Robotic nipple-sparing mastectomy: a comparative analysis with conventional and endoscopic techniques through a systematic review

Abstract

Robotic nipple-sparing mastectomy (R-NSM) has emerged as an innovative approach in breast cancer surgery, offering improved aesthetic outcomes and patient satisfaction. However, its adoption remains controversial due to limited regulatory approval, higher costs, and the need for further comparative evidence. This systematic review aims to evaluate and compare conventional, endoscopic, and robotic NSM techniques to clarify their respective benefits, limitations, and outcomes. Following OSF registration (osf.io/6xt4s), a systematic review was conducted, identifying studies on nipple-sparing mastectomy (NSM) across multiple databases (January 2025). No language or data availability restrictions were applied. Study quality was assessed using the QualSyst criteria (range: 0.0-1.0). Twelve studies met inclusion criteria (ten observational, two clinical trials), with quality scores ranging from 0.75 to 0.95. R-NSM was associated with longer operative times (+ 25-60 min) and higher costs (+ $3,700-$5,000 per procedure). However, it demonstrated superior aesthetic outcomes, with concealed scars and higher patient satisfaction at 1-year follow-up (p = 0.03). Oncologic safety was comparable among NSM techniques, with no significant differences in recurrence, survival, or positive margin rates. While R-NSM initially resulted in prolonged hospital stays (+ 1.5-3 days), this effect diminished with surgical experience. In addition, R-NSM was linked to reduced intraoperative blood loss and a lower risk of severe postoperative complications, particularly nipple-areola complex necrosis. R-NSM offers promising benefits in selected patients, particularly regarding cosmetic outcomes and reduced complications. However, challenges remain, including high costs, longer surgical times, and the need for standardized protocols. Future research should focus on optimizing surgical techniques, refining patient selection, and conducting high-quality randomized controlled trials to establish its definitive role in breast cancer management.

Keywords: Breast cancer; Breast surgery; Esthetic outcomes; Minimally invasive breast surgery; Nipple-sparing mastectomy; Oncologic safety; Robotic surgery.