Transition to robotic surgery in urologic oncology: a comparative analysis between pre-robotic and robotic eras in a high-volume tertiary center

Abstract

The transition from open and laparoscopic techniques to robotic-assisted surgery has transformed the landscape of urologic oncology. However, few studies have directly compared institutional outcomes before and after the adoption of robotic platforms. The objective is to evaluate the clinical and organizational impact of implementing robotic surgery by comparing perioperative outcomes and hospital metrics between the pre-robotic era (2019–2020) and the robotic era (2021–2023) in a high-volume tertiary referral center. A retrospective cohort analysis was conducted on patients undergoing radical prostatectomy (RP), partial nephrectomy (PN), or radical cystectomy (RC) between January 2019 and December 2023. Surgical approach was laparoscopic (RP, PN) or open (RC) during 2019–2020, and robotic for all procedures from 2021 onward. Data on operative time, length of stay (LOS), extended hospitalizations (> 15 days), and 30-day readmissions were collected and compared between the two periods. A total of 1179 procedures were performed, with a marked increase in surgical volume after the implementation of robotic platforms (189 procedures in 2019–2020 vs. 990 in 2021–2023). The robotic era was associated with a significant reduction in median LOS across all procedures: RP (7.5–3.0 days), PN (6.5–4.1 days), and RC (15.5–7.3 days). The rate of extended hospitalizations dropped from 20.3 to 2.1% overall. Readmission rates remained stable, except for RC, which maintained a higher rate in both eras. Operative times remained comparable between the two periods. The transition to robotic-assisted surgery was associated with a substantial increase in surgical volume and significant improvements in perioperative outcomes, including shorter hospital stays and fewer prolonged admissions, while maintaining surgical safety. These results underscore that such improvements are primarily linked to the structured implementation of the program under the guidance of experienced robotic surgeons, rather than to the technology itself.

Introduction

Since its inception in the early 2000 s, robotic-assisted surgery has transformed the landscape of urologic oncology, becoming the preferred approach for complex procedures such as radical prostatectomy (RP), radical cystectomy (RC), and partial nephrectomy (PN). The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA), approved in 2000, provided a platform that addressed critical limitations of conventional laparoscopy—chiefly restricted maneuverability and two-dimensional vision—through improved dexterity, 3D imaging, tremor filtration, and ergonomics [1, 2].

While robotic-assisted radical prostatectomy (RARP) has become the gold standard for localized prostate cancer in many countries [3], similar adoption trends are now observed in robotic partial nephrectomy (RAPN) and robotic radical cystectomy (RARC), driven by the need for precision in anatomically constrained regions and the pursuit of organ preservation and functional outcomes [4–6].

Despite these advances, several barriers persist, including high initial investment, the need for specialized training, and variability in outcome reporting. Moreover, much of the existing literature derives from high-volume multicenter studies, which may obscure the nuances of implementation at the institutional level. Understanding how robotic programs evolve, adapt, and scale within single centers is critical for the generalizability and reproducibility of outcomes [7–9].

In our high-volume tertiary referral center, robotic platforms were introduced in 2021. The transition coincided with the appointment of A.P. as department chairman, an experienced robotic surgeon, whose leadership and expertise were pivotal in ensuring the safe adoption of robotic procedures. Prior to this, RP and PN were performed laparoscopically, and RC via open surgery. This unique transition allowed for a direct comparison of outcomes between two distinct surgical eras.

The aim of this study is to provide a 5-year comparative analysis of surgical activity, perioperative outcomes, and hospital metrics between the pre-robotic era (2019–2020) and the robotic era (2021–2023). By examining the evolution across three major oncologic procedures—RP, PN, and RC—this study offers practical insights for institutions planning or refining robotic surgery programs.

Materials and methods

This single-center, retrospective, observational cohort study was conducted at a high-volume tertiary referral center in Northern Italy (Veneto Institute of Oncology IOV-IRCCS, Padua). The primary objective was to evaluate the clinical and organizational impact of robotic surgery implementation by comparing perioperative outcomes, surgical volumes, and procedural efficiency between the pre-robotic era (Jan 2019–Dec 2020) and the robotic era (Jan 2021–Dec 2023).

Patients’ selection

Eligible patients were adults (≥ 18 years) diagnosed with histologically confirmed urologic malignancies of the prostate, kidney, or bladder, who underwent one of the following robotic procedures:

• Radical prostatectomy (RP)

• Partial nephrectomy (PN)

• Radical cystectomy (RC)

During the pre-robotic era, RP and PN were performed using conventional laparoscopic techniques, while RC was performed via open surgery. From 2021 onward, all procedures were intended to be performed robotically.

Patients were excluded if they had incomplete clinical records or if the procedure was converted to a different surgical approach.

In the robotic era, any intervention performed with an open approach or converted intraoperatively was excluded from the analysis to ensure methodological consistency.

Robotic program implementation

The robotic surgery program was formally launched in early 2021, with the introduction of a da Vinci Xi dual-console system. Crucially, the presence of a high-volume surgeon with prior robotic expertise allowed the program to bypass many of the typical limitations of the learning curve, highlighting the central role of the surgeon over the device itself.

A structured modular training pathway was developed, including virtual simulation, dual-console mentoring, supervised cases, and progressive autonomy for younger surgeons. A robotic-dedicated operating room was established, supported by uniform perioperative workflows, standardized anesthetic protocols, and adherence to Enhanced Recovery After Surgery (ERAS) principles. In parallel, a dedicated operating room team was formed, with scrub nurses and staff specifically trained in robotic procedures through a similar stepwise pathway of simulation, mentoring, supervised cases, and gradual autonomy.

Data collection and outcomes

Data were obtained from institutional surgical registries, electronic health records (EHRs), operative reports, and discharge summaries. Collected variables included patient demographics (age, sex, BMI). Intraoperative data encompassed the type and date of the procedure and total operative time (measured skin-to-skin). Postoperative information included the length of hospital stay, the occurrence of extended hospitalizations (defined as stays longer than 15 days), and readmissions within 30 days. To ensure objectivity and minimize reporting bias, all data were independently assessed by two urologists not directly involved in the surgical procedures.

All interventions were carried out by a dedicated team of high-volume urologic oncologists. The robotic program progressively expanded to include younger surgeons under supervision. Procedures were performed in a fully equipped, robotic-dedicated operating theater, following standardized perioperative workflows, uniform anesthetic protocols, and enhanced recovery after surgery (ERAS) principles [10].

Statistical analysis

Descriptive statistics were used to summarize the demographic, clinical, and perioperative characteristics of the study population. Categorical variables were reported as absolute numbers and corresponding percentages, while continuous variables were expressed as the mean with standard deviation (SD) for normally distributed data or as the median with interquartile range (IQR) for non-normally distributed data. The normality of distribution was assessed using the Shapiro–Wilk test.

Comparative analyses were conducted between the two predefined eras:

• Pre-robotic era (2019–2020): laparoscopic RP and PN, open RC

• Robotic era (2021–2023): RARP, RAPN, and RARC

Comparisons were performed both globally and stratified by procedure type (RP, PN, RC), evaluating differences in operative time, LOS, proportion of extended hospitalizations (> 15 days), and 30-day readmission rate.

Categorical variables were compared using the Chi-square test or Fisher’s exact test, depending on sample size. Continuous variables were compared using the Student’s t-test for normally distributed data or the Mann–Whitney U test for non-parametric data.

Temporal trends across the study period were also explored descriptively to illustrate the progressive institutional transition, but statistical comparisons focused primarily on the two aggregated periods.

No imputation was performed for missing data. All statistical tests were two-sided, and a p-value below 0.05 was considered indicative of statistical significance. Analyses were conducted using STATA/SE version 18.0 (StataCorp LLC, College Station, TX, USA).

Results

General trends and institutional growth

Over the 5-year study period (2019–2023), a total of 1179 major urologic oncology procedures were performed at our institution, including RP, PN, and RC. The surgical activity was stratified into two distinct eras:

• the pre-robotic era (2019–2020), during which 189 procedures were performed using laparoscopic (RP, PN) or open (RC) techniques

• the robotic era (2021–2023), during which 990 procedures were completed.

This shift represents a more than fivefold increase in surgical volume following the introduction of robotic technology, reflecting not only institutional investment in minimally invasive surgery but also the consolidation of surgical expertise and a growing acceptance among patients.

The most marked increase was observed in RP, with procedures increasing from 117 cases in the pre-robotic era to 622 in the robotic era, corresponding to a 431% increase.

PN and RC both showed similar increases, rising from 43 to 184 procedures (+ 328%) and 29 to 184 procedures (+ 534%), respectively.

Then annual volume for each procedure type and era is summarized in Table 1, which visually separates the pre-robotic (white background) and robotic periods (gray background).

Table 1.

Annual distribution of major urologic oncology procedures—radical prostatectomy (RP), partial nephrectomy (PN), and radical cystectomy (RC)—performed during the pre-robotic era (2019–2020, white background) and robotic era (2021–2023, gray background)

Procedure	Pre-robotic era		Total pre-robotic era	Robotic era			Total robotic era
	2019	2020		2021	2022	2023
RP	64	53	117	150	224	248	622
PN	19	24	43	55	61	68	184
RC	10	19	29	45	57	82	184
Total	93	96	189	250	342	398	990

The steepest rise occurred in 2021, the year robotic surgery was introduced, where overall volume jumped by 160% compared to the previous year (from 96 to 250 cases). Trends then stabilized, with continued growth in 2022 (+ 37%) and 2023 (+ 16%), as detailed in Table 2.

Table 2.

Annual number and year-over-year percentage change (Δ%) in major urologic oncology procedures—radical prostatectomy (RP), partial nephrectomy (PN), and radical cystectomy (RC)—performed between 2019 and 2023

Year	RP (n)	RP Δ%	PN (n)	RP Δ%	RC (n)	RP Δ%	Total procedures (n)	Total Δ % versus previous year
2019	64	–	19	–	10	–	93	–
2020	53	− 17.2	24	+ 26.3	19	+ 90	96	3
2021	150	+ 183	55	+ 129.2	45	+ 136.8	250	160
2022	224	+ 49	61	+ 10.9	57	+ 26.7	342	37
2023	248	+ 10.7	68	+ 11.5	82	+ 43.9	398	16

Δ% (delta) indicates the relative variation in the number of procedures compared to the previous year

White background indicates the pre-robotic era (2019–2020), while gray background indicates the robotic era (2021–2023)

These data are visually represented in Fig. 1, which clearly illustrates the transition between eras and the associated increase in procedural volume. The chart highlights the important expansion in robotic prostatectomies, as well as steady growth in robotic partial nephrectomy and cystectomy cases.

Fig. 1.

Annual number of major urologic oncology procedures—radical prostatectomy (RP), partial nephrectomy (PN), and radical cystectomy (RC)—performed between 2019 and 2023. The pre-robotic era (2019–2020) is shown in light red background, and the robotic era (2021–2023) in light blue

In addition to the shift toward RARC, the type of urinary diversion evolved substantially over the study period. In the pre-robotic era (2019–2020), orthotopic neobladders accounted for 9% of cases. In contrast, during the robotic era (2021–2023), the rate increased to 16%. This reflects a progressive expansion of reconstructive expertise and patient selection criteria over time.

Operative times

Table 3 reports the operative times, expressed in minutes, for RP, PN, and RC, stratified by year from 2019 to 2023. For each procedure and year, the median operative time is presented with interquartile ranges (IQR), providing a standardized summary of surgical duration over time.

Table 3.

Median operative times (in minutes) with interquartile ranges (IQR) for robotic-assisted radical prostatectomy (RARP), partial nephrectomy (RAPN), and radical cystectomy (RARC) from 2019 to 2023

Year	RP	PN	RC
2019	160 (145–172)	141 (113–185)	286 (241–312)
2020	158 (143–170)	120 (100–156)	280 (238–315)
2021	138 (125–158)	137 (110–153)	250 (213–286)
2022	140 (128–160)	117 (99.5–139)	276 (238–312)
2023	118 (105–132)	135 (109–152)	260 (212–285)

A comparison between the pre-robotic era (2019–2020) and the robotic era (2021–2023) reveals distinct trends across procedures:

• RP showed a clear and progressive reduction in operative time, with the median dropping from 160 min in 2019 to 118 min in 2023

• PN showed more variability. While the median operative time was slightly lower in 2020 (120 min), it increased in 2021 (137 min) and then stabilized around 135 min in 2023

• RC exhibited a meaningful decrease in operative time, with a median of 286 min in 2019 compared to 260 min in 2023. Despite a temporary rise in 2022, the overall trend supports a gain in efficiency following the transition to a robotic technique.

Overall, the transition to a robotic surgical platform did not lead to longer operative times. On the contrary, particularly for RP and RC, it coincided with a measurable improvement in surgical efficiency. Importantly, this trend should also be interpreted in light of the learning curve of less-experienced surgeons who began their robotic training in 2021, as well as the progressive standardization of perioperative workflows and the dedicated training of the entire operating room team (including anesthesiologists, scrub nurses, and staff), which collectively contributed to greater efficiency over the study period.

Hospital stays and readmission

The overall trends in hospital stay duration and incidence of extended hospitalization (> 15 days) by procedure type are graphically represented in Figs. 2 and 3. These visual summaries reveal a consistent and progressive reduction in median LOS over the years for all three procedures, with a marked shift following the introduction of robotic surgery in 2021.

Fig. 2.

Median hospital length of stay (LOS) by procedure type—radical prostatectomy (RP), partial nephrectomy (PN), and radical cystectomy (RC)—from 2019 to 2023. The background shading indicates the pre-robotic era (2019–2020, light red) and the robotic era (2021–2023, light blue)

Fig. 3.

Percentage of patients with extended hospital stay (> 15 days) by procedure type—radical prostatectomy (RP), partial nephrectomy (PN), and radical cystectomy (RC)—from 2019 to 2023. The background shading indicates the pre-robotic era (2019–2020, light red) and the robotic era (2021–2023, light blue)

The transition from the pre-robotic era was associated with a notable decline in LOS across all procedures. This was particularly evident for RC, where median LOS decreased from 17 days in 2019 to less than 7 days in 2023. Detailed data and specific analyses are provided in the following sections.

Figure 3 further illustrates a sharp decline in the percentage of patients requiring prolonged hospitalization (> 15 days), particularly for RC, where the proportion fell from 80% in 2019 to just 3.7% in 2023. This trend was paralleled by the near disappearance of extended stays in RP and consistently low rates in PN. Detailed data and specific analyses are provided in the following sections.

The trend in 30-day hospital readmissions by procedure type is illustrated in Fig. 4. Following the transition to the robotic era in 2021, readmission rates for RP and PN remained consistently low, with values generally below 2%.

Fig. 4.

Percentage of 30 days hospital readmissions by procedure type—radical prostatectomy (RP), partial nephrectomy (PN), and radical cystectomy (RC)—from 2019 to 2023. The background shading indicates the pre-robotic era (2019–2020, light red) and the robotic era (2021–2023, light blue)

In contrast, RC demonstrated persistently higher readmission rates, ranging from 5.3 to 13.3%, with a peak in 2021. This trend likely reflects the higher complexity and perioperative morbidity associated with RC. Notably, during the robotic era, there was a marked increase in the proportion of patients undergoing orthotopic neobladder reconstruction, which may have contributed to the transient rise in readmissions due to the more demanding postoperative management of this urinary diversion. Further analyses are provided in the dedicated outcomes sections.

Radical prostatectomy outcomes

RP represented the most frequently performed procedure across the study period, with a total of 739 interventions—117 in the pre-robotic era and 662 in the robotic era.

The introduction of a robotic platform in 2021 led to a steady and marked increase in surgical volume, culminating in more than a fivefold growth compared to the early period. Notably, this institutional expansion was not accompanied by a deterioration in outcomes. On the contrary, key perioperative metrics significantly improved, despite the increased procedural load.

Median hospital stay decreased significantly from 9 days in the pre-robotic era to 3 days in the robotic era, reflecting a relative reduction of nearly 70%. Similarly, the proportion of patients with extended hospitalizations (> 15 days) dropped from 9.4% in the first year to just 0.4% in 2023.

Despite the rise in procedural volume, 30-day readmission rates remained low and stable across both eras. Specifically, readmissions ranged from 0.7 to 3.1%, with only minor annual fluctuations and no clear upward trend.

These findings underscore the clinical and organizational benefits of a structured robotic program, demonstrating that scaling up surgical activity can coexist with enhanced efficiency and sustained postoperative outcomes. All related data are summarized in Table 4.

Table 4.

Perioperative outcomes for radical prostatectomy from 2019 to 2023, stratified by surgical era

Median (1st–3rd q) or n (%)	Pre-robotic era		Robotic era
	2019	2020	2021	2022	2023
Number of procedures	64	53	150	224	248
Length of hospital stay (days)	9 (8–11)	7 (6–9)	3.5 (3–4)	3 (2.5–3.5)	2.8 (2.3–3.3)
Extended hospital stay (> 15 days)	6 (9.4%)	0 (0%)	0 (0%)	0 (0%)	1 (0.4%)
Readmissions within 30 days	2 (3.1%)	1 (1.9%)	1 (0.7%)	2 (0.9%)	5 (2%)

Data include number of cases, median hospital stay, proportion of extended hospitalizations (> 15 days), and 30-day readmission rates. White background indicates the pre-robotic era (2019–2020), while gray background indicates the robotic era (2021–2023)

Radical cystectomy outcomes

A total of 213 radical cystectomies were performed during the study period, with 29 cases in the pre-robotic era and 184 in the robotic era. The transition to robotic surgery was accompanied by a substantial increase in surgical volume—rising from 10 procedures in 2019 to 82 in 2023—and a marked improvement in perioperative outcomes.

Median LOS decreased significantly, from 17 days in 2019 to 7 days in 2023, corresponding to a 59% reduction. The proportion of patients experiencing extended hospitalizations (> 15 days) dropped markedly from 80% in 2019 to 3.7% in 2023. Readmission rates, however, remained relatively high compared to other procedures, fluctuating between 5.3 and 13.3%. This variability may be partly explained by the shift in urinary diversion practices over time. In the pre-robotic era, orthotopic neobladder reconstructions were rarely performed (5 cases), whereas in the robotic era, 25 neobladders were constructed—likely contributing to a more complex postoperative course and greater readmission risk. All outcome data are summarized in Table 5.

Table 5.

Perioperative outcomes for radical cystectomy during the pre-robotic era (2019–2020) and robotic era (2021–2023), including number of cases, median hospital stay, proportion of extended hospitalizations (> 15 days), and 30-day readmission rates

Median (1st–3rd q) or n (%)	Pre-robotic era		Robotic era
	2019	2020	2021	2022	2023
Number of procedures	10	19	45	57	82
Length of hospital stay (days)	17 (15–20)	14 (12–17)	7.5 (6–9)	7.5 (6–9)	7 (6–8)
Extended hospital stay (> 15 days)	8 (80%)	9 (47.4%)	3 (6.7%)	6 (10.5%)	3 (3.7%)
Readmissions within 30 days	1 (10%)	1 (5.3%)	6 (13.3%)	6 (10.5%)	10 (12.2%)

White background indicates the pre-robotic era (2019–2020), while gray background indicates the robotic era (2021–2023)

To address the potential bias introduced by the implementation of intracorporeal neobladder reconstruction in the robotic era, we performed a sub-analysis of perioperative outcomes of RARC stratified by the type of urinary diversion. In the pre-robotic era, only five neobladders were performed compared to 25 in the robotic cohort. When the analysis was restricted to patients undergoing ileal conduit diversion, the significant reduction in length of hospital stay (median 15 [13–17] vs. 7 [6–8] days) and in the rate of prolonged hospitalization (> 15 days: 58.3% vs. 5.5%) remained evident. Detailed results of this sub-analysis are reported in Table 6.

Table 6.

Perioperative outcomes of robot-assisted radical cystectomy (RARC) stratified by type of urinary diversion

Median (1st–3rd q) or n (%)	Pre-robotic era		Robotic era
	Ileal conduit	Neobladder	Ileal conduit	Neobladder
Number of procedures	24	5	164	25
Length of hospital stay (days)	15 (13–17)	16 (14–20)	7 (6–8)	8 (7–9)
Extended hospital stay (> 15 days)	14 (58.3%)	3 (60%)	9 (5.5%)	2 (8%)
Readmissions within 30 days	2 (8.3%)	1 (20%)	18 (11%)	4 (16%)

Partial nephrectomy outcomes

A total of 227 partial nephrectomies were performed during the study period, 43 in the pre-robotic era and 184 in the robotic era, reflecting a more than fourfold increase in surgical volume following the implementation of robotic platforms.

This transition was associated with a progressive and consistent improvement in perioperative outcomes.

Overall operative times were not significantly different between the pre-robotic and robotic eras. Slightly longer operative times were observed during the early phase of the robotic program, likely due to the learning curve and the adoption of the technique for more complex cases over time. All robotic procedures were performed using a clampless technique, while in the pre-robotic era, the decision to clamp or not was more variable, depending on surgeon preference.

Median LOS decreased from 7.2 days in 2019 to 3.9 days in 2023, marking a 46% reduction. Notably, no cases of extended hospitalization (> 15 days) were reported throughout the 5-year period.

The 30-day readmission rate remained low across both eras, with only sporadic events in 2020 (2 patients, 8.3%), 2022 (1 patient, 1.6%), and 2023 (1 patient, 1.47%). All outcome data are summarized in Table 7.

Table 7.

Perioperative outcomes for partial nephrectomy during the pre-robotic era (2019–2020) and robotic era (2021–2023), including number of cases, median hospital stay, proportion of extended hospitalizations (> 15 days), and 30-day readmission rates

Median (1st–3rd q) or n (%)	Pre-robotic era		Robotic era
	2019	2020	2021	2022	2023
Number of procedures	19	24	55	61	68
Length of hospital stay (days)	7.2 (6.2–8.2)	6 (5–7)	4.8 (3.8–5.8)	4.3 (3.3–5.3)	3.9 (2.9–4.9)
Extended hospital stay (> 15 days)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
Readmissions within 30 days	0 (0%)	2 (8.3%)	0 (0%)	1 (1.6%)	1 (1.47%)

White background indicates the pre-robotic era (2019–2020), while gray background indicates the robotic era (2021–2023)

Summary of outcomes

The overall trends across the three major procedures demonstrate significant enhancements in perioperative management following the transition to robotic surgery. Radical prostatectomy showed the greatest procedural growth, accompanied by a marked reduction in hospital stay and a near disappearance of extended admissions, with consistently low readmission rates despite increased surgical volume. Partial nephrectomy maintained an excellent safety profile, with short hospitalizations, no prolonged stays, and minimal readmissions.

Radical cystectomy, although significantly improved in terms of hospitalization metrics, remained the most challenging procedure in the post-discharge phase, with readmission rates remaining higher. This reflects the intrinsic complexity of the procedure and the broader adoption of more advanced urinary diversions in recent years. These findings confirm the feasibility and safety of expanding robotic surgery in oncologic urology, highlighting the importance of tailored perioperative pathways and dedicated postoperative support based on procedural complexity.

Discussion

Over the past decade, robotic-assisted surgery has evolved from a pioneering technique to a well-established standard of care for major urologic oncologic interventions, including RARP, RAPN, and RARC. Its widespread adoption reflects not only technological maturation but also the accumulation of robust clinical evidence supporting its safety, efficacy, and reproducibility across diverse surgical scenario [11–13]. As clinical expertise has grown and institutional protocols have matured, robotic platforms have been progressively integrated into routine practice, enabling broader application even in complex or high-risk cases.

This 5-year single-institution analysis highlights the transformative role of robotic-assisted surgery in the context of a urology department undergoing significant growth, within a center that progressively established itself as a regional reference point for urologic oncology following the implementation of a dedicated robotic surgery program. A pivotal element of this transformation was the shift from a pre-robotic era (2019–2020), where procedures were performed using laparoscopic or open techniques, to a fully robotic era (2021–2023). This evolution marked a turning point not only in surgical approach but also in perioperative outcomes and institutional capacity.

As demonstrated by the arrival of A.P., whose previous experience with RARC and intracorporeal urinary diversion facilitated the rapid and safe expansion of indications, outcomes improve when robotic surgery is performed by surgeons already proficient in advanced minimally invasive techniques. Similarly, Giannarini et al. recently reported that the efficient implementation of a RARC program with intracorporeal diversion was feasible in a previously RARC-naïve center, confirming that structured mentorship and institutional expertise are key to overcoming the learning curve [14].

A defining feature of this evolution was the marked growth across all three major robotic urologic procedures: RARP, RAPN, and RARC, demonstrating that robotic surgery, when appropriately implemented, can be extended across a broad spectrum of oncologic indications.

When comparing the two eras, the robotic era was associated with substantial improvements across multiple dimensions. Median operative times for RARP and RARC decreased significantly, while those for RAPN remained stable despite increasing case complexity. More notably, all three procedures saw clear reductions in hospital stay, with RARP decreasing from a median of 9 days to 2.8 days, and RARC from nearly 17 days to under 7 days. Readmission rates remained stable, suggesting that earlier discharge did not compromise postoperative safety. These findings underscore how the structured implementation of a robotic program can drive not only technical but also systemic efficiency. These trends suggest that the implementation of a structured and standardized robotic training program—encompassing simulation, dual-console mentoring, and gradual autonomy—was effective in ensuring surgical efficiency during the program’s expansion. Moreover, the data underscore how consistent operative protocols and a high-volume institutional framework can mitigate the potential learning curve effects associated with team growth and increasing procedural volumes. In this context, robotic surgery appears not only reproducible and scalable but also capable of delivering time-efficient results even during periods of rapid institutional transition.

RP displayed the clearest benefit from the transition, with a near fourfold rise in case volume and a marked reduction in both operative time and hospitalization. When comparing eras, operative time decreased from a median of 160 min (2019–2020) to 132 min (2021–2023), while the hospital stay was reduced from 9 to 2.8 days, alongside a near-complete elimination of prolonged hospitalizations. These improvements likely stem from refinements in surgical technique, enhanced perioperative care, and the institutional standardization of postoperative protocols. Such results are consistent with literature demonstrating superior perioperative metrics and earlier functional recovery following robotic-assisted prostatectomy compared to open or laparoscopic approaches [15–18].

PN also benefited from the robotic era, with stable operative times despite increased complexity and a consistent decline in hospital stay. Importantly, no patients required extended hospitalizations across the 5-year span, confirming the safety and reproducibility of the procedure. These outcomes confirm that robotic platforms provide the precision and control necessary to manage renal masses while minimizing perioperative morbidity [19, 20].

RC, the most technically demanding procedure, showed the most pronounced volume increase—an eightfold rise over 5 years. Hospital stays decreased from nearly 17 days (pre-robotic) to under 7 days (robotic era), with a progressive improvement in perioperative management. These data reflect the effectiveness of robotic approaches, particularly when embedded within ERAS protocols, in optimizing outcomes [10, 21].

Importantly, during the robotic era, our institution introduced orthotopic neobladder reconstruction as a urinary diversion option in selected patients undergoing RARC. This represents a significant evolution compared to the pre-robotic period, where no neobladder procedures were performed. Although still reserved for highly selected patients with favorable profiles, the ability to offer a minimally invasive neobladder reflects growing surgical expertise and the functional potential of robotic techniques. This transition further highlights how the robotic platform supports personalized surgical strategies aimed at maximizing both oncologic control and postoperative quality of life.

However, despite improvements in length of stay and intra-hospital care, RC continued to show comparable 30-day readmission rates across both eras (approximately 10–12%), likely reflecting the intrinsic complexity of the procedure and the vulnerability of the population undergoing it. These findings are consistent with national data identifying cystectomy as a high-risk surgery in terms of early complications and rehospitalization [22–24].

An additional consideration when interpreting outcomes in RARC is the potential selection bias inherent to robotic cohorts. As reported by the Italian Radical Cystectomy Registry, patients undergoing robotic cystectomy are often younger, healthier, and more likely to receive neoadjuvant therapy compared to those selected for open or laparoscopic approaches [25]. This must be considered when comparing outcomes across surgical techniques, especially regarding morbidity and survival.

Nevertheless, a particularly relevant and evolving trend is the progressive extension of robotic surgery to higher risk patient populations, including elderly, comorbid, and functionally vulnerable individuals. Our experience reflects this shift, with increasing adoption of robotic cystectomy and partial nephrectomy in patients who were previously considered borderline candidates for minimally invasive surgery due to advanced age or complex clinical profiles. These changes are consistent with prior reports, including the review by Pal et al. [26] and the position paper by Rocco and colleagues [27], which emphasize that the refinement of robotic techniques and perioperative protocols has paved the way for expanding indications—provided that procedures are performed in high-volume centers with structured training and standardized workflows.

Importantly, despite concerns about postoperative morbidity in frail patients, recent evidence suggests that robotic cystectomy remains feasible and safe even in octogenarians, when conducted within experienced institutions and with appropriate preoperative optimization and perioperative care planning [28]. This evolution in surgical candidacy underscores the growing role of robotic platforms in managing complex or high-risk urologic oncology cases within controlled and well-equipped environments.

A critical driver of our institutional success was the implementation of a structured, modular training program—combining simulation, dual-console mentoring, and continuous performance feedback. This approach accelerated the acquisition of surgical proficiency, promoted a team-based culture, and fostered adherence to standardized operative and perioperative protocols. The availability of a robotic-dedicated operating room with consistent anesthetic and nursing workflows further enhanced procedural efficiency and minimized variability. The importance of a structured training model has been extensively described by Mottrie et al. [29], who highlighted its key role in ensuring the safe and effective adoption of robotic surgery.

From a health system perspective, the long-term investment in robotic platforms is validated by gains in throughput, reduction of hospitalization-related costs, and complication avoidance. Moreover, newer models—including platform sharing, adoption of next-generation systems, and increased market competition—may improve financial sustainability over time [30].

Nonetheless, these results should not be interpreted as universally generalizable. Robotic surgery remains a resource-intensive endeavor, requiring not only cutting-edge technology but also highly specialized personnel, multidisciplinary coordination, and institutional commitment to quality. As our data demonstrate, outcomes such as reduced length of stay, low complication rates, and procedural expansion are only achievable within structured, high-volume environments equipped with expert teams and comprehensive perioperative infrastructure [31]. Moreover, our data underscore that procedural safety and efficiency can be preserved even amid rapid growth in surgical activity. The sustained performance across all key metrics—hospital stay, readmission, and operative time—despite increasing case numbers and team expansion reinforces the role of structured robotic programs in delivering scalable, high-value care.

In conclusion, robotic-assisted surgery has matured into a consolidated standard for major urologic oncology. The transition from pre-robotic to robotic eras was marked by measurable improvements in surgical performance, perioperative outcomes, and the expansion of indications, including more complex procedures such as orthotopic neobladder reconstruction. When implemented in high-volume, quality-driven centers, robotic surgery delivers reproducible, safe, and scalable cancer care across a growing and increasingly complex patient population.

It is important to underline that the improvements observed during the robotic era should not be attributed to the robotic platform alone. The transition coincided with the arrival of an experienced robotic surgeon, the implementation of a structured modular training program for junior staff, and the establishment of a robotic-dedicated operating room with standardized perioperative workflows. These elements, together with the natural growth of the unit and consolidation of surgical expertise, likely contributed synergistically to the observed outcomes. Therefore, the improvements reported in this study reflect not only the adoption of robotic technology but also the strengthening of institutional expertise and infrastructure.

Limitations

This study presents several limitations, primarily related to its retrospective and single-center design. First, the absence of a control cohort undergoing open or laparoscopic surgery precludes direct comparisons across surgical approaches. Second, although perioperative outcomes and hospital metrics were thoroughly documented, long-term oncologic and functional outcomes—such as disease-specific survival, continence, sexual function, and quality of life—were not systematically evaluated. Third, no formal cost-effectiveness or health-economic analysis was conducted, limiting the ability to draw conclusions on financial sustainability.

In addition, variability in surgeon experience and patient complexity over the study period may have influenced clinical outcomes and learning curves, especially during the early phases of robotic program implementation. Finally, the findings may have limited external generalizability, particularly to low-volume or resource-constrained centers lacking dedicated training infrastructure and standardized perioperative workflows.

Future prospective studies should aim to validate our findings and expand the scope of investigation beyond perioperative outcomes. Key factors to be addressed include long-term oncological results, functional recovery (continence, sexual function, renal function), patient-reported outcomes (QoL and PROMs), cost-effectiveness evaluations, and the influence of the learning curve and surgeon-specific variables on clinical outcomes.

Conclusion

This 5-year single-center study demonstrates that the structured implementation of robotic-assisted surgery can lead to measurable and sustained improvements in the management of major urologic oncologic procedures. Through a combination of institutional investment, protocolized perioperative care, and structured team training, robotic platforms were successfully integrated into routine clinical workflows, enabling significant reductions in hospital stay and low rates of readmissions across RARP, RAPN, and RARC.

Notably, the improvements observed in perioperative outcomes are the result of both the integration of robotic technology and the parallel consolidation of institutional expertise, standardized training, and organizational growth. Robotic surgery should thus be interpreted as a catalyst within a structured program, rather than as an isolated determinant of improved outcomes.

This emphasizes that robotic surgery should not be viewed as a guarantee of success per se; rather, outcomes depend on the expertise of the surgical team, particularly when led by experienced robotic surgeons. Nevertheless, ongoing challenges—including financial sustainability, equitable access, and long-term outcome validation—must be addressed through multicenter collaboration, registry-based benchmarking, and health-economic modeling. As robotic surgery continues to evolve, its responsible expansion will rely not only on technological advancement, but on the capacity of healthcare systems to support quality-driven, team-based, and patient-centered innovation in surgical oncology.

Author contributions

Conceptualization, A.P., F.M., and S.D.B.; methodology, A.P., F.M., and L.D.G.; validation, A.P., F.M.; formal analysis, F.M., L.D.G., F.S., M.C., A.S., P.G., A.A.; resources, F.S. and S.D.B.; data curation, F.M., D.D.M., L.D.G., A.A.; writing—original draft preparation, F.M.; writing—review and editing, A.P., L.D.G., S.D.B.; visualization, D.D.M., L.D.G., F.S., M.C., A.S., P.G., A.A.; project administration, A.P. and F.M. All the authors have read and agreed to the published version of the manuscript.

Funding

This research received “Ricerca Corrente” funding from the Italian Ministry of Health to cover publication costs.

Data availability

No datasets were generated or analyzed during the current study.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was conducted in accordance with the principles of the Declaration of Helsinki. As it is a retrospective observational analysis based on anonymized data collected during routine clinical practice, no formal approval from an ethics committee was required under current national regulations.