Over the past 25 years, a fundamental change has occurred in the role of laparoscopic and minimally invasive surgical techniques in the field of urology. The development of minimally invasive techniques were appealing to both patients and providers for the goals of decreased postoperative pain, more cosmetic surgical results, decreased rates of blood transfusions and decreased postoperative recovery time. While complex urological surgeries were described including laparoscopic nephrectomy by Clayman et al. in 1991 [6] and laparoscopic radical prostatectomy by Schuessler et al. in 1997 [29], these initial techniques were not widely utilized in part due to the lengthy learning curves and need for advanced laparoscopic surgical techniques required for proficiency.

The approval of the Intuitive Da Vinci robotic surgical platform (Mountain View, CA) by the Food and Drug Administration in 2000 and the description of the feasibility of robotic assisted laparoscopic prostatectomy (RALP) by Binder et al. in 2001 [4] proved to be critical advances towards the wide dissemination and utilization of robotic surgery.

Between these initial feasibility studies and today, robotic surgical techniques have become increasingly widely adopted. Between 2003 and 2010, the proportion of RALP adopters (as defined as performing >50 % of prostatectomies with robotic assistance) rose from 0.7 to 42 % in the United States [5]. Similarly, while robotic partial nephrectomies comprised only 23.9 % of all partial nephrectomies performed in the Nationwide Inpatient Sample between 2008 and 2010, there was a marked relative annual increase of 45.4 % for robotic partial nephrectomies observed during that time period [15]. These trends in the utilization of robotic urological surgeries would suggest that robotic surgery will be an increasingly critical element of the contemporary urologic practice.

In this chapter, we will describe an evidence based approach towards creating a comprehensive robotic surgery program. While the introduction of new minimally invasive surgical technology provides opportunities for significant benefits for patients, the implementation of this technology may also have significant pitfalls. In the United States, the period of the introduction of robotic technology was associated with higher risks for voiding and erectile dysfunction [1], and thus a structured and organized approach to the creation of a robotic surgery is critically important to obtain the excellent oncologic and functional results observed in several large high volume center studies [12, 13, 23].

Prior to acquiring a robotic surgical system, an economic analysis and plan should be developed for the purchase and maintenance of the robot. An accurate assessment is critically important for determining the economic limitations of an institution and if the current surgical volume is sufficient to support both the fixed (cost of purchasing the robotic platform, maintenance contracts) and variable (cost of training, disposal instruments, operative time) costs associated with the initiation of a robotics program. While urologic surgery comprises a significant portion of robotic procedures, acquiring a robotic surgical platform represents a hospital wide resource and consultation with colleagues in across several surgical specialties including gynecology [14], general [32], transplant [16], and colorectal surgery [9] can be helpful in determining if there is appropriate demand for a robotic platform as well as devising a plan for dividing costs and surgical block time for this resource. Administrative support is also vitally important to help assist with marketing, updating websites and educational resources for patients, supply management and to track costs and reimbursements associated with a robotic surgery program.

The initial cost of a robotic system can be significant ranging from $1 million to $2.5 million for each unit [2], and additional per procedure costs have been estimated as $1,600 per case as an additional variable cost and $3,200 per case, if the amortized cost of the robotic system is included [11]. These costs can be related to several factors including disposable surgical instruments and maintenance contracts and the additional cost is typically not covered as an additional fee by Medicare or most private insurance companies, so hospitals should account for the additional per procedural costs associated with this technology. Many other factors may also contribute to hospital related costs including blood transfusion [11], length of hospital stay [24], and operative time [3], and the overall cost effectiveness of robotic surgery remains a contentious area of debate and discussion [33].

Nevertheless, hospitals acquiring a robotic platform should perform a market analysis to determine potential for growth, regional and local competition and reimbursement and payers to thoroughly evaluate the potential of introducing this technology. While fixed costs regarding the purchase and upkeep of the machine are stable regardless of use, a high volume surgical center with an experienced robotics team should allow for a standard and efficient operative experience that can reduce variable costs and complications and provide the most cost effective approach to providing robotic urologic surgery.

Marketing and website design are an essential part of the success of any new program, including robotic surgery. Prior to the purchase of a robot and establishing your robotic program, a well-balanced marketing team with financial resources specifically dedicated to your department should be implemented. A formal marketing plan should be developed, including assigning staff to develop a referral base to recruit new patients for your practice. It is important to implement the marketing strategies once proficiency of the surgical procedure has been accomplished. While the robotic platform is an excellent tool for providing minimally invasive surgery, it is no substitute for meticulous surgical technique and surgeon skill.

A website should be established which provides education and background information on the disease process at hand, and the potential advantages of using the robot vs other surgical modalities. It is important to reference published peer-reviewed data and to provide contact information for your practice for patients to contact you.

Educational brochures may be provided to patients and referring physicians to provide more information about the surgery being performed. These brochures can be used both for physician reference and for patients to educate themselves on the benefits of robotic surgery. While it may be tempting to delegate the creation and oversight of marketing materials, the attending surgeon should play an active role to produce materials which are educational for patients and are also well balanced. Unfortunately, many of the available materials presently on robotic surgery do not provide a balanced message. It has been previously reported that 42 % of websites regarding robotic prostatectomy failed to mention potential risks and many that many websites claimed benefits which have not been supported in evidence based medicine [22]. Prior studies have shown that the language used in these marketing materials may have a significant impact on patient decision making and that words such as “innovative” or “state of art” may strongly influence patient’s choice towards surgical treatment [10]. Given these findings, it is critical to provide a balanced message that weighs both risks and benefits associated with robotic surgery.

The media of the twenty-first century has created new marketing strategies for robotic surgeons. Television, newspaper and hospital website advertisements have been created by the manufacturers of the robotic system, and hospitals and surgeons around the country have helped in getting the word out. Many patients will present to your office requesting robotic surgery as an alternative due to an advertisement they have seen on television or on social media and so it is advisable to have a comprehensive approach towards marketing and patient education.

Once the decision has been made to acquire a robotic surgical platform, a dedicated robotic operating room should be designated. A large OR with appropriate high definition video screens should be requested due to specific space requirements for the surgical console, surgical cart and the robotic platform and need for additional support staff, particularly during the learning curve of robotic surgery.

This beginning can be a particularly challenging time for a new attending as multiple team members are learning a new technology and their role during robotic operations. In many operating rooms, the support staff including the circulating nurse, surgical technician and surgical assistant may freely rotate between specialties and rooms depending on staffing needs. Given the unique aspects of robotic surgery, including docking and undocking the robot, the use of specialized disposable instrumentation and challenges associated with bedside assisting and draping, we strongly recommend identifying a specialized team of support staff who would benefit from additional training and experience to help smoothly facilitate robotic surgery from start to finish. In community settings, this dedicated team approach was used for comparable outcomes to academic settings with an estimated learning curve of 20–25 cases for robotic prostatectomy [25].

The attending surgeon should act as a leader for the implementation of a robotic surgical program. The lead attending is responsible for the performing the clinical aspects of care including preoperative counseling, performing the operation and postoperative follow up as well as responsible for coordinating the logistics and necessary training for support staff. In addition to good operative technique, strong communication and effective leadership are critically important for a fledgling robotics program. Depending on the experience of the surgeon, robotics proctoring and credentialing may be required prior to independent practice.