Clinical superiority and economic viability of robotic surgery for prostate cancer: A quantitative meta-analysis

Objective Prostate cancer is a leading malignancy among men worldwide. Surgical management, including open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and robot-assisted radical prostatectomy (RARP), remains a cornerstone for treating localized disease. This meta-analysis aimed to evaluate the clinical efficacy and cost-effectiveness of RARP compared with those of ORP and LRP. Methods A systematic search of the PubMed/MEDLINE, Embase, Cochrane, and Scopus databases was conducted up to March 2025. Random effects meta-analysis was used to calculate odds ratios (ORs) and mean differences with 95% confidence intervals (CIs). Meta-regression was used to explore the sources of heterogeneity. An expanded 20-year Markov model with probabilistic sensitivity analysis was used to assess cost-effectiveness using averaged multi-study inputs and meta-derived transition probabilities. Future costs and health outcomes (quality-adjusted life years, QALYs) were discounted at an annual rate of 3%. Results Forty studies were included (33 on clinical outcomes and 7 on cost-effectiveness). RARP was associated with significantly lower odds of urinary incontinence (vs. LRP: OR = 0.58, 95% CI: 0.53 to 0.63, p < 0.01; vs. ORP: OR = 0.68, 95% CI: 0.55 to 0.84, p < 0.01) and erectile dysfunction (vs. LRP: OR = 0.43, 95% CI: 0.33 to 0.55, p < 0.01; vs. ORP: OR = 0.74, 95% CI: 0.60 to 0.90, p < 0.01). In addition, RARP was associated with lower overall complications (OR = 0.70, 95% CI: 0.52 to 0.93, p = 0.01) than LRP, and lower biochemical recurrence (OR = 0.72, 95% CI: 0.57 to 0.92, p = 0.008) and lower all-cause mortality (OR = 0.52, 95% CI: 0.34 to 0.78, p = 0.002) than ORP. The 20-year Markov model yielded incremental cost-effectiveness ratios (ICERs) of US $16,547/QALY for RARP versus LRP and US $27,610/QALY versus ORP. Conclusion Compared with LRP and ORP, RARP clearly demonstrates clinical superiority in terms of functional recovery and oncologic control. With ICERs below commonly accepted high-income thresholds over a 20-year horizon, RARP may offer good value in resource-rich settings. However, ICERs exceed the willingness-to-pay thresholds of typical low- and middle-income countries, highlighting the need for cost-reduction strategies, targeted adoption in high-benefit subgroups, or the integration of emerging lower-cost robotic platforms to improve accessibility in low- and middle-income countries.