title: Robotic prostatectomy is associated with increased patient travel and treatment delay.
abstract: BACKGROUND
  New technologies may limit access to treatment. We investigated radical prostatectomy (RP) access over time since robotic introduction and the impact of robotic use on RP access relative to other approaches in the modern era.
  
  
  METHODS
  Using the National Cancer Data Base, RPs performed during the eras of early (2004-2005) and late (2010-2011) robotic dissemination were identified. The primary endpoints, patient travel distance and treatment delay, were compared by era, and for 2010-2011, by surgical approach. Analyses included multivariable and multinomial logistic regression.
  
  
  RESULTS
  138 476 cases were identified, 32% from 2004-2005 and 68% from 2010-2011. In 2010-2011, 74%, 21%, and 4.3% of RPs were robotic, open, and laparoscopic, respectively. Treatment in 2010-2011 and robotic approach were independently associated with increased patient travel distance and longer treatment delay (p<0.001). Men treated robotically had 1.1-1.2 times higher odds of traveling medium-to-long-range distances and 1.2-1.3 higher odds of delays 90 days or greater compared to those treated open (p<0.001). Laparoscopic approach was associated with increased patient travel and treatment delay, but to a lesser extent than the robotic approach (p<0.001). In high-risk patients, treatment delays remained significantly longer for minimally invasive approaches (p<0.001). Other factors associated with the robotic approach included referral from an outside facility, treatment at an academic or high-volume hospital, higher income, and private insurance. Potential limitations include the retrospective observational design and lack of external validation of the primary outcomes.
  
  
  CONCLUSIONS
  The robotic approach is associated with increased travel burden and treatment delay, potentially limiting access to surgical care.
authors.affiliation: Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Maurice
authors.affiliation: Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States;; Division of Urology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States.
authors.forename: Hui
authors.initials: H
authors.lastname: Zhu
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Cleveland, OH, United States.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kim
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Cleveland, OH, United States.
authors.forename: Robert
authors.initials: R
authors.lastname: Abouassaly