Establishing a sustainable and high-utilization robot-assisted surgery platform in a regional cancer center: insights...

Adoption of robot-assisted surgery (RAS) in regional non-urban cancer centers is constrained by high fixed costs and insufficient case volumes to achieve financial sustainability. Break-even thresholds vary widely (120-300 cases/year) across institution types; however, operational models for resource-constrained settings remain poorly characterized. To evaluate whether a financially sustainable, high-utilization RAS platform centered on colorectal cancer surgery can be established in a regional, non-urban cancer center through a four-phase, cross-departmental, volume-driven strategy guided by break-even analysis. A single da Vinci Xi system was shared across surgical departments. Annual fixed costs totaled ¥47,500,000, incremental revenue was ¥650,000/case, and variable instrument costs were ¥300,000, ¥350,000, and ¥400,000. A four-phase strategy was implemented: anchoring volume through urology, expanding into colorectal surgery via structured proctorship, broadening colorectal indications, and dynamically allocating robotic capacity across departments. Annual RAS volume reached 254 cases in 2025, exceeding the break-even threshold of 200-250 cases across cost scenarios. Robot-assisted colorectal surgery increased fifteen-fold between April and October 2025, stabilizing at 6-9 cases/month. Weekday utilization reached 1.2-1.5 cases/day in high-volume months and remained at or above 100% throughout the maturation phase. A sensitivity analysis confirmed that procedural volume, not instrument cost variation, is the dominant determinant of financial sustainability. A sustainable, high-utilization RAS platform is achievable within 18-24 months using a four-phase, volume-driven strategy. Under Japan's reimbursement structure, 200-250 annual cases represent the critical break-even threshold. This framework offers a transferable roadmap for non-urban cancer centers facing barriers to adoption.