Why pay more for robot in breast surgery: literature review and analysis of costs

Background and Objective: Robot-assisted nipple-sparing mastectomy (R-NSM) has emerged as a novel surgical approach in breast cancer treatment, suggesting advantages in cosmetic outcomes, ergonomic performance, and surgical outcomes. Despite its growing adoption, the high costs associated with robotic systems have raised concerns about its financial sustainability. This review aims to assess the clinical benefits, economic implications, and cost-effectiveness of R-NSM compared to conventional nipple-sparing mastectomy (C-NSM), using both current literature and real-world data from a high-volume cancer center. Methods: A comprehensive narrative review was conducted, utilizing PubMed and Google Scholar to identify relevant publications up to March 31, 2025. Search terms included "Robotic Nipple-Sparing Mastectomy", "R-NSM", "Conventional NSM", "Surgical outcomes", "Cost analysis", and "Healthcare economics". No language restrictions were applied. Institutional cost data and national procurement records were incorporated to contextualize economic findings. Study selection and data extraction were performed independently by multiple authors with consensus resolution. Key Content and Findings: The review explores surgical outcomes, oncologic safety and patient satisfaction, related to economic factors of R-NSM. Evidence shows R-NSM is non-inferior to C-NSM regarding safety and may reduce complications such as nipple necrosis, and the need of subsequent surgical interventions. Patients report improved cosmetic and psychosocial outcomes. However, R-NSM adds an average of €3,700-€4,000 per case, largely due to extended operative time and higher disposable instrument costs. These costs align with international data. Institutional volume, shared robotic platforms, and potential reductions in secondary procedures may help offset expenses over time. Conclusions: R-NSM offers promising benefits in terms of patient outcomes and surgical precision, but its widespread adoption hinges on economic feasibility. Transparent reporting is crucial to inform practice. Institutions must weigh costs against clinical value, with broader adoption likely influenced by surgical expertise, reimbursement models, and evolving technology. Future quality-adjusted life year (QALY)-based cost-utility analyses and multinational studies will be essential to define its role in breast cancer surgery.