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To assess the long-term cost-effectiveness of robot-assisted radical prostatectomy (RARP) versus open radical prostatectomy (ORP) for localized prostate cancer from the perspective of the French public healthcare system using real-world data. This nationwide comparative cohort study used the French National Health Data System including men undergoing first prostatectomy between 2012 and 2015 with up to eight years follow-up. Patients were allocated to RARP or ORP based on hospital equipment. Inverse probability weighting using a high-dimensional propensity score adjusted for confounding. Outcomes included progression-free survival and direct medical costs. Incremental cost-effectiveness ratios were estimated with bootstrapping and acceptability curves. Sensitivity analyses incorporated additional robotic costs, and hospital volume. Among 27,951 patients, 10,040 underwent RARP and 17,911 ORP; median follow-up was 6.7 years. RARP was associated with lower total costs (€44,631 vs. €47,434) and slightly longer progression-free survival (+0.10 years), yielding a dominant profile. Cost savings reached €3,623 overall and were greatest in highvolume centers. The probability of cost-effectiveness exceeded 90% across thresholds. When robotic costs were included, RARP remained cost-effective, with incremental cost-effectiveness ratios around €19,000-€25,000 per progression-free year depending on volume. RARP provides improved progression-free survival with reduced healthcare expenditures compared with ORP in France, resulting in a robust dominant or highly cost-effective profile over the long term. Findings were consistent across hospital volumes and sensitivity analyses. These real-world results support reassessment of reimbursement policies and suggest that wider adoption of RARP may deliver sustained clinical and economic value for the healthcare system overall.