The Association of Robotic Surgical
Technology and Hospital Prostatectomy
Increasing Market Share Through the Adoption of Technology
Joan M. Neuner, MD, MPH1; William A. See, MD2; Liliana E. Pezzin, PhD, JD1; Sergey Tarima, PhD3;
and Ann B. Nattinger, MD, MPH1
BACKGROUND: Despite limited and conflicting evidence for the efficacy of newly developed robotic technology for
laparoscopic prostatectomy, this technology is spreading rapidly. Because the newer technology is more costly, rea-
sons for this rapid adoption are unclear. The authors of this report sought to determine whether hospital acquisition
of robotic technology was associated with volume of prostate cancer surgery. METHODS: The inpatient dataset of
claims records from 2002 to 2008 and the acquisition dates of robotic technology were used to examine the rates of
prostatectomy in Wisconsin hospitals. In analyses that accounted for hospital and referral region characteristics,
changes in hospital prostatectomy volume were examined for their association with technology acquisition. Overall
trends in the rate of prostatectomy also were examined over the study period. RESULTS: In total, 10,021 prostatecto-
mies were performed in 52 hospitals in Wisconsin’s 8 health referral regions during the study period. The mean
quarterly prostatectomy volume in hospitals that did not acquire the technology was 4.5 in 2002 and 3.1 in 2007/2008.
In contrast, the mean quarterly prostatectomy volume in hospitals that went on to acquire robotic technology was 16.5
in 2002 and 24.8 in 2007/2008. In adjusted models, the acquisition of a robot was associated with a 114%
annual increase (95% confidence interval, 62%-177% annual increase) in hospital prostatectomy volume. The average
Wisconsin hospital prostatectomy volume was unchanged during 2002 through 2006 but increased by 25.6% in 2007.
CONCLUSIONS: Robotic technology acquisition occurred rapidly in Wisconsin hospitals, and hospitals that acquired
a robot had large increases in prostatectomy volume. Cancer 2012;118:371–7. V
C 2011 American Cancer Society.
neoplasms/surgery, prostatic neoplasms/therapy, prostate cancer.
device approval,legislationand jurisprudence, physician’spractice patterns/trends, prostatic
Technology is the largest single factor driving increases in health care costs.1Some of the concerns about technol-
ogy costs relate to overuse; that is, patients undergoing unnecessary procedures.2,3However, another concern is that some
new technologies provide little or no greater health benefit than older technologies. Both physicians and hospitals have
been criticized for adopting new,expensive technologies in advance of evidence that they improve healthoutcomes.1,4,5In
addition, the widespread adoption of technologic innovations before the completion of trials demonstrating their safety
and effectiveness mayleadtoa situationin whichitis difficulttoconductthesetrials.
We were interested in the possible incentives for ‘‘premature’’ technology adoption, that is, the adoption of incom-
pletely tested technology. Specifically, we were interested in the extent to which market competition considerations may
promote the adoption of unproven technologic innovations. We examined this by studying the surgical treatment of
DOI: 10.1002/cncr.26271, Received: February 11, 2011; Revised: April 10, 2011; Accepted: April 21, 2011, Published online June 29, 2011 in Wiley Online Library
Corresponding author: Joan M. Neuner, MD, MPH, Medical College of Wisconsin, Center for Patient Care and Outcomes Research, 8701 Watertown Plank Road,
Suite H2755, Milwaukee, WI 53226; Fax: (414) 955-6689; firstname.lastname@example.org
1Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin;2Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin;
3Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
J.M.N., W.A.S., L.E.P., and A.B.N. conceived and designed the study; S.T., J.M.N., W.A.S., L.E.P., and A.B.N. analyzed and interpreted the data; J.M.N. and A.B.M.
drafted the article; W.A.S., L.E.P., and S.T. critically revised the article for important intellectual content; and J.M.N., W.A.S., L.E.P., S.T., and A.B.N. provided final ap-
proval of the version to be published. J.M.N. had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the
January 15, 2012
prostate cancer. Prostate cancer is the most common can-
cer among men in the United States, and the traditional
surgical treatment for prostate cancer is open total prosta-
tectomy. A robot that facilitates a less invasive laparo-
scopic option for prostatectomy was approved by the US
Food and Drug Administration (FDA) and introduced to
the USmarketin 2000.
Evidence for the effectiveness of robotic technology
appears to be in its early stages. Early adopters of this
robot-assisted laparoscopic technology reported some
benefits in terms of reduced blood loss and shorter recov-
ery time,6,7but the studies generally were based on small,
selected samples. Several follow-up studies have demon-
strated higher rates of adverse outcomes, including incon-
tinence and impotence,8,9and the estimated costs of the
surgery are 13% higher than the costs with nonrobotic
techniques.10The effect of the new technology on long-
term cancer outcomes, such as mortality and recurrence,
remains unknown. A recent study indicated greater use of
androgen blockade treatment in the months after laparo-
scopic prostatectomy compared with the use of such treat-
ment after open prostatectomy, suggesting that some
Thus, a full decade after the introduction of roboti-
cally assisted total prostatectomy, evidence for its risks
and benefits is conflicting, and no randomized controlled
trial has been undertaken. Despite the lack of evidence
supporting its adoption, the use of robot-assisted laparo-
scopy for the treatment of prostate cancer has increased
rapidly in the past few years.4One possible explanation
for the rapid uptake of robot-assisted technology despite
inconsistent supporting evidence is that hospitals acquire
and market the technology to increase their prostate can-
cer surgical volumes. For the current study, we tested this
hypothesis using statewide Wisconsin data. We also
examined whether recently reported increases in prosta-
tectomy10,11also occurred in Wisconsin, hypothesizing
that robotic technology is associated not only with
changes in the location of care but also with an increase in
the overall number of men undergoing surgical therapy
MATERIALS AND METHODS
Our primary source of information was the Wisconsin
Inpatient Discharge database. The Wisconsin Inpatient
Database consists of all inpatient discharges from acute
care, nonfederal hospitals in the state of Wisconsin. These
data are collected under a state legislative mandate and are
made available to researchers by the Wisconsin Hospital
Association. The database includes patient demographic
data, admission and discharge data, and diagnostic and
procedure data, including International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD9-
CM) codes. The Wisconsin Hospital Association Survey
also was used for information regarding the for-profit sta-
Study Population and Definitions
We focused on patients who underwent total retropubic
prostatectomy between January 2002 and June 2008,
years when the adoption progressed rapidly in other areas
of the United States. This procedure, which is very exten-
sive compared with partial prostatectomy (eg, transure-
thral resection of the prostate), is used solely for cancer
surgeryand isidentified byICD9-CMcode605.
We identified all general hospitals in which these
patients underwent surgery as well as each hospital’s
health referral region (HRR), which is defined as the ge-
ographic unit that represents each hospital’s market for
tertiary care. HRRs were developed first to capture pat-
terns of hospital use for major cardiac surgery,12but they
have been used subsequently to study a variety of treat-
ments, including medical treatments of prostate can-
cer.13-15Wisconsin hospitals that were located in
neighboring states’ HRRs were excluded. One Wiscon-
sin hospital that closed during the study and performed
only 33 prostatectomies in the 4 years before closure also
was excluded from the study. Pairs of hospitals that
merged during the study period were considered to be
individual hospitals before the merger and a single new
hospital after the consolidation.
The primary outcome of interest was quarterly sur-
gical volume measured as the number of prostatectomies
performed by each hospital in each of the 26 calendar
quarters in the 6.5-year study period. Information regard-
ing whether each hospital had purchased the robotic tech-
nology and the date of acquisition of the system was
obtained from the system’s (sole) manufacturer and con-
firmed with each hospital. To accommodate training or
other procedures associated with adoption of the new
technology, the correlation between robot acquisition and
the annual prostatectomy rate was assessed assuming that
actual use of the new technology lagged by 3 months from
the manufacturer’s reported date of purchase. Additional
January 15, 2012
For data regarding prostate cancer incidence,
Wisconsin state tumor registry estimates were used.16The
Institutional Review Board of the Medical College of
The association between hospitals’ robotic acquisition
and prostatectomy surgical volume was examined using
generalized estimating equation (GEE) Poisson models.
The Poisson count data specification was chosen in view
of the relatively low quarterly surgical volume of certain
hospitals during the study period. The GEE method
enabled us to account for within-hospital correlation in
prostatectomy surgical volumes over time. In addition to
controlling for hospital-invariant time trends on prosta-
tectomy rates, which were measured by a set of binary
indicators of calendar quarter, our multivariate models
between adoption of robotic technology and prostatec-
tomy volume. These included mean age of prostatectomy
patients, proportion of the hospital’s prostatectomy surgi-
cal patients covered by public programs (Medicare and
Medicaid, separately), and indicators for the hospitals’
referral region (to account for competition or other differ-
ences between hospitals’ prostatectomy markets). Because
only 1 Wisconsin hospital that performed prostatectomy
was a for-profit institution during the study years, this
variable was not included in the models. One of the
authors (S.T.)performedall analyses.
In total, 52 hospitals performed 10,021 prostatectomies
in the state of Wisconsin and its HRRs between January
1, 2002 and June 30, 2008. Of those, 12 hospitals (23%)
acquired the robot technology by December 31, 2007.
Hospitals that acquired robot technology were distributed
in 6of the8WisconsinHRRs.
Table 1 lists the 2002 ‘‘baseline’’ values of surgical
volumeand other hospital characteristics for the 12 hospi-
tals that were classified as ‘‘adopters’’ compared with
system over the study period). Although there were no
statistically significant differences between adopter and
nonadopter hospitals with respect to the age and payer
composition of their prostatectomy patients, adopter
hospitals had slightly younger patients (P ¼ .005) and
a higher volume of prostatectomies (P < .001) before
Association of Robotic Technology and
Prostatectomy Surgical Volume
The trajectory of prostatectomy volume in robotic
and 2. In 2002, a total of 1404 prostatectomies were per-
formed in Wisconsin hospitals (Fig. 1). Between the first
and final 12-month periods of the study (January 1, 2002
to December 30, 2002 and July 1, 2007 to June 30, 2008,
respectively), the mean quarterly (3-month) prostatec-
tomy volume among adopter hospitals rose from 16.5 to
24.8. The mean prostatectomy surgical volume among
nonadopter hospitals decreased during the same period
tion of prostatectomies by adopter hospitals, as measured
by the proportion of all prostatectomies performed by
hospitals that eventually acquired the robot system, rose
from 48.1%in the first quarter of 2002 to 72% in the sec-
There was substantial variability in volume between
hospitals. For example, in 2007, the adopter hospitals’
median quarterly prostatectomy volume was 22 with an
interquartile range (IQR) of 14 to 34. Nonadopter hospi-
tals had a 2007 median quarterly prostatectomy volume
of3 (IQR,0-4;minimum0, maximum18).
In multivariate models that were adjusted for char-
was associated with more than a doubling of a hospital’s
Table 1. Hospital Characteristics by Adopter Status of Hospitals
CharacteristicAdopter Hospitals, N 5 12a
Nonadopter Hospitals, N 5 40
Quarterly prostatectomy volume in 2002: Mean ? SD
Age of patients undergoing prostatectomy: Mean ? SD, y
Median no. of hospitals in HRR
16.52 ? 8.98
60.26 ? 6.80
4.54 ? 4.34
61.30 ? 7.10
Abbreviations: HRR, health referral region; SD, standard deviation.
aAdopter hospitals are those that acquired a robotic laparoscopic system between January 2001 and December 2007.
Robotic Technology and Hospital Volume/Neuner et al
January 15, 2012
prostatectomy volume. Specifically, a 114% increase
(95% confidence interval [CI], 62%-177% increase)
in the quarterly rate of prostatectomy occurred after
3 months (Fig. 2). Results of sensitivity analyses in which
the lag between robot purchase date and its use was
changed to 6 months revealed a similar increase in prosta-
tectomy rates (112% increase; 95% DI, 60%-179%
Figure 2. Wisconsin hospital prostatectomy volume is illustrated among adopter hospitals (quarterly) before and after the acquisi-
tion of robotic technology (n ¼ 12). Changes in the volume of total suprapubic prostatectomy among hospitals with robotic technol-
ogy in Wisconsin are shown.The median quarterly numbers are shown with interquartile ranges and minimum and maximum values.
Figure 1. Quarterly prostatectomy volume is illustrated in Wisconsin hospitals for the years 2002 through 2008. This chart shows
the number of prostatectomy surgeries performed quarterly overall and stratified by hospitals that acquired robotic technology
for laparoscopic surgery (adopter hospitals) and hospitals that did not acquire robotic technology (nonadopter hospitals). The
number of hospitals that acquired robotic technology by each calendar quarter is indicated below the graph.
January 15, 2012
Overall Prostatectomy Use
robots increased the overall use ofprostatectomy, weexam-
ined overall use of prostatectomy in the context of Wiscon-
sin prostate cancer incidence. There was no change in the
total number of prostatectomies performed in our cohort
hospitals between January 2002 and 2006 (Fig. 1). How-
pitals increased by 25.6% compared with 2002 (adjusted P
¼ .07). This increase was sustained through June 2008.
The incidence of prostate cancer decreased in Wisconsin
during the study period from an estimated 4238 men in
2002 (age-adjusted incidence of 169 in 100,000 men) to
3900 men in 2006 (142 in 100,000 men).16Therefore, we
underwent surgery (prostatectomy) in 2002, and 38.1%
During 2002 through 2008, 23% of Wisconsin hospi-
tals acquired robotic technology that was used for lap-
aroscopic prostatectomies; and, by 2007, more men
underwent prostatectomies at hospitals with robotic
technology than at hospitals without it. The acquisi-
tion of robotic technology was associated with a 114%
increase in hospital prostatectomy volume within 3
months. In contrast, the average prostatectomy volume
of hospitals that did not acquire the technology fell.
Hospitals’ insurance patterns and the regions in which
they were located did not explain these results. The
average Wisconsin total prostatectomy volume rose
>20% between 2002 and 2008 despite decreasing
prostate cancer incidence, which raises the question of
whether the care of men with prostate cancer also was
shifted toward surgery and away from alternative treat-
ments, such as radiotherapy or watchful waiting.
The hospitals that acquired robotic technology dur-
ing the study time frame arguably adopted the technology
prematurely, because the evidence regarding its effective-
ness still is incomplete. The first studies of robotic prosta-
tectomy, mostly from early centers for the technology,
reported reductions in blood loss and length of hospital
stay compared with open prostatectomy.6A recent study
from 1 large center demonstrated reassuringly similar 3-
year rates of biochemical recurrence-free survival after
robotic prostatectomy compared with open procedures.17
Most population-based studies, however, have been less
encouraging: One study noted more postoperative urethral
strictures with laparoscopic techniques (either robot-sup-
ported or not) than with open techniques,9and another
noted more incontinence and impotence.8Studies of long-
term outcomes, including cancer recurrence and mortality,
There is also some evidence that the favorable effect
of experience reported for open prostatectomy18,19also
may occur with robotic prostatectomy20; if so, then the
centralization of prostatectomy that occurred in our study
may be beneficial and even cost-effective.21However, of
concern is the large number of surgeries that would be
required for optimal outcomes, a number probably higher
than that achieved by most hospitals19and surgeons10,20
in our study. Our study was limited by our inability to
examine individual physician surgical volumes. However,
physicians themselves appear to have concerns about their
outcomes with the newer procedures. One population-
based study8indicated increased postoperative use of
hormone therapies for patients who underwent laparo-
We hypothesize that the rapid adoption of robotic
in part by awareness that technology increases hospitals’
appeal to patients. Manufacturers increasingly market devi-
ces directly to patients.22Patients request pharmaceuticals
from health care providers, and it is possible that they also
ing specific devices. Physicians do advocate for technology
to both hospital administrators and local insurers,23report-
ing that they associate technology with quality23,24and that
technology increases their sense of community leadership.23
Our study adds to this literature through its finding that the
effects of a specific technology on hospital surgical volume
are rapid and large enough to be perceived by hospital deci-
sion-makers. Even the first adopter hospitals in a commu-
nity had doublings in volume after robotic acquisition that
The magnitude of the effects of new technology
interventions to support proven treatments would have to
be strong to be effective. One possible strategy to promote
theuseof proventechnologies isstrongertiesbetweenproof
of effectiveness and reimbursement. Although effective in
countries with a centralized health care system, this
approach may be more challenging in the United States.
For example, 2 recent Medicare panels, the first for com-
ondfor CT colonography,
effectiveness dataandinitially advised thatMedicaredecline
Robotic Technology and Hospital Volume/Neuner et al
January 15, 2012
coverage for the procedures. There was much controversy
phy decision eventually was reversed.25The factors behind
such controversies have not been well described, but physi-
cian interests and perhaps patient interests in technology,
the many stakeholders involved once a product has been
approved, or the great psychological value placed on ‘‘los-
ing’’ something once gained26may hinder insurers from
Another potential and perhaps stronger intervention
would be strengthened FDA regulation of devices. In
contrast to pharmaceuticals, for which initial randomized
trials are required, Congress currently mandates that the
FDA use the ‘‘least burdensome’’ of 3 possible evaluation
categories for devices.27Robotic technology for prostatec-
tomies was approved under the least restrictive of these
categories, 1 that allows manufacturers to state that a
product is nearly identical to previously approved devices.
It is possible that a requirement for the use of more strin-
gent categories may improve care. However, even for the
most stringent FDA category (premarket reviews),
evidence of efficacy may be minimal. A recent systematic
review of cardiovascular device approvals indicated that
only 27% referenced a randomized study, and only 52%
referenced a study with any controls.28,29Thus, further
FDAchanges alsomaybe required.
In 2010, there was still no evidence from observatio-
nal studies that robotic technology is clearly beneficial for
prostatectomy; and, to date, no randomized trial is in pro-
gress. Given recent studies suggesting that survival in most
(eg, Gleason ?7 disease), but not all (eg, Gleason 8-10 dis-
ease) patientswithlocalized disease managed conservatively
is now similar to that of age-matched control individu-
als,30,31trials of any prostate cancer treatments are particu-
larly important. Recruitment for a randomized trial of
robotic technology may be difficult, however, given the
rapid spread of the technology. Our study indicated that
the majority of all prostate cancer surgeries in Wisconsin
were performed in hospitals with robotic technology in
2008. Consistent with our findings, 43% of prostatecto-
mies in Surveillance, Epidemiology, and End Results can-
cer registries were performed laparoscopically in 2006 and
2007, a large increase from the 9.2% of surgeries in 2003.8
The manufacturer reported in 2009 that 86% of all prosta-
Our study’s findings also are notable for the increase
in Wisconsin hospitals’ prostatectomy use in 2007 and
2008, suggesting that new technology may create greater
demand for procedures. The short time frame of our study
tatectomies are a recent development in the state only adds
sible increases in prostatectomy use are consistent with a
study that noted a substantial increase among a national
sample of inpatients,10and we add to that study’s findings
by demonstrating that the increase is limited to hospitals
acquiring robotic technology. Furthermore, it has been
demonstrated that other technology also changes surgical
rates. For example, after the introduction of laparoscopic
cholecystectomy in the 1990s, the overall cholecystectomy
rate increased by 28%.2Wisconsin cancer statistics indicate
that prostate cancer rates had been decreasing in the state—
as inmuch of the United States—during the 5 years leading
up to 2007,16suggesting that increasing cancer incidence is
Because there was no specific hospital procedure
(ICD9) code for robotic technology use at the time of our
formed with versus without robotic technology at hospitals
that had acquired the technology. It is possible that some
hospitals that acquired the technology were not using it for
all patients. However, this would not change our finding
In addition, like another recent analysis,32we were not able
to fully account for the possibility that hospitals that
adopted the robotic technology may have differed by some
characteristics in our analysis. However, our analysis did
account for several characteristics that plausibly could affect
robotic acquisition decisions (competition represented by
HRR, case mix of insurance type, and patient age). We also
adjusted for within-hospital correlation, in which we
allowed each hospital to act as its own ‘‘control.’’ Future
studies focused on clinical outcomes of prostate cancer at
thepatient levelcould use techniques like instrumentalvari-
able analyses, and also should examine other technologies,
mated to increase costs yearly by more than $282 million
In conclusion, we observed that robotic technology
acquisition occurred rapidly in Wisconsin hospitals dur-
ing a 6-year period and was associated with a substantial
increase in hospitals’ prostatectomy volumes. The rapid
acquisition and deployment of expensive technology of
unproven value has the potential for far-reaching implica-
tions for patients and health care delivery systems.
Increases in cost per episode of care, together with overuse
(redistribution of patients previously treated with other
January 15, 2012
modalities) may be associated with significant cost Download full-text
increases.10Although the centralization of care delivery
may benefit patients with access to earlyadopter hospitals,
it risks of harm to patients who are treated at nonadopter
sites whose surgical volumes fall below those required for
optimal care delivery. In circumstances like robotic pros-
tatectomy in which it may no longer be possible to dem-
controlled trials, rigorous comparative-effectiveness stud-
ies may be required.34A recently funded study may be
able to compare different surgical and radiotherapy
options for prostate cancer.35Given our findings of the
widespread use of new technologies, such studies should
be done early, should be drawn from wide populations,
and should include the measurement of centralization of
careand othermutablefactorsthat affectoutcomes.
This research was conducted using internal funding from the Medi-
cal College of Wisconsin.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
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