When the first laparoscopic nephrectomy was performed in 1990, urologists opened the door to minimally invasive approaches and improved patient outcomes in our field. New robotic surgical systems are being developed with modular designs, open access consoles, haptic feedback, smaller instruments, and machine learning integration. This surge in robotic surgery technologies promises to transform the landscape of surgical procedures in urology over the next 10 to 20 years.

For hospitals, the integration of robotic surgery signifies a paradigm shift toward minimally invasive procedures, offering benefits such as reduced patient discomfort, less blood loss, shorter hospital stays, and quicker recovery periods. For surgeons, it provides performance enhancement with improved visualization, tremor reduction, and ergonomic advantages, like the ability to sit rather than stand during long procedures. The introduction of robotic surgery also implies significant financial investment and a commitment to training and credentialing surgeons. Despite these challenges, the overall use of robotic surgery has grown substantially, with more than 12 million procedures performed globally and over 60,000 surgeons trained on the da Vinci system. The rising number of companies developing robotic surgery systems indicates a burgeoning market that is expected to foster increased competition, reduced costs, and heightened innovation.¹

While there are myriad advantages conferred by robot-assisted laparoscopic procedures, early data did not demonstrate a substantial advantage to the robotic platform²; however, more recent studies highlight reductions in short-term complication rates, surgeon fatigue, intraoperative blood loss, and postoperative analgesic usage.^3,4 Minimally invasive surgical approaches also improve scar cosmesis, and techniques have evolved to move incisions to cosmetically favorable sites.

The robotic platform first became available to our pediatric hospital in fall 2023, and the advantages have been immediately apparent. A planned reoperative pyeloplasty was easily transitioned to ureterocalicostomy. Use of the EndoWrist allowed retraction of a patulous kidney while simultaneously passing nephropexy sutures, unkinking an intrarenal ureteropelvic junction. An unexpected crossing vessel was found in a young infant, likely to have been missed in an open repair. Indocyanine green with use of the Firefly technology was found to be both more effective and less expensive than use of methylene blue. Operative times have quickly decreased and are already substantially shorter than for pure laparoscopic procedures.

The decision to start a robotics program was multifactorial, driven both by a desire to improve care for our patients and as a response to their demands. Costs of setting up a robotics program include capital acquisition, purchase of limited-use instruments, team training expenses, equipment maintenance, equipment repair, and operating room setup time. The average cost of the da Vinci robotic system is $1.4 million to $1.9 million, with annual maintenance approximately $240,000, though newer pay-per-click models are reducing the up-front costs. All necessary stakeholders in a hospital care system must address their direct needs in program development. To maintain the highest levels of patient care and safety, adequate training and credentialing procedures are necessary, as described in the AUA Standard Operating Practices for Urologic Robotic Surgery.⁵

When rigorously examined, newer robotic procedures generally cost more than their open counterparts. In the case of pediatric pyeloplasty, the median cost of an open vs robotic procedure in 2017 ranged from ∼$800 to more than $6100, with majority of the cost difference accounted for by operative time and supplies. There was substantial between-hospital variation in procedural cost, with an open pyeloplasty at 3 of the priciest hospitals costing more than a robotic pyeloplasty at other institutions.⁶

This variability is due in part to unavoidable capital and time expenditures when transitioning from open to robotic procedures, particularly novel procedures. When an established procedure such as robot-assisted laparoscopic prostatectomy is considered, the variability is minimized. A 2022 systematic review examining the cost-effectiveness of robot-assisted laparoscopic prostatectomy demonstrated a substantial increase in quality-adjusted life-years for the robotic cohort—albeit at a higher cost. When capital expenditures were not considered, the authors demonstrated cost savings for the robotic procedure.⁷ Additional concerns regarding the transition to a robotic practice include the perceived learning curve,⁸ which has become shorter as surgeons gain greater robotic experience during residency, as well as the environmental impact associated with use of disposable surgical instruments⁹ and progressive loss of open surgical skills among our resident trainees.¹⁰

Robotics is no longer the future of urologic surgery—it is the present. Earlier exposure to novel robotic tools will allow us to perform increasingly complex procedures in a minimally invasive fashion, while reducing morbidity to our patients and ourselves. We have all learned valuable lessons working backward to adapt open procedures to the robotic platform. Our trainees, who grew up in the robotic era, will likely use newer technologies to perform novel procedures in the near future. As the robotic toolkit continues to expand with next-generation innovations, it is our duty to use them wisely to improve patient care.