Comparative Analysis of Robotic-Assisted Surgery Versus Traditional Surgery in the Treatment of Endometriosis: A Narrative Review

Background: Endometriosis is a prevalent gynecological condition among women that causes infertility, severe pain, and reduces quality of life. Despite the rapid growth in the use of robotic-assisted surgery (RAS) for various medical specialties, little is known about its effectiveness compared to traditional human-performed surgery for endometriosis treatment. This narrative review aims to compare the effectiveness of RAS compared to conventional surgery in improving various patient outcomes in endometriosis treatment.

Randomized controlled trials (RCTs) and quasi-experimental studies were searched on PubMed and Web of Science in November 2024. Studies were eligible if they compared the effectiveness of RAS and conventional surgical procedures for endometriosis treatment for improving various patient outcomes.

Only one RCT has been conducted on this subject matter, and there is one ongoing RCT that is anticipated to be completed by 2026. The only RCT published so far reported three outcomes, namely condition-specific quality of life, operative time, and complications (and blood loss and conversion rates to laparotomy). The RCT revealed that both RAS and conventional surgery improved quality of life, but there were no significant differences between them. Observational cohort studies have not so far reported on quality of life as a clinically important outcome. Also, no significant differences were noted regarding complications, blood loss, and conversion rates to laparotomy, which is consistent with meta-analyses of observational cohort studies. However, although the RCT reported no significant differences between the two arms regarding operative time, all the meta-analyses of observational studies revealed that RAS was significantly inferior to conventional surgery in this outcome. Even so, the RCT noted that the operative time for RAS was relatively longer than conventional surgery, although not statistically significant.

This narrative review identified significant literature gaps, namely, no RCT reporting on pain as a clinically important outcome. Also, the currently available RCT is of moderate quality due to double-blinding concerns. Generally, RAS does not offer any outstanding advantages compared to conventional surgery, but it can be considered a safe and effective alternative.

Endometriosis, RCT, robotic-assisted surgery, conventional surgery

- Ahuja, A. S. (2019). Should RCT’s be used as the gold standard for evidence based medicine? Integrative Medicine Research, 8(1), 31–32. https://doi.org/10.1016/j.imr.2019.01.001 - Burns, P. B., Rohrich, R. J., & Chung, K. C. (2011). The levels of evidence and their role in evidence-based medicine. Plastic and Reconstructive Surgery, 128(1), 305–310. https://doi.org/10.1097/PRS.0b013e318219c171 - Chen, S.-H., Li, Z.-A., & Du, X.-P. (2016). Robot-assisted versus conventional laparoscopic surgery in the treatment of advanced stage endometriosis: A meta-analysis. Clinical and Experimental Obstetrics & Gynecology, 43(3), 422–426. - Csirzó, Á., Kovács, D. P., Szabó, A., Fehérvári, P., Jankó, Á., Hegyi, P., Nyirády, P., Sipos, Z., Sára, L., Ács, N., Szabó, I., & Valent, S. (2024). Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: A systematic review and meta-analysis. Surgical Endoscopy, 38(2), 529–539. https://doi.org/10.1007/s00464-023-10587-9 - Handa, A., Gaidhane, A., & Choudhari, S. G. (2024). Role of robotic-assisted surgery in public health: Its advantages and challenges. Cureus. https://doi.org/10.7759/cureus.62958 - Lai, T.-J., Heggie, R., Kamaruzaman, H.-F., Bouttell, J., & Boyd, K. (2024). Economic evaluations of robotic-assisted surgery: Methods, challenges and opportunities. Applied Health Economics and Health Policy. https://doi.org/10.1007/s40258-024-00920-1 - Moradi, Y., Shams-Beyranvand, M., Khateri, S., Gharahjeh, S., Tehrani, S., Varse, F., Tiyuri, A., & Najmi, Z. (2021). A systematic review on the prevalence of endometriosis in women. Indian Journal of Medical Research, 154(3), 446. https://doi.org/10.4103/ijmr.IJMR_817_18 - Pavone, M., Baroni, A., Campolo, F., Goglia, M., Raimondo, D., Carcagnì, A., Akladios, C., Marescaux, J., Fanfani, F., Scambia, G., & Ianieri, M. M. (2024). Robotic assisted versus laparoscopic surgery for deep endometriosis: A meta-analysis of current evidence. Journal of Robotic Surgery, 18(1), 212. https://doi.org/10.1007/s11701-024-01954-2 - Restaino, S., Mereu, L., Finelli, A., Spina, M. R., Marini, G., Catena, U., Turco, L. C., Moroni, R., Milani, M., Cela, V., Scambia, G., & Fanfani, F. (2020). Robotic surgery vs laparoscopic surgery in patients with diagnosis of endometriosis: A systematic review and meta-analysis. Journal of Robotic Surgery, 14(5), 687–694. https://doi.org/10.1007/s11701-020-01061-y - Riley, K. A., Benton, A. S., Deimling, T. A., Kunselman, A. R., & Harkins, G. J. (2019). Surgical excision versus ablation for superficial endometriosis-associated pain: A randomized controlled trial. Journal of Minimally Invasive Gynecology, 26(1), 71–77. https://doi.org/10.1016/j.jmig.2018.03.023 - Sheng, S., Zhao, T., & Wang, X. (2018). Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: A network meta-analysis. Medicine, 97(34), e11817. https://doi.org/10.1097/MD.0000000000011817 - Singh, S. S., Gude, K., Perdeaux, E., Gattrell, W. T., & Becker, C. M. (2020). Surgical outcomes in patients with endometriosis: A systematic review. Journal of Obstetrics and Gynaecology Canada, 42(7), 881-888.e11. https://doi.org/10.1016/j.jogc.2019.08.004 - Song, Z., Li, S., Luo, M., Li, H., Zhong, H., & Wei, S. (2023). Assessing the role of robotic surgery versus laparoscopic surgery in patients with a diagnosis of endometriosis: A meta-analysis. Medicine, 102(50), e33104. https://doi.org/10.1097/MD.0000000000033104 - Soto, E., Luu, T. H., Liu, X., Magrina, J. F., Wasson, M. N., Einarsson, J. I., Cohen, S. L., & Falcone, T. (2017). Laparoscopy vs. Robotic Surgery for Endometriosis (LAROSE): A multicenter, randomized, controlled trial. Fertility and Sterility, 107(4), 996-1002.e3. https://doi.org/10.1016/j.fertnstert.2016.12.033 - Terho, A. M., Mäkelä-Kaikkonen, J., Ohtonen, P., Uimari, O., Puhto, T., Rautio, T., & Koivurova, S. (2022). Robotic versus laparoscopic surgery for severe deep endometriosis: Protocol for a randomised controlled trial (ROBEndo trial). BMJ Open, 12(7), e063572. https://doi.org/10.1136/bmjopen-2022-063572 - WHO. (2023). Endometriosis [World Health Organization]. https://www.who.int/news-room/fact-sheets/detail/endometriosis - Working group of ESGE, ESHRE, and WES, Keckstein, J., Becker, C. M., Canis, M., Feki, A., Grimbizis, G. F., Hummelshoj, L., Nisolle, M., Roman, H., Saridogan, E., Tanos, V., Tomassetti, C., Ulrich, U. A., Vermeulen, N., & De Wilde, R. L. (2020). Recommendations for the surgical treatment of endometriosis. Part 2: Deep endometriosis†‡¶. Human Reproduction Open, 2020(1), hoaa002. https://doi.org/10.1093/hropen/hoaa002 - Yao, Q., Sun, Q.-N., Ren, J., Wang, L.-H., & Wang, D.-R. (2023). Comparison of robotic‑assisted versus conventional laparoscopic surgery for mid–low rectal cancer: A systematic review and meta-analysis. Journal of Cancer Research and Clinical Oncology, 149(16), 15207–15217.https://doi.org/10.1007/s00432-023-05228-6