Evolution of Robotic Urology in Clinical Practice from the Beginning to Now: Results from the GRAND Study Register

Background and objective Major urological guidelines do not currently recommend robot-assisted surgery compared with laparoscopic or open surgery due to the lack of high-quality evidence. We aimed to provide real-world data on the evolution of robotic urology and to compare its perioperative outcomes with those of laparoscopic and open surgeries. Methods We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005–2021), and performed multiple patient-level analyses. We included patients undergoing major urological surgeries and report the largest study in the field with 993 276 patients. Key findings and limitations An open approach was performed in 733 416 cases, a laparoscopic approach in 109 428, and a robot-assisted approach in 150 432. Overall, 442 811 (45%) patients underwent radical prostatectomy, 129 943 (13%) radical cystectomy, 192 340 (19%) radical nephrectomy, 123 648 (12%) partial nephrectomy, 56 114 (5.6%) nephroureterectomy, and 48 420 (4.9%) pyeloplasty. The number of patients undergoing robot-assisted surgery increased exponentially, while the number of patients undergoing open surgery decreased substantially throughout the past few years. Patients undergoing minimally invasive surgery displayed slightly better, but clinically insignificant, baseline characteristics. After adjusting for the major risk factors in the multivariate regression analysis, robotic versus open surgery was associated with significantly lower odds of mortality for all five major oncological surgeries and with lower odds of intensive care unit admission, transfusion, and length of hospital stay for all six major urological surgeries. Conclusions and clinical implications Robotic surgery is becoming the mainstay in major urological operations. Patient summary Patients selected for robotic surgery in Germany presented better perioperative outcomes compared to those operated with an open approach.