










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Ergonomics, learning curve, robotic 
assistance, surgical outcomes, surgeon 
volume, urologic surgery

None declared. Received on April 5, 2022 
Accepted on May 22, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(5):323–330

DOI: 10.48083/PPSC8658

Outcomes of Robotic Surgery  
for Low-Volume Surgeons

Sridhar Panaiyadiyan, Rajeev Kumar

Department of Urology, All India Institute of Medical Sciences, New Delhi, India

Abstract

When the outcomes are equivalent to the open technique, conventional laparoscopy is a preferred surgical approach 
because of its minimal invasiveness. However, outcomes following laparoscopy depend on the surgeon’s expertise, and 
there is a significant learning curve to attain efficiency in complex reconstructing laparoscopic procedures. Robotic 
assistance bridges the gap between open and laparoscopic procedures and allows surgeons with limited laparoscopy 
experience to offer the benefits of minimally invasive surgery to their patients. While existing data do not show better 
outcomes with robot assistance compared with laparoscopy for most procedures, these studies are based on data from 
high-volume surgeons and centers. In reality, a significant number of surgeries are performed by low-volume centers 
and surgeons, and robotic assistance may enable them to offer benefits of minimally invasive surgery equivalent to 
those of higher volume centers since robotic assistance is associated with a shorter learning curve than laparoscopy. 
We review the data on the outcomes of robotic surgery for low-volume surgeons with a focus on centers and surgeons 
in Asia.

Introduction

Urology as a specialty has always been at the forefront of technological advancement and has rapidly embraced 
innovations in devices and techniques. Acceptance of new technology usually depends on its being better for the 
patient or the health care system[1]. However, being “better” is often associated with being more expensive and thus 
new technologies must prove themselves to not only give better outcomes but also to do so at a cost that is acceptable 
for the improvements in outcome at a population level. Being “better for the surgeon” is rarely considered a valid 
reason for accepting technology that may increase overall costs of treatment.

Among surgical approaches, laparoscopy is universally accepted as the preferred option wherever it has been shown 
to have outcomes equivalent to open surgery. This is because it provides better cosmesis, lower postoperative pain and 
earlier recovery; all outcomes that are better for the patient and the health care systems[2]. However, outcomes vary 
among surgeons and, depending on surgeon expertise, the possible procedures range from simple ablative to complex 
reconstructive ones that require intracorporeal suturing[3]. Surgical outcomes improve with increasing case load 
and plateau after a certain level[4]. Once expertise is achieved, outcomes are equivalent irrespective of the surgical 
approach. However, despite having been available over 30 years, laparoscopy remains challenging for complex recon-
structive procedures and has a steep learning curve for such procedures[5].

The introduction of robotic assistance into the surgical armamentarium aimed to bridge the gap between open 
approaches and laparoscopy and to enable minimally invasive surgery[6]. However, despite having been available 
now for over 20 years, robotic surgery continues to be questioned and is often derided as a gimmick or marketing 
tool, primarily because of its high costs, longer operating times, and poor residency training[7,8]. These concerns 

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https://orcid.org/0000-0002-0783-1101
https://orcid.org/0000-0002-0783-1101
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are fuelled by a lack of studies showing the superiority of 
robotic assistance over laparoscopy[9]. In the absence of 
a difference, it is difficult to justify the use of expensive 
robotic assistance over pure laparoscopy.

Most of this data comes from surgeons and centers 
that have high volumes. It is only to be expected that 
once expertise has been acquired through high volumes 
the outcomes are likely to be similar with each tech-
nique. In the real world, most urologists do not have 
the high volumes of these surgeons or centers[10,11]. 
However, the patients they treat deserve the same 
outcomes as those at high-volume centers and it is perti-
nent to assess whether robotic assistance helps low-vol-
ume surgeons provide the benefits of minimally invasive 
surgery to their patients, which they may not have been 
able to do through pure laparoscopy.

The learning curve for robot-assisted surgery is 
shorter than that for conventional laparoscopy in 
maiden users[12]. Robot assistance allows surgeons 
trained in open surgery to transition easily to minimally 
invasive surgery without significant laparoscopy expe-
rience, and laparoscopy-naïve surgeons have rapidly 
gained competence in robot-assisted radical prosta-
tectomy (RARP)[13]. As a corollary, it is plausible that 
robotic assistance may aid surgeons in a low-volume 
setting to deliver better outcomes than would be asso-
ciated with laparoscopy, while providing all the advan-
tages of minimally invasive surgery[11].

With this hypothesis, we reviewed the literature for 
data on outcomes of robot-assisted surgeries for low-vol-
ume surgeons for common urological surgeries such as 
robot-assisted radical prostatectomy (RARP), robot-as-
sisted partial nephrectomy (RAPN), robot-assisted radi-
cal cystectomy (RARC), and robot-assisted laparoscopic 
pyeloplasty (RALP). This is particularly relevant for Asia 
since the penetration of robot-assisted surgeries in Asia 
trails the western world. By 2017, there were 4271 da 
Vinci Surgical Systems (Intuitive Surgical Inc.) installa-
tions worldwide of which 82% were in the Unites States 

Europe as compared with 13% in Asia but with a trend 
towards increasing Asian installations by 2018[14]. As 
per the recent data, over 5500 da Vinci Surgical Systems 
have been installed in 67 countries worldwide[15].

Low-Volume Robotic Surgeons and/or Hospital
What constitutes “ low-volume” for surgeons and 
hospitals is not clearly defined. Considering RARP 
as the most common robotic urology surgery, in 2011, 
Gershman et al. found that 70% of hospitals in the 
United States were performing less than 50 RARP 
per year and the complications, hospitalizations, and 
transfusion rates all declined with increasing experience 
until around 100 RARPs were being performed per 
year[16]. While evaluating the impact of surgeon 
experience, Bravi et al. reported a decline in positive 
margins from 16.7% to 9.6% with increase of surgeon 
experience from 10 to 250 procedures[17]. Based on the 
evaluation of 9810 RARPs in Sweden, Godtman et al.[18] 
defined very low-volume (surgeon < 13 or hospital < 50 
cases), low-volume (surgeon 13 to 25 or hospital 50 to 
100 cases), intermediate (surgeon 25 to 50 or hospital 100 
to 150 cases), high-volume (surgeon 50 to 76 or hospital 
150 to 200 cases) and very high volume (surgeon ≥ 75 
or hospital ≥ 200 cases) surgeons and hospitals. Based 
on the Swedish national guidelines for prostate cancer, 
Godtman et al. defined these cut-off values as a multiple 
of the minimum number of RARPs that should be 
performed by the surgeon and the center. It is expected 
that these numbers would differ for other procedures. 
This lack of consensus on the definition of low-volume 
surgeon would be related to the different learning curve 
in achieving a benchmark optimum outcome.

Methods
We searched PubMed/MEDLINE, Embase, Web of 
Science, and Google Scholar databases for relevant 
studies published in English using the following MeSH 
key words: (robotic urology surgery OR robotic radical 
prostatectomy OR R ARP OR radical cystectomy 
OR RARC OR partial nephrectomy OR pyeloplasty) 
AND (low-volume surgeons OR low-volume center 
OR learning curve). The abstracts and full articles of 
systematic reviews and meta-analyses were reviewed. 
Case reports, letters, short communications, and articles 
in languages other than English language were excluded.

Radical Prostatectomy
Reviewing the outcomes of radical prostatectomies done 
at high-volume centers, Coelho et al. showed that RARP 
delivered better outcomes in terms of weighted mean 
PSM, continence, and potency rates compared with 
retropubic and laparoscopic radical prostatectomies[19]. 
However, with the increasing adoption of robotic system 
in the recent years, there has been an increase in the 

Abbreviations 
EBL estimated blood loss
LNY lymph node yield
LPN laparoscopic partial nephrectomy
OT operative time
PSM positive surgical margin
RALP robotic-assisted laparoscopic pyeloplasty
RAPN robotic-assisted partial nephrectomy
RARC robotic-assisted radical cystectomy
RARP robotic-assisted radical prostatectomy
WIT warm ischemia time

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number of RARP being done at low-volume centers[20]. 
It is now estimated that between 33% and 70% of 
RARP in the United States are done by low-volume 
surgeons[10].

With conventional laparoscopic radical prosta-
tectomy, the number needed to attain a 90% recur-
rence-free probability is estimated to be 750 cases[21]. In 
contrast, with RARP, about 80 to 120 cases are needed 
to attain a comparable perioperative, oncological, and 
functional outcomes[22]. Further, with increasing 
experience in RARP, the perioperative complications 
declined from 9.8% in low-volume surgeons to 6.7% in 
intermediate-volume surgeons and to 2.2% in high-vol-
ume surgeons[23]. In a retrospective analysis from India, 
Garg et al. showed an inverse stage migration pattern 
in their RARP practice. Over the time, with increasing 
experience in RARP, patients with more unfavorable 
disease characteristics underwent RARP[24].

A recent multi-national and multicenter retrospec-
tive study discussed the RARP outcomes (n = 207) of 3 
fellowship-trained surgeons from low-volume regions 
of Gulf Cooperation Council countries[25]. This study 
showed trifecta outcomes comparable to those of inter-
national centers. At the 12-month follow-up, 35.8% of 
patients were potent, 94.6% were continent, and 9.2% 
had biochemical recurrence[25]. In a recent study from 
low-intermediate volume center, Afferi et al. retrospec-
tively analyzed 604 men who underwent nerve-sparing 
RARP[26]. At a median follow-up of 28 months, the 
authors reported an increase in the pentafecta outcomes 
from 38% to 44%, with erectile dysfunction being the 
main limiting factor for non-achievement of pentafecta 
in 71% cases. However, in high-risk prostate cancers, 
biochemical recurrence limited the pentafecta achieve-
ment (61%)[26].

Partial Nephrectomy
T he cu rrent sta nda rd of ca re for sma l l rena l 
masses is partial nephrectomy[27]. Prior reports 
showed equivalent oncological outcomes between 
open a nd lapa roscopic approaches for pa r t ia l 
nephrectomies[28,29]. However, laparoscopic partial 
nephrectomy (LPN) is a technica lly demanding 
procedure requiring intracorporeal suturing with 
si mu lta neous considerat ion of wa r m ischemia 
time (WIT) to prevent ischemic renal injury[30]. 
Considering that laparoscopic radical nephrectomy 
was easier to perform, it was hy pothesised that 
partial nephrectomy was underutilized for eligible 
candidates[31]. Af ter successful incorporation of 
robotic assistance into radical prostatectomy, robot-
assisted partial nephrectomy (RAPN) was quickly 
and widely adopted[32]. A surgeon needs to perform 
fewer RAPN than LPN to attain a comparable level of 

competency[33]. It is estimated that about 565 cases are 
required to achieve the target WIT (< 20 to 25 minutes) 
in LPN[34], whereas it requires about 20 and 50 cases, 
for RAPN for equivalent WIT and operative time (OT), 
respectively[5]. In contrast, expert renal surgeons require 
< 30 cases of RAPN to achieve an equivalent proficiency.

In a low-volume center in Kuwait, a fellow-
ship-trained robotic surgeon retrospectively assessed the 
perioperative, trifecta, and pentafecta outcomes follow-
ing 43 RAPN cases performed over 6 years. Operative 
time and estimated blood loss (EBL) improved signifi-
cantly after the first quartile of patients (n = 14). Trifecta 
and pentafecta outcomes were achieved in 93% and 
81.8% cases, respectively. A higher number of complex 
cases with RENAL nephrometry scores of 7 to 12 were 
performed in the second (n = 14) and third (n = 15) 
quartiles[35].

In a prospective study, Dias et al. reported outcomes 
of RAPN by a laparoscopy trained surgeon with no prior 
robotic surgery experience. In 108 cases performed 
over 5 years, WIT ≤ 20 minutes, OT ≤ 150 minutes, 
and EBL < 100mL were achieved after 44, 44, and 54 
cases, respectively. A trifecta outcome was achieved 
in 67.6% cases[36]. Motoyama et al. in a retrospective 
study reported the outcomes of 65 RAPN performed 
by a surgeon with no prior LPN experience but with 
extensive robotic surgery experience[37]. The learning 
curve was analyzed by dividing cases into 5 groups of 13 
consecutive patients. Trifecta outcomes were achieved in 
89.2% cases. The authors reported a WIT of ≤ 20 minutes 
and console time of ≤ 150 minutes could be achieved at 
fourth and sixth procedures, respectively[37].

In terms of complications, a multicenter study 
showed that a low-volume surgeon performing < 7 cases 
of RAPN per year had a complication rate (18.1% versus 
15.9% versus 16.1%, P = 0.81) comparable to high-volume 
(15 to 30 RAPN cases/year) and very high-volume (> 30 
RAPN cases/year) surgeons[38]. In a recent database 
study involving 124 institutions in Japan, Yokoyama 
et al. reported the trends and safety of RAPN done at 
low-volume (n = 616) and high-volume (n = 3106) insti-
tutions. After propensity score matching, the authors did 
not find any significant differences in anesthesia time, 
blood transfusions, and complication rates between 
low-volume and high-volume centers[39]. Similarly, data 
from a single-center study in Turkey confirmed that a 
comparable trifecta outcome (77%) can be achieved by 
low-volume surgeon[40].

Radical Cystectomy
Radical cystectomy with urinary diversion has one of the 
highest morbidity rates among urological procedures, 
with postoperative complication rates of up to 69%[41]. 
Minimally invasive surgery, both pure laparoscopy 

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and robot-assisted, are feasible alternatives to open 
radical cystectomy. Data from the RAZOR trial suggest 
that RARC is associated with decreased blood loss, 
transfusion rate, and hospital stay compared with the 
open approach[41]. Further, RARC has been shown to 
be non-inferior to the open approach in terms of 3-year 
progression-free and overall survival[42]. The learning 
curve for such complex procedures is estimated to be 21 
to 30 cases when using benchmarks of operating time 
of < 6.5 hours, lymph node yield (LNY) of 20, and < 5% 
positive surgical margin (PSM). The number needed to 
reach the target OT was 21 cases. A total of 8, 20, and 
30 cases were required to attain a LNY of 12, 16, and 20, 
respectively. Similarly, 30 cases were required to reach 
competency for PSM[43].

Guru et al. divided 100 consecutive RARC procedures 
into 4 quartiles. The overall mean OT and EBL were  
343 minutes and 598 mL, respectively. The mean 
OT reduced from 375 minutes in first quartile to  
352 minutes in the last quartile. Similarly, the LNY 
increased from 14 nodes in first quartile to 23 nodes in 
the last quartile. While there were 4 cases of PSM in the 
first quartile, none of the patients in the last quartile had 
a positive margin. The authors reported no difference in 
the complication rate over time[44].

Experience in one robot-assisted procedure helps 
improve outcomes in other procedures. Hayn et al., 
using the International Robotic Cystectomy Consortium 
database, report that surgeons with prior experience in 
RARP provide better RARC outcomes with significant 
differences in OT, EBL, and LNY between surgeons with 
< 50 RARPs and those with 51 to 100 RARPs[45].

The adoption of RARC has been increasing in Asian 
countries in recent years. A single-center retrospective 
analysis from India of the initial experience of 63 RARC 
with extracorporeal urinary diversion reported a mean 
OT, EBL, and hospital stay of 348 minutes, 868 mL, and 
10.4 days, respectively. The mean LNY was 12.4, ranging 
between 3 and 25 nodes[46]. These data are very similar 
to those reported from larger centers[44].

Pyeloplasty
Robotic assistance has also helped lower the steep 
learning curve associated with laparoscopic pyeloplasty 
for uretero-pelvic junction obstruction[47]. It has been 
documented to be of particular advantage in patients 
with anatomical variations like lower moiety uretero-
pelvic junction obstruction, malrotated kidneys, and 
secondary uretero-pelvic junction obstruction[48–52].

RALP is a relatively simple procedure and has been 
considered as a gateway to advanced reconstructive 
procedures[53]. A novice can achieve an operating time 
within 1 standard deviation of the open pyeloplasty 

after 15 to 20 cases[54]. However, it takes only about  
5 cases for a surgeon expert in open procedures[55]. It is 
not surprising that robotic assistance does not offer any 
benefit to experienced laparoscopic surgeons with good 
intracorporeal suturing skills[56]. However, a relatively 
faster learning curve could prompt low-volume surgeons 
to offer RALP to their patients to deliver comparable 
outcomes.

Ergonomics
The ergonomics of the procedures for surgeons are often 
under-reported, and poor ergonomics affect physical, 
mental, and economic well-being. A greater degree 
of adverse ergonomic problems are expected among 
urologists who perform a wide range of operative 
procedures such as open, laparoscopic, robotic, 
endoscopic, and microscopic surgeries[57]. Catanzarite 
et al. have shown that work-related musculoskeletal 
disorders are prevalent in 66% to 90%, 73% to 100%, and 
23% to 80% for open, laparoscopic, and robotic surgeries, 
respectively[58]. Surgeon fatigue after performing a 
conventional laparoscopic pyeloplasty may limit the 
number of procedures that may be performed on the 
same day[59]. Specifically, post-procedure fatigue affects 
precise intracorporeal suture placement[60]. Although 

TABLE 1. 

Learning curve of common robotic urological 
procedures 

Procedure* 
Number of cases 

required 
Outcome measures

RARPa 80–120 cases[21]
Perioperative, 

oncological, and 
functional outcomes

RAPN
20 cases[5]
50 cases[5]

WIT
OT

RARC 21–30 cases[41]
OT < 6.5 hours; LNY of 

20; PSM < 5%

RALP 15–20 cases[52] OT

RARP: robotic-assisted radical prostatectomy; RAPN: robotic-assisted 
partial nephrectomy; RARC: robotic-assisted radical cystectomy;  
RALP: robotic-assisted laparoscopic pyeloplasty; WIT: warm ischemia 
time; OT: operative time; LNY: lymph node yield and PSM: positive 
surgical margin

* All the data provided here are originated from surgeons trained in 
both open and laparoscopy except (a) Denotes the learning curve of  
a surgeon with no prior laparoscopic experience.

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robot-assisted surgery appears to be ergonomically 
better, it too can lead to a strain on trunk, wrist, and 
fingers[58]. For instance, one of the most common 
ergonomic issues while performing robotic surgery is 
abducted shoulder and not maintaining a right angle 
with the biceps, resulting in lifting off the elbows from 
the armrest. Surgeons have to use the clutch control to 
mitigate the abnormal posture[57].

The learning curves of common robotic urological 
procedures are shown in Table 1. These numbers should 
be interpreted with some caution as the data could 
be heterogenous as the data include different cohorts. 
Further, various confounders affecting the outcomes 
of different robotic procedures were not addressed. 
However, our work provides an overview of data on 
outcomes of common robot-assisted surgeries for 
low-volume surgeons.

Role of Various Robotic Training Models
Various training models have the potential to help low-
volume robotic surgeons deliver a reasonable surgical 
outcome without compromising patient safety. In this 
context, expert proctorship helped trainees achieve 
efficiency and early performance of independent robotic 
procedures. With the introduction of dual-console da 
Vinci Si or Xi Surgical systems, the proctorship program 
has become more convenient for both proctor and 
trainee[61–63]. As the technology advances, the future 

looks promising for telementoring, which may facilitate 
remote proctorship[64]. A fellowship program has been 
considered the most structured robotic training model 
as it involves a systematic method of training[65]. The 
trainees perform progressive steps of the operation 
in succession under the guidance of an expert robotic 
surgeon with constant and immediate feedback[61]. 
Lastly, simulation-based training allows trainees to 
develop surgical skills without risking patient safety. It 
provides an objective assessment of particular surgical 
skills. In recent years, various robotic simulation 
platforms have been developed and are commercially 
available. In particular, the da Vinci skills simulator is 
closely attached to the surgeon console that would be 
otherwise used for robotic-assisted surgeries[66].

Conclusion
Robotic assistance has the potential to help low-volume 
surgeons and hospitals offer minimally invasive surgery 
to their patients. Robotic assistance enables surgeons to 
reach a higher degree of competence more quickly and 
easily. While the costs associated with robot assistance 
continue to be high, the potential benefit of minimally 
invasive surgery over open surgery would help mitigate 
concerns. Ergonomic benefits for the surgeon are 
unmeasured, but may also be a significant advantage of 
robotic-assisted surgery.

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