Consensus Statement on Robotic Mastectomy

Expert Panel From International Endoscopic and Robotic Breast Surgery Symposium (IERBS) 2019

Hung-Wen Lai, MD, PhD; Antonio Toesca, MD; Benjamin Sarfati, MD, MSc; Hyung Seok Park, MD, PhD; Gilles Houvenaeghel, MD; Jesse C. Selber, MD, MPH; Fiona Tsui-Fen Cheng, MD, MS; Wen-Ling Kuo, MD, PhD; Nickolas Peradze, MD; Seung Yong Song, MD, PhD; Chi Wei Mok, MBBS, FRCSEd


Annals of Surgery. 2020;271(6):1005-1012. 

In This Article

Abstract and Introduction


Objectives: To achieve a consensus statement on robotic mastectomy.

Background: Robotic-assisted surgery has gained much attention especially the results of few case series reporting on the technical feasibility, safety and early oncologic outcomes of robotic-assisted mastectomy in a few centers worldwide. The aim of this consensus statement was to develop and provide standardized guidelines on robotic mastectomy based on consensus statement by a panel of experts from indications to outcome measures and indicators, thereby providing a valuable guide for breast surgeons worldwide.

Methodology: An internationally representative expert panel of 10 surgeons was invited to participate in the generation of a consensus statement. 52 statements were created in 6 domains: indications, contraindications, technical considerations, patient counseling, outcome measures and indicators, training and learning curve assessment. Experts were asked to vote if they agree, disagree or of the opinion that the statement should be rephrased. Two electronic rounds via online survey of iterative rating and feedback were anonymously completed, followed by a final round of in-person meeting during the inaugural International Endoscopic and Robotic Breast Surgery Symposium 2019 from May 24 to 25, 2019. Consensus was reached when there was at least 80% agreement on each statement.

Results: A total of 53 statements with at least 80% agreement were generated after 3 rounds of voting; 21 statements from first round of voting, 20 statements from second round of voting and 12 statements from the final round of in-person meeting. All experts agreed that the consensus statement served as expert recommendations but not mandatory for a successful and safe practice of robotic mastectomy.

Conclusion: Robotic mastectomy is a promising technique and could well be the future of minimally invasive breast surgery whereas proving to be safe and feasible. The first consensus statement on robotic mastectomy from an international panel of experts serves as an extremely important milestone and provides recommendations for breast surgeons keen to embark on this technique.


Robotic-assisted nipple sparing mastectomy (R-NSM) was first reported in 2015 by Toesca et al whereby a case series of 3 patients who were BReast CAncer gene mutation carries received risk reducing mastectomy and the authors concluded that the technique resulted in a feasible and safe operation with better aesthetic outcomes.[1] Over the course of next few years, there were a few case reports and series[1–12] reporting on respective institutional experience in the development of R-NSM with authors from one of the institutions reporting on the learning curve evaluation of this technique in a separate study.[13] Single port with gas inflation systems were most frequently used techniques,[2,5,7,9,14] alternatively gasless R-NSM was also reported.[15] In terms of reconstructive options, most authors perform immediate direct to implant reconstruction[7,9,14] except for 2 studies whereby pedicled[6,16,17] and free autologous[18] flap were used. It has to be noted that these studies were mostly retrospective in nature and the numbers were small, hence limiting its widespread applicability of the study results.

The advantages reported in all studies were similar and that include better visualization with 3-dimensional optics and improved ergonomics from instruments with high degree of freedom of movement. The 3 main disadvantages of this technique were attributed to prolonged operative time, increased cost and availability of robotic surgical platform.

Indications of R-NSM as reported in 4 case series[2,5,7,14] were early breast cancer, tumor less than 5 cm with no evidence of skin, chest wall or nipple areolar complex (NAC) involvement.

In terms of outcome measures, R-NSM was proven to be feasible and safe in all studies with low conversion rate, reasonable learning curve[13] and low complications rate. Of notable mention was the very low (0%) NAC necrosis rate across all studies[2,5,7,14] in which the authors of 1 study[7] attributed the low NAC necrosis rate to placement of incision far from the NAC and better visualization with 3-dimensional optics on a robotic surgical platform. Oncologic outcomes were not reported as the follow up duration was relatively short in all studies. More recently, authors from one of the institutions presented the first oncological outcome data showing a local recurrence-free survival of 100% with a mean duration follow up of 19 months.[19] Excellent aesthetic outcomes were reported in all studies and in addition, 1 study described patient-reported satisfaction rate in which majority of patients were satisfied with the operation especially with regards to placement and length of incision.[7] Robotic nipple sparing mastectomy was discussed as the next step in the evolution of minimally invasive breast surgery in a recent article.[20]

However, a recent US Food and Drug Administration (FDA) safety communication[21] seemed to be casting a doubt and raising a need for closer scrutiny and evaluation of this technique to ensure oncological safety are not compromised with the use of this technique in the management of breast cancer. The purpose of this consensus statement was to create an internationally endorsed statement on robotic mastectomy from indications to outcome measures and indicators, thereby providing a valuable guide for breast surgeons worldwide.