Radical prostatectomy is the main surgical treatment for prostate cancer and is associated with various short-term complications. Racial and ethnic minority patients have worse postoperative outcomes than White patients following prostate cancer surgery. One of the factors that may contribute to the racial differences in postoperative outcomes is the differential use of new medical technology of robot-assisted surgery (RAS) across racial and ethnic groups. Patients undergoing robot-assisted radical prostatectomy (RARP) have been shown to have reduced short-term complications, length of stay (LOS), and readmissions and comparable long-term survival compared with patients undergoing open radical prostatectomy (ORP). Previous studies demonstrated that racial and ethnic minority patients with prostate cancer were less likely to receive RARP than White patients. However, critical gaps remain in 1) understanding current evidence on racial and ethnic disparities related to RAS in pelvic cancer surgery thoroughly; 2) determining the impact of RARP on racial and ethnic disparities in postoperative outcomes among prostate cancer patients, and; 3) investigating the role of surgeons on the differential use of RARP across racial and ethnic groups. To address these gaps, this dissertation conducted a systematic review to comprehensively understand racial and ethnic disparities in the use of RAS in four major pelvic cancer treatments (prostate, uterine, bladder, and rectal cancers). Following the systematic review, empirical analyses were performed using linked New York State Cancer Registry and statewide discharge records to determine the contribution of RARP to racial and ethnic disparities in the short-term outcomes after prostate cancer surgery, including determining the presence and pattern of interaction between race/ethnicity and RARP use. Based on a multilevel framework, two important hypotheses were also tested to assess surgeons’ influence on the use of RARP across racial and ethnic groups through access to care and the process of care. The systematic review found consistent evidence that Black and Hispanic patients were less likely to receive RAS than White patients in all four pelvic cancer surgeries. There is a lack of formal assessment to determine the impact of RAS use on racial and ethnic disparities in postoperative outcomes. The systematic review also found that racial and ethnic minorities were less likely to receive treatment at RAS-performing or high-technology centers than White patients. But there is a paucity of research examining physician-level factors that may be related to differential use of RAS across racial and ethnic groups. The first empirical analysis detected a statistical interaction between race/ethnicity and procedure approach that was present on the additive scale but not on the multiplicative scale. Specifically, when undergoing RARP rather than ORP, non-Hispanic Black (NHB) and Hispanic men with prostate cancer, as compared to non-Hispanic White (NHW) men, experienced a greater reduction in the risk of adverse short-term outcomes of major events (NHB vs. NHW: RERI -0.32, 95% CI (-0.70,-0.01); Hispanic vs. NHW: RERI -0.28, 95% CI (-0.74,0.09)) and prolonged LOS (NHB vs. NHW: RERI -0.32, 95% CI (-0.70,-0.01); Hispanic vs. NHW: RERI -0.28, 95% CI(-0.74,0.09)) on the absolute risk (additive) scale. The second empirical analysis confirmed the two hypotheses related to surgeons’ role in the racial and ethnic disparities related to RARP use. First, NHB and Hispanic patients were more likely to be treated by surgeons who were low-RARP users (NHB vs. NHW: OR 1.73, 95% CI 1.58-1.90; Hispanic vs. NHW: OR 2.14, 95% CI 1.90-2.41) or by surgeons at non-RARP facilities (NHB vs. NHW: OR 4.26, 95% CI 3.45-5.27; Hispanic vs. NHW: OR 4.01, 95% CI 3.44-4.67) than NHW patients, supporting racial and ethnic disparities in access to care. Second, when treated by the same surgeon and having similar conditions, NHB and Hispanic patients were less likely to receive RARP than NHW patients (NHB vs. NHW: OR 0.73, 95% CI 0.59-0.91; Hispanic vs. NHW: OR 0.72, 95% CI 0.55-0.96), supporting racial and ethnic disparities in the process of care. In summary, this dissertation identified gaps in current literature and showed that NHB and Hispanic patients with prostate cancer were less likely to receive but benefitted more from RARP than NHW patients. Increasing equitable penetration of robot-assisted technology may help reduce racial disparities in patient outcomes after radical prostatectomy. This dissertation also revealed that NHB and Hispanic patients were less likely to be treated by high-RARP-use surgeons and less likely to receive RAPR when treated for similar conditions by the same surgeons than NHW patients. Addressing structural barriers faced by racial and ethnic minority patients during care-seeking and the process of care can help reduce disparities in RAS use.

Contrairement aux autres biens meubles, les navires, les aéronefs et les objets spatiaux affectés à la navigation internationale sont rattachés à un Etat. Le lien de droit public établi entre ces engins et l’Etat est communément appelé « nationalité ». Mais ce terme n’exprime pas à leur propos une institution à tous égards identique à la nationalité des personnes. Le rattachement examiné ne repose en effet pas sur des éléments de fait (naissance, ascendance etc.), mais uniquement sur un acte administratif interne, l’immatriculation. L’étude de la pratique, notamment des conventions internationales et des législations nationales, montre clairement que – contrairement à ce qu’on soutient souvent – il n’y a pas lieu de subordonner ce rattachement à un lien effectif. Ce qui importe, compte tenu notamment du fait que ces engins évoluent dans des espaces soustraits à toute compétence territoriale, est d’identifier l’Etat qui est seul compétent à l’égard de l’« ensemble organisé » formé par le véhicule, les personnes et la cargaison à bord, et qui est responsable de ses activités. Le droit international interdit dès lors la double immatriculation, mais il laisse aux Etats le pouvoir discrétionnaire de déterminer les conditions d’attribution de leur « nationalité », sans subordonner l’opposabilité internationale de celle-ci à quelque autre exigence que ce soit. Le danger est toutefois que cela favorise un certain laxisme de l’Etat d’immatriculation, ce qui exposerait au risque que des dommages graves soient causés aux personnes impliquées dans les activités de ces engins et – surtout – aux tiers. Mais ce sont les obligations internationales imposées et les droits corrélatifs reconnus dans le chef de l’Etat d’immatriculation qui sont déterminants à cet égard et non quelque mystérieuse « effectivité » du rattachement. Autrement dit, s’il n’est pas nécessaire d’imposer à l’Etat d’immatriculation des conditions internationales limitant sa liberté dans l’attribution de sa « nationalité » aux engins, il est indispensable d’exiger que celui-ci respecte ses obligations, c’est-à-dire exerce effectivement son contrôle et sa juridiction. Cette constatation se vérifie quel que soit l’engin en cause. Le rattachement créé par l’immatriculation constitue donc une institution "sui generis", commune aux navires, aéronefs et objets spatiaux et dont le régime juridique est encadré par le droit international. / Unlike any other movable property, ships, aircraft and space objects that are engaged in international navigation are linked to a State. The legal connection established between these craft/vessels and the State is commonly referred to as “nationality”. However, in this case the term does not represent an institution identical in all respects to the nationality of persons. With regard to vessels, the legal connection to a State is not based on factual elements (such as birth, descent etc.), but merely on the internal administrative act of registration. The study of State practice, notably international conventions and national laws, clearly shows that – contrary to what is often argued – there is no need to make this connection dependent on a pre-existing effective link. What matters most, given that these craft navigate in international space beyond the territorial jurisdiction of sovereign States, is to identify the State that holds sole jurisdiction over said “organized entity” consisting of the vehicle, the persons and the cargo on board and that is responsible for its activities. Public international law therefore prohibits dual registration, but leaves States free to determine the conditions under which they will confer their “nationality”, without imposing any other requirement for the opposability of this legal bond to third States. The danger is that this situation encourages laxity on the part of the States of registry and therefore creates the potential for serious damage incurred by persons involved in these vessels’ activities and – mostly – by third persons. In this regard, it is the international obligations and corresponding rights of the States of registry which are critical, and not a mysterious “effectiveness” of the legal bond. In other words, it is not necessary to impose on the State of registry any international conditions which would limit its freedom with regard to the conferral of its “nationality” upon vessels. It is however indispensable to require that said State complies with its obligations, meaning that it has to effectively exercise its jurisdiction and control over those craft. This statement holds true regardless of the craft concerned. The legal bond created by the registration therefore constitutes a "sui generis" institution, common to ships, aircraft and space objects, and whose legal regime is governed by international law.