helping preserve breast aesthetics and function while facilitating direct-to-implant reconstruction, potentially reducing the need for secondary procedures (16,17,24). In the randomized trial, tissue expander use was significantly lower in the R-NSM group (12.5%) versus C-NSM (27.5%) (14).

While these findings suggest a potential for long-term cost savings by reducing secondary interventions, such outcomes remain difficult to quantify due to the lack of standardized published data, variability across case series, and differences in reconstructive practices among institutions and plastic surgery teams. Furthermore, the recent shift toward one-stage reconstruction using advanced materials and techniques, many of which were not widely available until a few years ago, adds complexity to direct comparisons.

Market dynamics and institutional strategy

The economic landscape of robotic surgery is rapidly evolving. The emergence of new devices and manufacturers is expected to drive down costs and stimulate innovation (18,34). As more centers adopt robotic systems prices will reduce, and wider access and improved cost-efficiency may follow.

Beyond direct financial considerations, robotic procedures like R-NSM may offer strategic benefits to institutions. Hospitals with advanced surgical platforms and specialized teams often gain visibility and reputational value (35,36). Patient demand for minimally invasive, cosmetically favorable options can increase surgical volume, which not only enhances institutional number of cases and reimbursement, but also expands opportunities for clinical research. Higher patient enrollment facilitates participation in trials and innovation studies, ultimately benefiting patient care and outcomes.

Patient preferences are increasingly influencing regulatory and institutional investment decisions. Studies show that patients prioritize cosmetic results, quicker recovery, and overall quality of life in addition to oncologic safety (35). These expectations can play a role in shaping hospital policy, such as decisions to invest in robotic platforms and make them available across multiple specialties, including breast surgery.

Perspective from other specialties (brief overview)

While evidence from breast surgery continues to grow, similar cost-effectiveness discussions are taking place in other fields such as liver, gynecologic, pancreatic, thoracic, and prostate surgery (37-40). Studies in liver and pancreatic surgery have shown that robotic approaches, despite higher initial costs, can reduce complications and hospital stays (41,42). In gynecologic and abdominal surgeries, robotic techniques have shortened recovery times and decreased readmission rates (43,44). Likewise, thoracic and prostate procedures have demonstrated benefits such as reduced blood loss and fewer complications (45-48).

Although variability exists in study design and endpoints, the overall trend suggests that the clinical benefits of robotic surgery may justify higher upfront investments, especially when viewed from a long-term healthcare resource perspective.

Economic considerations—how much more

Understanding the cost differential between C-NSM and R-NSM is central to evaluating the sustainability of adopting robotic techniques in breast surgery. As highlighted by international consensus recommendations (49), a detailed assessment of these costs is critical for informing clinical decisions and institutional investments.

In this section, we break down the main contributors to the added cost of R-NSM, based on both published literature and our own institutional experience using the multiport and SP Da Vinci robotic systems. The financial analysis must consider multiple layers: operative time, material costs, and infrastructure amortization, against potential gains in outcomes, efficiency, and patient satisfaction.

Operating room time

The most immediate cost difference lies in operative time. The randomized controlled trial (14) demonstrated that R-NSM (Multiport) adds approximately 1 hour and 18 minutes per procedure compared to C-NSM. Our initial experience with the SP system shows a comparable time extension. At our institutional cost of approximately 800 EUR per OR hour, this adds around 1,040 EUR per R-NSM procedure. Importantly, this additional time tends to decrease as the surgical team advances along the learning curve (6).

Disposable and semi-disposable materials

R-NSM incurs significantly higher costs for disposable materials. These include robotic sterile kits, arm covers, single-access ports, cannula reducers, and dedicated introducers and instruments (3,33,50,51). In our institution, this totals about 2,293 EUR for Multiport and 2,401 EUR for SP: approximately 2,000 EUR more than C-NSM (28).

Semi-disposable tools like robotic scissors and graspers also contribute to incremental cost. Although these instruments are reusable for 10–25 cases depending on the model, they still add 662–801 EUR per procedure based on distributed cost (28). These figures can vary by institution and procurement terms.

Robotic platform and maintenance

The acquisition cost of a robotic system ranges from 1.5 to 3 million EUR, excluding annual maintenance (28). While this is not calculated into per-case costs, hospitals with high robotic case volume across specialties can dilute amortization costs over time. For this reason, robotic system investment must be considered within a strategic institutional framework rather than case-by-case decisions.

Comparative cost summary

In our center, the estimated average cost of C-NSM is around 4,500 EUR. In comparison, Multiport R-NSM costs about 8,195±1,040 EUR, and SP R-NSM costs approximately 8,442±790 EUR. This translates to an additional +3,695 EUR and +3,942 EUR, respectively, excluding fixed costs such as platform acquisition and reusable optics. These differences are detailed in Table 2.

Despite the slightly higher cost of the SP system (+247 EUR on average), the difference falls well within 1 standard deviation (SD) and has a very small Cohen’s d effect size (~0.27), indicating that the variance is negligible. This suggests that, from a purely cost perspective, the decision between Multiport and SP may not be significant.

International comparison

To place these findings in a broader context, we compared our local data, converted from EUR to USD, with reports from other countries. As shown in Table 3, published studies consistently show R-NSM costs more than C-NSM by approximately 2,060 to 5,175 USD.

This cross-regional alignment reinforces the conclusion that while robotic mastectomy adds financial burden per case, the range of added costs is relatively consistent, and the long-term impact will depend on institutional use patterns, reimbursement models, regional economic conditions and evolving market dynamics.

Discussion

R-NSM has emerged as an innovative minimally invasive technique, proposing advantages in cosmetic outcomes, precision, and ergonomics for surgeons. Evidence from clinical trials and meta-analyses suggests that R-NSM is at least comparable to conventional nipple-sparing mastectomy in terms of safety and oncologic efficacy, with some studies reporting lower complication rates, particularly regarding nipple necrosis and severe adverse events (9,14-18).

In this study, we chose to compare the costs of R-NSM with C-NSM rather than E-NSM for several reasons. First, endoscopic procedures can rely mainly on reusable laparoscopic instruments and equipment already available in virtually every operating room, and therefore do not incur substantial additional costs compared with conventional surgery—after the learning curve is completed and OR time becomes the same. In contrast, robotic procedures require dedicated consumables and semi-disposable tools that significantly increase per-case expenses. From an economic perspective, comparing robotic with endoscopic mastectomy is therefore economically equivalent to comparing robotic with conventional mastectomy. However, from a broader perspective, conventional NSM remains the most widely performed technique and the gold standard worldwide. Although indications for R-NSM and E-NSM are overlapping, making these techniques theoretically more comparable, in most settings the majority of eligible patients still undergo conventional open NSM, due to surgeon preference and institutional availability. Taken together, these considerations make the comparison with conventional mastectomy the most relevant and informative.

Despite the stated benefits of minimally invasive surgery, the financial burden of robotic surgery remains a central concern. Our cost analysis confirms that R-NSM is associated with an average additional cost of approximately 3,700–4,000 EUR per case, aligning with international reports showing differences ranging from 2,060 to over 5,100 USD (7,8,26,52). However, the sustainability of this cost differential depends on institutional factors such as surgical volume, access to shared robotic platforms, reimbursement models, and future reductions in technology cost.

Importantly, robotic surgery may reduce the need for secondary procedures, enable more efficient one-stage reconstructions, and improve patient satisfaction, factors that may lead to long-term savings and better quality of care. Though difficult to quantify precisely due to variability across centers and evolving reconstructive techniques, these aspects should be considered in prospective value-based evaluations of R-NSM (14,16,17,24).

Our experience shows negligible cost differences between Multiport and SP robotic systems (~247 EUR; Cohen’s d≈0.27), indicating that from a cost perspective alone, the choice between systems may be driven more by institutional logistics and equipment availability than by economic constraints. Nonetheless, as the SP system is more recent and less widespread, access may be limited for many institutions, and broader adoption will depend on market dynamics and further data on cost-efficiency.

The present analysis has several limitations that must be acknowledged. We did not incorporate potential indirect or secondary costs: hospital stay, which in our institution is comparable for both conventional and minimally invasive mastectomy (about 48 hours); postoperative pain management, because at our institution it is standardized with an initial analgesic regimen determined by the anesthesiologist during the first 24 hours, oral acetaminophen from post-operative day one with occasional intravenous support, and shows no differences between groups; and rehospitalization rate for surgical complications, which might represent an important cost component but will be specifically addressed in ongoing comparative trials with surgical outcomes as defined endpoints. Likewise, return to work, although highly relevant from a health economics perspective, is more influenced in our experience by adjuvant treatment and individual social factors than by surgical technique, and will be better evaluated in future quality-adjusted life year (QALY)-based studies.

Finally, while list prices of robotic consumables may be accessible at the institutional level, the true per-case cost is not universally established and remains unclear to many surgeons and institutions. We believe that transparent reporting of our institutional costs therefore provides meaningful value to the literature.

We acknowledge that this narrative review reflects the experience of a high-volume, specialized cancer center. Costs, resource utilization, and outcomes may differ significantly in smaller or lower-volume institutions. Furthermore, our study does not include formal cost-utility analyses using QALYs, increasingly recognized as essential in country-specific health economics, as the willingness-to-pay threshold in Italy is not fixed and such analyses were beyond the scope of the present study. As shown by Mok et al. (26), such models provide a comprehensive framework for comparing long-term value, and could be included in future economic evaluations of robotic breast surgery. It is important to emphasize that the findings presented here should not be generalized across different healthcare systems since costs, reimbursement schemes, and insurance coverage differ widely between countries.

Despite the limitations and beyond methodological choices, we believe that transparent reporting of institutional costs carries significant value for the scientific community. Only a limited number of centers have published detailed, itemized cost analyses, yet these data are consistently requested at international meetings and remain a central concern among surgeons and healthcare providers. By contributing our institutional experience, we aim not to suggest a contest over which technique is “cheaper,” but rather to provide practical, transparent information that enriches the collective evidence base. The more institutions contribute their data, the more accurate and comprehensive future comparative analyses will become.

Conclusions

In conclusion, R-NSM is a promising addition to the surgical options for treating breast cancer, offering advantages in specific clinical and patient-centered domains. However, its adoption must be guided by institutional capabilities, surgical expertise, and economic considerations. Ongoing research, including multi-center studies and QALY-based models, will be key to determining the role of robotic techniques in the standard care pathway for breast cancer.

Acknowledgments

The authors acknowledge the use of OpenAI’s ChatGPT (GPT-4) for partial assistance with language rephrasing and clarity enhancement during manuscript preparation.

Some preliminary data included in this manuscript were previously presented in abstract or poster form at the Global Breast Cancer Conference (GBCC) 2025, Seoul, South Korea, and at the American Society of Breast Surgeons (ASBrS) Annual Meeting 2025, Las Vegas, USA.

No other individuals contributed to this work in a manner warranting acknowledgment.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Visnu Lohsiriwat and Chayanee Sae-Lim) for the series “Transformative Approaches in Breast Surgery: Cutting-Edge Innovation, and Practice” published in Gland Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-351/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-351/prf

Funding: This work was supported by the Italian Ministry of Health, Ricerca Corrente 2025, FPRC 5x1000 MUR 2022- POLLINE, FPRC 5x1000 Ministero Salute 2023-ODEON.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-351/coif). The series “Transformative Approaches in Breast Surgery: Cutting-Edge Innovation, and Practice” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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