Original Title: Chirurgie robotique - Pertinence et modalités optimales d’encadrement pour trois indications oncologiques : hystérectomie totale en cas de cancer de l’endomètre, prostatectomie radicale en cas de cancer de la prostate et néphrectomie partielle en cas de cancer du rein

Authors' objectives: In Québec as elsewhere, multi-indication surgical robots are used across a wide range of oncological and non-oncological indications in various specialities. This upsurge is posing challenges and raising questions for decision-makers, especially regarding this technology’s clinical relevance and added value, the utilization costs, decisions related to the purchase of new robots or the upgrading of those reaching end of useful life, the measures for ensuring equitable access, and effective resource management. It is in this context that the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d’excellence en santé et en services sociaux (INESSS) first, to assess the value of robotic surgery – compared with other surgical approaches such as laparoscopic surgery and open surgery – for performing a total hysterectomy for endometrial cancer, a radical prostatectomy for prostate cancer and a partial nephrectomy for renal cancer8. Second, the INESSS was mandated to outline the most appropriate approach to managing this service offering, already in place within Québec healthcare institutions for different indications. This work will support decision-makers in their strategic orientation and resource allocation decisions.

Authors' results and conclusions: RESULTS (#1 ONCOLOGIC SURGERY FACING DEMOGRAPHIC AND CONTEMPORARY CHALLENGES): In Québec, in 2023-2024, the mean age of individuals with cancer who had a radical prostatectomy, a total hysterectomy or a partial nephrectomy was approximately 65 years. Most of the women who underwent a total hysterectomy had obesity, according to the gynecologic oncologists consulted (#2 AN OVERVIEW OF THE OFFER BASED ON THE DEPLOYMENT OF ROBOTS, THE AVAILABLE EXPERTISE, AND ORGANIZATIONAL ISSUES): • Québec ranks among the Canadian provinces with the most da Vinci robots, with a ratio per million population slightly higher than that in Ontario, but behind New Brunswick and Saskatchewan. • With approximately 20 surgeons trained in robotics by specialty (urologic oncology and gynecologic oncology) practising within institutions with robots, the offer varies according to the local organization and to the management of the waiting lists, which are usually surgeon-specific, at each facility. (#3 FUNDING FOR PURCHASING, USING AND REPLACING ROBOTS: AN ISSUE HERE AS ELSEWHERE): As in other jurisdictions, the initial purchase of most of the multi-indication surgical robots in Québec’s health and social services system has been funded through philanthropy. (#4 ROLE OF ROBOTIC SURGERY AND COEXISTENCE WITH THE OTHER SURGICAL APPROACHES ): Few health technology assessment agencies and learned societies or professional medical associations have taken a position regarding the specific role of robotic surgery. When minimally invasive surgery is preferred, no distinction is made between laparoscopy and robotics for the three indications of interest. (#5 BETWEEN THE LITERATURE AND PRACTICE: HOW ROBOTIC SURGERY IS PERCEIVED): Surgeons who use robots generally have a very positive perception of the clinical and organizational advantages of this approach. Although less common, some surgeons, generally those who do not use robots, express doubts about the real benefits of robotic surgery for the healthcare system compared to the other surgical approaches. (#6 CLINICAL SUPERIORITY OF ROBOTIC SURGERY GENERALLY INCONCLUSIVE WHEN COMPARED TO THE MAIN COMPARATOR USED IN QUÉBEC): Compared to laparoscopy, robotic radical prostatectomy appears to offer certain advantages in terms of urinary and erectile function recovery (very low to low level of scientific evidence), although laparoscopic prostatectomies are practically no longer performed in Québec. For robotic total hysterectomies, the only clinical advantage observed compared to laparoscopy – the main comparator in Québec – is the lower risk of conversion to open surgery (moderate level of scientific evidence), which is a clinically significant aspect according to the gynecologic oncologists consulted. (#7 ADDITIONAL COSTS AND A LARGER CARBON FOOTPRINT WITH THE ROBOTIC APPROACH FOR GENERALLY SIMILAR CLINICAL BENEFITS): Increasing the annual number of procedures could reduce the average cost per robotic procedure by spreading the fixed costs, such as those for equipment maintenance, over a higher volume. However, this effect would be limited, since the variable costs associated with the robotic approach, such as those associated with purchasing consumables, increase with the volume of procedures. (#8 GOVERNANCE AND A PRACTICE FRAMEWORK NECESSARY FOR THE OPTIMAL USE OF ROBOTIC SURGERY IN QUÉBEC): Unlike some other organizations in Canada and around the world, there is currently no province-wide governance structure in Québec for providing strategic guidance on robotic surgery and implementing it in a harmonized manner within the institutions.

Authors' recommendations: On the basis of the overall value assessment, and given that robotic surgery is already well established in Québec, with a fleet of over a dozen multi-indication robots, INESSS calls for a certain degree of caution in future directions and has therefore drawn up a set of recommendations aimed at providing a framework for, strengthening and even maximizing, if appropriate, the offer of robotic surgery services for the three indications of interest and, where appropriate, guiding future decisions on expanding this offer to other clinical indications, so as to: • Strive for cost-effectiveness by optimizing resource utilization; • Support the organization of the services by relying on clear, harmonized governance and steering mechanisms; • Foster consistency in clinical conditions of access.

Authors' methods: For each indication of interest, rapid literature reviews were carried out in accordance with INESSS’s rapid review guidelines. A structured literature search in the bibliographic databases was conducted, targeting relevant items, namely, systematic reviews with meta-analyses, randomized and non-randomized comparative studies, economic studies, clinical practice guides, guidelines and health technology assessment reports. The structured literature search covered the period between 2015 and 2024. In addition, manual searches were carried out in other complementary sources.

Project Status: Completed

Year Published: 2026

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Technologies/Chirurgie_robotique_Hysterect_prostect_nephrect_avis_INESSS.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)