{"paper_id":"12444ae2-cf98-4e62-8599-abe8e7d2572d","body_text":"1\nVol.:(0123456789)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports\nChanges in anti‑Müllerian \nhormone values for ovarian reserve \nafter minimally invasive benign \novarian cystectomy: comparison \nof the Da Vinci robotic systems \n(Xi and SP) and the laparoscopic \nsystem\nYunjeong Park , Ayoung Song , Junghyun Jee , Nayoung Bae , Sumin Oh , Jung‑Ho Shin  & \nYong Jin Kim *\nTo investigate the impact on the ovarian reserve after minimally invasive ovarian cystectomy \nusing two platforms, the Da Vinci robotic system (Xi and SP) and the laparoscopic system. Patients \nunderwent laparoscopic or Da Vinci robotic (Xi or SP) ovarian cystectomy for benign ovarian cysts \nbetween January 1, 2018, and December 31, 2022 at Guro Hospital, Korea University Medical center. \nWe measured the change of AMH values (%) = [(postAMH − preAMH)] × 100/preAMH. No significant \ndifferences in preoperative age, cyst size, estimated blood loss during surgery, hemoglobin drop, \nlength of hospital stay, adhesion detachment rate and cyst rupture rate were observed. However, the \noperative time was significantly shorter in the laparoscopic group than that in the robotic group (67.78 \n± 30.58 min vs. 105.17 ± 38.87 min, p < 0.001) The mean preAMH and postAMH were significantly \nhigher with the Da Vinci robotic group than with the laparoscopic group (preAMH: 5.89 ± 4.81 ng/mL \nvs. 4.01 ± 3.59 ng/mL, p = 0.02, postAMH: 4.36 ± 3.31 ng/mL vs. 3.08 ± 2.60 ng/mL, p = 0.02). However, \nthe mean ΔAMH was not significantly different between two groups. ΔAMH also did not demonstrate \nsignificant differences among the three groups; laparoscopic, Xi and SP robotic. Even in the patient \ngroups with preAMH < 2 and diagnosed with endometriosis, the ΔAMH did not show significant \ndifferences between the laparoscopic and robotic groups. The Da Vinci robotic system is no inferior to \nconventional laparoscopic systems in preserving ovarian function.\nKeywords Anti-Müllerian hormone, Ovarian reserve, Robotic surgical procedures, Laparoscopy, Benign \novarian cyst\nPreservation of ovarian function during surgery takes precedence as the foremost consideration for fertility \npreservation in the context of minimally invasive surgical procedures. Benign ovarian cysts may require surgi -\ncal treatment because of torsion, pain, infertility, and decreased ovarian reserve, in which laparoscopic ovarian \ncystectomy has been the gold  standard1. However, as laparoscopic surgery has been demonstrated to reduce \novarian function, determining the most suitable technique is  important2.\nThe development of minimally invasive surgical methods, such as laparoscopic and robotic systems, has led \nto increased patient satisfaction not only in terms of pain relief but also in cosmetic aspects, including the attain-\nment of smaller scars. In 2000, the Da Vinci robotic system was approved by the Food and Drug Administration \n(FDA) and began to be used in the field of surgery. The Da Vinci SP system was developed and approved by the \nOPEN\nDepartment of Obstetrics and Gynecology, Korea University College of Medicine, 148 Gurodong-ro, Guro-Gu, \nSeoul 08308, South Korea. *email: zinigo@gmail.com\n\n2\nVol:.(1234567890)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\nFDA in 2018, and can operate an articulating camera and up to three robotic instruments through an umbilical \nincision approximately 25 mm in  size3.\nSeveral indicators have been used to evaluate ovarian reserve. Antral follicle count and ovarian volume are \nnot recommended because of the variability in the menstrual cycle and lack of  sensitivity4. Follicle stimulation \nhormone (FSH) has the disadvantages of significant variation and low reproducibility depending on the men-\nstrual cycle. Estradiol is less influenced by the menstrual cycle compared to FSH, although its predictive power \nis limited. Inhibin B is also unsuitable as it fluctuates according to gonadotropin-realizing hormone agonist and \nFSH levels.\nSerum anti-Müllerian hormone (AMH) is a glycoprotein belonging to the transforming growth factor-β \nsuperfamily. AMH is synthesized from the granulosa cells of the pre-antral and antral follicles. It mainly inhibits \nthe early stages of follicular development and affects tissue growth, differentiation, and regression of fetal Mül-\nlerian ducts. Moreover, it is less affected by gonadotropin or the menstrual cycle. Therefore, AMH is currently \nthe most widely used marker for evaluating ovarian  reserve4–6.\nThis study aimed to investigate the impact of minimally invasive ovarian cystectomy using the Da Vinci \nrobotic system (Xi and SP) and a laparoscopic system on ovarian reserve.\nMaterials and methods\nStudy population\nThis study included patients who underwent laparoscopic or Da Vinci robotic (Xi or SP) ovarian cystectomy \nfor benign ovarian cysts between January 1, 2018, and December 31, 2022, at a single institution. All patients \nin this study received information about laparoscopic and robotic surgery, fully understood them, and decided \non their preferred choice. This retrospective study was conducted through an electronic medical record review. \nThis study was approved by the Institutional Review Board and Ethics Committee of the Guro Hospital, Korea \nUniversity Medical Center (IRB no. 2023GR0186).\nThe inclusion criteria were as follows: (1) patients with confirmed AMH values within 1 month preoperatively \nand within 1 month–1 year postoperatively; (2) with histopathologically confirmed benign ovarian cysts; (3) \nwomen aged 15–46 years; and (4) with regular menstrual cycles (21–35 days) at the time of surgery.\nThe exclusion criteria were as follows: (1) pregnancy; (2) BMI ≥ 35 kg/m 2; (3) use of medications such as \noral contraceptive pills or other hormonal agents within 6 months of surgery; (4) underwent oophorectomy; (5) \nprior surgery for borderline or malignant tumors of the ovary; (6) history of uncontrolled infections, diabetes, \nhypertension, ischemic heart disease, myocardial infarction within 6 months, or serious health conditions such \nas liver or kidney disease; (7) undergoing cancer treatment or diagnosed with cancer within the past 5 years; (8) \nuse of anticancer drugs, immunosuppressive drugs, or steroid drugs; (9) presence of autoimmune diseases; and \n(10) history of organ transplantation.\nOutcome measures\nThe primary outcomes were serum AMH levels including, preoperative AMH (preAMH) value, postoperative \nAMH (postAMH) value, and AMH change value (ΔAMH). The preAMH level was determined within 4 weeks \nbefore surgery, and the postAMH level was determined from 1 month to 1 year after surgery. The ΔAMH is \nexpressed as a percentage value; ΔAMH = (postAMH − preAMH) × 100/preAMH\nThe secondary outcomes were operative outcomes, including histologic findings, operative time (min), esti-\nmated blood loss (mL), hemoglobin level change (g/dL), adhesiolysis, cyst rupture during surgery, transfusion, \nconversion to laparotomy, and length of hospital stay. The operative time was calculated as the time from skin \nincision to skin closure, including the docking time when the robotic surgery was performed. The change in \nhemoglobin level was calculated as the difference between the preoperative level and the level on postoperative \nday 1. Adhesiolysis was selected only when specific adhesion detachment was reported in the surgical records.\nStatistical analysis\nAll statistical analyses were performed using SPSS version 26.0 (SPSS, Armonk, NY , USA). The mean ± standard \ndeviation or median interquartile range (IQR) was used to describe the distribution of the data after the Kol-\nmogorov–Smirnov normality test. Differences among the three groups were evaluated using the Kruskal–Wallis \ntest or analysis of variance for continuous variables, and multiple comparisons were performed by post hoc test \nusing the least significant difference method. Significance was set at p < 0.05.\nResults\nStudy population characteristics\nIn total, 132 patients were enrolled in this study. Among them, 74 underwent laparoscopic surgery and 58 \nunderwent robotic surgery (21 with Xi robotic surgery, and 37 with SP robotic surgery).\nComparison of operative outcomes between the laparoscopic system and robotic systems\nNo significant differences in age, BMI, parity, histopathologic type, position, and maximum size (cm) of the ovar-\nian cysts were observed between the groups. The estimated blood loss during surgery, hemoglobin drop, length \nof hospital stay, adhesion detachment rate, and cyst rupture rate also indicated no significant differences. The \noperative time was significantly shorter in the laparoscopic group than in the robotic group (68.51 ± 30.99 min \nvs. 105.17 ± 38.87 min, p < 0.001) (Tables 1 and 2)\nThe mean preAMH levels were significantly higher with the Da Vinci robotic group than with the laparoscopic \ngroup (5.89 ± 4.81 ng/mL vs. 4.01 ± 3.59 ng/mL, p = 0.02). The mean postAMH was also higher with the Da Vinci \nrobotic group than with the laparoscopic group (4.36 ± 3.31 ng/mL vs. 3.08 ± 2.60 ng/mL, p = 0.02). However, \n\n3\nVol.:(0123456789)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\nthe mean ΔAMH was not significantly different between the two groups (−13.21% ± 57.10% in the laparoscopic \nsystem vs. − 18.36% ± 39.64% in the robotic system, p = 0.56) (Table  3).\nComparison of operative outcomes between the laparoscopic system and Xi and SP robotic \nsystems\nThe patients who underwent SP robotic surgery were younger than those who underwent laparoscopic surgery \n(26.84 ± 6.10 years old vs 29.96 ± 6.74 years old, p = 0.034). No significant differences in BMI and parity of \npatients were observed among the groups. The histopathological type, position, and maximal size (cm) of the \novarian cysts demonstrated no significant differences among the three groups. Estimated blood loss (mL), hemo-\nglobin drop (g/dL), adhesiolysis, cyst rupture, and length of hospital stay also indicated no significant differences \namong the groups. The operative time for Xi and SP robotic surgeries were longer than that for the laparoscopic \nsurgery (101.62 ± 48.93 min, 107.19 ± 32.41 min vs. 67.78 min, p < 0.001) (Tables 4 and 5).\nSignificantly higher preAMH levels were noted in the SP robotic surgery group than in the laparoscopic sur-\ngery group (6.35 ± 5.26 vs. 4.01 ± 3.59, p = 0.023). The postAMH value was also higher in the SP robotic surgery \ngroup than that in the laparoscopic surgery group (4.66 ± 3.54 vs. 3.08 ± 2.60, p = 0.029). However, the ΔAMH \nTable 1.  Baseline characteristics of the patients. a Case in which a mature teratoma was identified \nconcomitantly with an endometrioma.\nLaparoscope (N = 74) Robot (N = 58) p\nAge (years) 29.96 ± 6.74 28.16 ± 6.12 0.115\nBMI (kg/m2) 23.07 ± 4.78 22.72 ± 3.61 0.638\nParity\n Nullipara 65 (87.84%) 53 (91.38%) 0.270\n Para 1 or more 9 (12.16%) 5 (8.62%)\nHistologic finding\n Endometrioma 31 (41.89%) 28a (48.28%) 0.468\n Mature cystic teratoma 30 (40.54%) 23 (39.66%) 0.919\n Cystadenoma 9 (12.16%) 6 (10.34%) 0.746\n Other cyst 4 (5.41%) 1 (0.17%) 0.246\n Cyst size, in maximum (cm) 6.45 ± 2.57 7.00 ± 2.77 0.314\nCyst position\n Unilateral 56 (75.68%) 41 (70.69%) 0.523\n Bilateral 18 (24.32%) 17 (29.31%)\n CA 125 (U/mL) 54.47 ± 75.19 37.43 ± 37.56 0.186\nTable 2.  Operative outcomes. a Transfusion.\nLaparoscope (N = 74) Robot (N = 58) p\nOperative time (min) 67.78 ± 30.58 105.17 ± 38.87 < 0.001\nEstimated blood loss (mL) 62.84 ± 93.29 93.97 ± 103.91 0.073\nHb drop (g/dL) 1.69 ± 1.00 1.87 ± 0.91 0.278\nAdhesiolysis 48.65% (36/74) 36.84% (21/57) 0.177\nCyst rupture 91.67% (66/72) 85.96% (49/57) 0.318\nComplications 2a (transfusion) 0\nConversion 0 0\nLength of hospital day 4.18 ± 0.73 4.29 ± 0.84 0.391\nTable 3.  Serum anti-Müllerian hormone (AMH) levels (ng/mL). AMH (%) = (postoperative AMH − \npreoperative AMH) × 100/preoperative AMH.\nLaparoscope (N = 74) Robot (N = 58) p\nPreoperative 4.01 ± 3.59 5.89 ± 4.81 0.015\nPostoperative 3.08 ± 2.60 4.36 ± 3.31 0.015\nΔAMH (%) − 13.21 ± 57.10 − 18.36 ± 39.64 0.560\n\n4\nVol:.(1234567890)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\ndid not demonstrate significant differences among the three groups (−13.21 ± 57.10% in laparoscopic system vs. \n−14.63 ± 47.80% in Xi system vs. −20.47 ± 34.73% in the SP system, p = 0.772) (Table  6).\nComparison of ΔAMH between the laparoscopic system and robotic systems in the patients \nwith preoperative AMH values of < 2.0\nEven in the patient group with a preAMH level of < 2.0, the preAMH and postAMH values were not significantly \ndifferent between the two groups. The ΔAMH was − 7.55 (IQR −48.79, 19.87) in the laparoscopic group (N = \n21) and – 29.73 (IQR −59.89, 9.46) in the robotic group (N = 11), indicating no significant difference between \nthe two groups (p = 0.72) (Table 7).\nComparison of operative outcomes between laparoscopic system and robotic system in \npatients diagnosed with endometriosis\nIn patients diagnosed with endometriosis from postoperative histopathology, preAMH, postAMH, and ΔAMH \nwere compared by dividing the group that underwent laparoscopic surgery (N = 31) and the group that under-\nwent robotic surgery (N = 28). The preAMH, postAMH and ΔAMH values were not significantly different \nTable 4.  Baseline characteristics of the patients. a Case in which a mature teratoma was identified \nconcomitantly with an endometrioma.\nLaparoscope (N = 74) Xi robot (N = 21) SP robot (N = 37) p\nAge (years) 29.96 ± 6.74 30.48 ± 5.56 26.84 ± 6.10 0.034\nBMI (kg/m2) 23.07 ± 4.78 23.23 ± 4.07 22.44 ± 3.35 0.720\nParity\n Nullipara 65 (87.84%) 19 (90.48%) 34 (91.89%) 0.529\n Para 1 or more 9 (12.16%) 2 (9.52%) 3 (8.11%)\nHistopathologic finding\n Endometrioma 31 (41.89%) 8 (38.10%) 20a (54.05%) 0.389\n Mature cystic teratoma 30 (40.54%) 11 (52.38%) 12 (32.43%) 0.333\n Cystadenoma 9 (12.16%) 2 (9.52%) 4 (10.81%) 0.939\n Other cyst 4 (5.41%) 0 (0%) 1 (2.7%) 0.484\n Cyst size, in maximum (cm) 6.45 ± 2.57 7.35 ± 3.54 6.80 ± 2.25 0.376\nCyst position\n Unilateral 56 (75.68%) 16 (76.19%) 25 (67.57%) 0.635\n Bilateral 18 (24.32%) 5 (23.81%) 12 (32.43%)\n CA 125 (U/mL) 54.47 ± 75.19 37.94 ± 46.36 37.13 ± 32.46 0.419\nTable 5.  Operative outcomes. a Transfusion.\nLaparoscope (N = 74) Xi robot (N = 21) SP robot (N = 37) p\nOperative time (min) 67.78 ± 30.58 101.62 ± 48.93 107.19 ± 32.41 < 0.001\nEstimated blood loss (mL) 62.84 ± 93.29 111.90 ± 125.40 83.78 + 79.80 0.116\nHb drop (g/dL) 1.69 ± 1.00 2.18 ± 1.27 1.70 ± 0.59 0.108\nAdhesiolysis 48.65% (36/74) 33.33% (7/21) 38.89% (14/36) 0.375\nCyst rupture 91.67% (66/72) 80.95% (17/21) 88.89% (32/36) 0.386\nComplications 2a (transfusion) 0 0\nConversion 0 0 0\nLength of hospital day 4.18 ± 0.73 4.43 ± 1.21 4.22 ± 0.53 0.422\nTable 6.  Serum anti-Müllerian hormone (AMH) levels (ng/mL). AMH (%) = (postoperative AMH − \npreoperative AMH) × 100/preoperative AMH.\nLaparoscope (N = 74) Xi robot (N = 21) SP robot (N = 37) p\nPreoperative 4.01 ± 3.59 5.09 ± 3.91 6.35 ± 5.26 0.023\nPostoperative 3.08 ± 2.60 3.81 ± 2.88 4.66 ± 3.54 0.029\nΔAMH (%) − 13.21 ± 57.10 − 14.63 ± 47.80 − 20.47 ± 34.73 0.772\n\n5\nVol.:(0123456789)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\nbetween the two groups (Table  8). There was no significant difference between the pre AMH, post AMH, and \nΔAMH in the laparoscopic (N = 31) and SP robot groups (N = 20) (Table 9).\nComparison of ΔAMH between the laparoscopic system and robotic system in the patients \nwith bilateral ovarian cysts\nThis study compared the rate of change in AMH level between the two platforms when bilateral ovarian cys-\ntectomy was performed using the laparoscopic and the SP robotic system. The preoperative AMH level in the \nlaparoscopic group was 2.57 ± 2.73 ng/mL, which was significantly lower than 8.29 ± 6.40 ng/mL in the SP robotic \nsystem (p = 0.011). The postoperative AMH level in the laparoscopic group was also significantly lower than \nin the SP robotic system (1.90 ± 1.99 ng/mL vs. 4.97 ± 4.07 ng/mL, p = 0.029). However, the ΔAMH decreased \nto − 13.90 ± 53.35% in the laparoscopic group and − 39.15 ± 25.91% in the SP robotic system, the difference \nbetween the two groups was not statistically significant (p = 0.140) (Table 10)\nDiscussion\nThis study investigated the effects of minimally invasive surgical techniques such as, laparoscopic and robotic \nsystems on the ovarian reserve in benign ovarian cyst surgery. The changes in AMH values were calculated as a \nrelative value (percentage) to assess the ovarian reserve. When the changes in the AMH values were compared for \neach surgical platform, no significant differences were observed between the laparoscopic and robotic systems. \nEven in the patient group with preAMH < 2.0, in the group diagnosed with endometriosis, and in the patient \ngroup who underwent bilateral ovarian cystectomy ΔAMH did not show significant differences between the \nlaparoscopic and robotic groups.\nA systematic review and meta-analysis of minimally invasive surgery for endometriosis in 2020 revealed that \nrobotic surgery had a longer surgical time but no inferior compared to laparoscopic surgery for length of hospi-\ntalization, intra/post-operative complication, blood loss, and conversion  rate7. Robotic surgery can be expected \nTable 7.  Serum anti-Müllerian hormone (AMH) levels (ng/mL). AMH (%) = (postoperative AMH − \npreoperative AMH) × 100/preoperative AMH.\nLaparoscope (N = 21) Robot (N = 11) p\nPreoperative 0.95 (0.46,1.48) 1.34 (0.74,1.87) 0.337\nPostoperative 0.90 (0.33,1.35) 0.81 (0.52,1.04) 0.540\nΔAMH (%) − 7.55 (− 48.79,19.84) − 29.73 (− 59.89,9.46) 0.715\nTable 8.  Serum anti-Müllerian hormone (AMH) levels (ng/mL). AMH (%) = (postoperative AMH − \npreoperative AMH) × 100/preoperative AMH.\nLaparoscope (N = 31) Robot (N = 28) p\nPreoperative 3.90 ± 3.16 4.47 ± 3.44 0.506\nPostoperative 2.49 ± 2.35 2.79 ± 2.35 0.609\nΔAMH (%) − 23.59 ± 72.69 − 31.43±36.39 0.609\nTable 9.  Serum anti-Müllerian hormone (AMH) levels (ng/mL). AMH (%) = (postoperative AMH − \npreoperative AMH) × 100/preoperative AMH.\nLaparoscope (N = 31) SP robot (N = 20) p\nPreoperative 3.90 ± 3.16 4.60 ± 3.60 0.467\nPostoperative 2.49 ± 2.35 2.92 ± 2.03 0.506\nΔAMH (%) − 23.59 ± 72.69 − 28.40 ± 36.83 0.786\nTable 10.  Serum anti-Müllerian hormone (AMH) levels (ng/mL).\nLaparoscope (N = 18) SP robot (N = 12) p\nPreoperative 2.57 ± 2.73 8.29 ± 6.40 0.011\nPostoperative 1.90 ± 1.99 4.97 ± 4.07 0.029\nΔAMH (%) − 13.90 ± 53.35 − 39.15 ± 25.91 0.140\n\n6\nVol:.(1234567890)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\nto be a more sophisticated operation due to the three-dimensional view and the natural movement of robotic \n instruments8. Another study in 2020 revealed that robotic surgery in bilateral ovarian endometrioma showed a \nbetter recovery rate of serum AMH and was beneficial for ovarian function  protection9.\nIn the subgroup analysis, based on an AMH value of 2, it was classified as a group < 2. We set this cut-off  \nvalue by referring to the results of previous studies that the median AMH was 1.9 ng/mL among Japanese nul -\nliparous women with a rapid decrease in fertility and serum AMH levels > 2 ng/mL, which demonstrated the \nhighest probability of live  birth10–12.\nA committee opinion published in 2015 by the American College of Obstetricians and Gynecologists recom-\nmends evaluating ovarian function in women undergoing ovarian  surgery13. The most widely used indicator for \nassessing ovarian function is AMH. AMH is an indicator of the size of the primordial oocyte pool, and it starts \nto increase in young adolescent women and reaches its peak at 25 years of age. Afterwards, it decreases at a rate \nof 0.2 ng/mL/year until age 35, and then at a rate of 0.1 ng/mL/year between ages 35 and 40. From the age of 40 \nonwards the median and average decrease in AMH is 0.1 ng/mL/year10. Over time, this decline leads to a decrease \nin AMH levels of approximately 5.6% per year, eventually reaching undetectable levels at  menopause6,10,14,15.\nHowever, the mechanism by which AMH levels decrease after ovarian surgery remains unclear. Normal ovar-\nian tissue can fall off during the process of stripping the cyst capsule during ovarian cyst surgery and damage the \nfunctional cortex during the electrocauterization process for hemostasis. Therefore, a decrease in the number of \npre-antral and small antral follicles may also reduce the AMH  levels16,17. It is widely known that when bilateral \novarian cysts are removed, the AMH level decreases significantly compared to when unilateral ovarian cyst is \n removed18–21. This is thought to be because more damage may be caused to normal ovarian tissue during the \nprocess of removing both ovarian  cysts19. Also the endometrioma itself may cause damage to the surrounding \novarian tissue, with decreasing serum AMH  level22. Reduced ovarian reserve postoperatively is reported to \nrecover at approximately 3–6  months23,24. Recovery of ovarian reserve could be attributed to the reperfusion of \novarian tissue, activation and rearrangement of ovarian  follicles2,25.\nThe Da Vinci SP robotic system has been widely used in gynecologic surgery since its introduction, with its \nFDA approval in 2018. To date, no study has analyzed the surgical outcomes of ovarian cysts according to the SP \nsurgical platform. To the best of our knowledge, this is the first study to compare surgical outcomes, particularly \novarian function, between conventional platforms and the SP robotic system.\nThe obese population is increasing worldwide, and this is a major burden on global health care. It is clear that \nthe obese population is the most challenging group in surgery. The thick abdominal wall and excessive visceral \nfat make intra-abdominal access difficult and limit the operative  field26. Fortunately, these problems have been \nsolved due to the development of minimally invasive surgery and improved operator skills. In particular, robotic \nsystems are known to be more useful in the obese group due to their short learning curve, 3D visualization, freer \nmovement, and tremor  cancellation27. However, it was difficult to compare the obese group in this study. The \npatients with BMI ≥ 35.0 kg/m2 were excluded from the analysis. This is because in Korea, 4.3% of women have \na BMI of 30.0–34.9 kg/m 2, and 0.75% have a BMI ≥ 35.0 kg/m 2, which is a big difference from the US group of \n39.8% with a BMI ≥ 30.0 kg/m 228,29.\nThe Xi and SP robotic surgeries required longer operative time than that of the laparoscopic surgery (101.62 \n± 48.93 min, 107.19 from 32.41 min vs. 67.78 min, p < 0.001), and was calculated from skin incision to closure \ntime. This could be calculated by considering the docking and undocking times; however, owing to the limita-\ntions of the retrospective study, determining exactly how many docking and undocking times the robot per -\nformed during each surgery was not possible. Moreover, the Da Vinci SP robotic system was introduced to our \ninstitution in 2020, and further research is needed to evaluate its proficiency and effectiveness, given its recent \nimplementation in early stage surgeries.\nThis study had some limitations. First, the study is retrospective in nature. The evaluation of the AMH value \nwas not performed in a batch period, depending on the operator; therefore, the measurement of the postAMH \nvalue was widely done within one year. Owing to the nature of the tertiary institution, many patients were sent \nback to the 1st or 2nd institution postoperatively; therefore, only few patients had their AMH measured multiple \ntimes. Second, the sample size was small as the robotic group was further divided according to the two systems, \nSP and Xi.\nCompared to the existing laparoscopic system, the robotic system does not demonstrate a significant differ-\nence in the preservation of the ovarian reserve; therefore, it will be widely selected as an option for minimally \ninvasive surgery.\nConclusion\nThe Da Vinci robotic system is no inferior to conventional laparoscopic systems in preserving ovarian function.\nData availiability\nThe data underlying this article will be shared on reasonable request to the corresponding author.\nReceived: 20 October 2023; Accepted: 16 April 2024\nReferences\n 1. Alborzi, S., Foroughinia, L., Kumar, P . V ., Asadi, N. & Alborzi, S. A comparison of histopathologic findings of ovarian tissue inad-\nvertently excised with endometrioma and other kinds of benign ovarian cyst in patients undergoing laparoscopy versus laparotomy. \nFertil. Steril. 92, 2004–2007. https:// doi. org/ 10. 1016/j. fertn stert. 2008. 09. 014 (2009).\n 2. Chang, H. J. et al. Impact of laparoscopic cystectomy on ovarian reserve: Serial changes of serum anti-Müllerian hormone levels. \nFertil. Steril. 94, 343–349. https:// doi. org/ 10. 1016/j. fertn stert. 2009. 02. 022 (2010).\n\n7\nVol.:(0123456789)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\n 3. Kwak, Y . H. et al. Da Vinci sp single-port robotic surgery in gynecologic tumors: Single surgeon’s initial experience with 100 cases. \nYonsei Med. J. 63, 179–186. https:// doi. org/ 10. 3349/ ymj. 2022. 63.2. 179 (2022).\n 4. Testing and interpreting measures of ovarian reserve. A committee opinion. Fertil. Steril. 114, 1151–1157. https:// doi. org/ 10. 1016/j. \nfertn stert. 2020. 09. 134 (2020).\n 5. Broekmans, F . J., Kwee, J., Hendriks, D. J., Mol, B. W . & Lambalk, C. B. A systematic review of tests predicting ovarian reserve and \nIVF outcome. Hum. Reprod. Update 12, 685–718. https:// doi. org/ 10. 1093/ humupd/ dml034 (2006).\n 6. La Marca, A. et al. Anti-mullerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum. \nReprod. Update 16, 113–130. https:// doi. org/ 10. 1093/ humupd/ dmp036 (2010).\n 7. Restaino, S. et al. Robotic surgery vs laparoscopic surgery in patients with diagnosis of endometriosis: A systematic review and \nmeta-analysis. J. Robot. Surg. 14, 687–694. https:// doi. org/ 10. 1007/ s11701- 020- 01061-y (2020).\n 8. Ercoli, A. et al. Robotic-assisted conservative excision of retrocervical-rectal deep infiltrating endometriosis: A case series. J. Minim. \nInvasive Gynecol. 24, 863–868. https:// doi. org/ 10. 1016/j. jmig. 2017. 03. 011 (2017).\n 9. Lee, H. J., Lee, J. S. & Lee, Y . S. Comparison of serum antimüllerian hormone levels after robotic-assisted vs. laparoscopic approach \nfor ovarian cystectomy in endometrioma. Eur. J. Obstet. Gynecol. Reprod. Biol. 249, 9–13. https:// doi. org/ 10. 1016/j. ejogrb. 2020. \n04. 010 (2020).\n 10. Seifer, D. B., Baker, V . L. & Leader, B. Age-specific serum anti-Müllerian hormone values for 17,120 women presenting to fertility \ncenters within the United States. Fertil. Steril. 95, 747–750. https:// doi. org/ 10. 1016/j. fertn stert. 2010. 10. 011 (2011).\n 11. Segawa, T. et al. Age-specific values of Access anti-Müllerian hormone immunoassay carried out on Japanese patients with infertil-\nity: A retrospective large-scale study. BMC Womens Health 19, 57. https:// doi. org/ 10. 1186/ s12905- 019- 0752-z (2019).\n 12. Lukaszuk, K. et al. Anti-Müllerian hormone (AMH) is a strong predictor of live birth in women undergoing assisted reproductive \ntechnology. Reprod. Biol. 14, 176–181. https:// doi. org/ 10. 1016/j. repbio. 2014. 03. 004 (2014).\n 13. Committee Opinion No. 618: Ovarian reserve testing. Obstet. Gynecol. 125, 268–273. https:// doi. org/ 10. 1097/ 01. AOG. 00004 59864. \n68372. ec (2015).\n 14. Bentzen, J. G. et al. Ovarian antral follicle subclasses and anti-mullerian hormone during normal reproductive aging. J. Clin. \nEndocrinol. Metab. 98, 1602–1611. https:// doi. org/ 10. 1210/ jc. 2012- 1829 (2013).\n 15. Nelson, S. M. Biomarkers of ovarian response: Current and future applications. Fertil. Steril. 99, 963–969. https:// doi. org/ 10. 1016/j. \nfertn stert. 2012. 11. 051 (2013).\n 16. Hemmings, R., Bissonnette, F . & Bouzayen, R. Results of laparoscopic treatments of ovarian endometriomas: Laparoscopic ovarian \nfenestration and coagulation. Fertil. Steril. 70, 527–529. https:// doi. org/ 10. 1016/ s0015- 0282(98) 00219-2 (1998).\n 17. Ercan, C. M. et al.  Antimullerian hormone levels after laparoscopic endometrioma stripping surgery. Gynecol. Endocrinol.  26, \n468–472. https:// doi. org/ 10. 3109/ 09513 59100 36321 34 (2010).\n 18. Ono, M. et al. Anti-Müllerian hormone levels following laparoscopic ovarian cystectomy with subcutaneous abdominal wall lifting \nfor ovarian endometriomas. CEOG 48, 91–97. https:// doi. org/ 10. 31083/j. ceog. 2021. 01. 5528 (2021).\n 19. Mansouri, G. et al. Effect of laparoscopic cystectomy on ovarian reserve in patients with ovarian cyst. Front. Endocrinol. Lausanne \n13, 964229. https:// doi. org/ 10. 3389/ fendo. 2022. 964229 (2022).\n 20. Wang, Y ., Ruan, X., Lu, D., Sheng, J. & Mueck, A. O. Effect of laparoscopic endometrioma cystectomy on anti-Müllerian hormone \n(AMH) levels. Gynecol. Endocrinol. 35, 494–497. https:// doi. org/ 10. 1080/ 09513 590. 2018. 15492 20 (2019).\n 21. Saito, N. et al. Comparison of the impact of laparoscopic endometriotic cystectomy and vaporization on postoperative serum \nanti-mullerian hormone levels. Asian J. Endosc. Surg. 11, 23–29. https:// doi. org/ 10. 1111/ ases. 12412 (2018).\n 22. Maneschi, F ., Marasá, L., Incandela, S., Mazzarese, M. & Zupi, E. Ovarian cortex surrounding benign neoplasms: A histologic \nstudy. Am. J. Obstet. Gynecol. 169, 388–393. https:// doi. org/ 10. 1016/ 0002- 9378(93) 90093-x (1993).\n 23. Li, H. et al. The optimal time of ovarian reserve recovery after laparoscopic unilateral ovarian non-endometriotic cystectomy. \nFront. Endocrinol. Lausanne 12, 671225. https:// doi. org/ 10. 3389/ fendo. 2021. 671225 (2021).\n 24. Goodman, L. R. et al.  Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am. J. \nObstet. Gynecol. 215(589), e581-589.e586. https:// doi. org/ 10. 1016/j. ajog. 2016. 05. 029 (2016).\n 25. Sugita, A. et al. One-year follow-up of serum antimüllerian hormone levels in patients with cystectomy: Are different sequential \nchanges due to different mechanisms causing damage to the ovarian reserve?. Fertil. Steril. 100, 516-522.e513. https:// doi. org/ 10. \n1016/j. fertn stert. 2013. 03. 032 (2013).\n 26. Gomel, V . Operative laparoscopy: Time for acceptance. Fertil. Steril. 52, 1–11. https:// doi. org/ 10. 1016/ s0015- 0282(16) 60779-3 \n(1989).\n 27. Wright, J. D. et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA 309, \n689–698. https:// doi. org/ 10. 1001/ jama. 2013. 186 (2013).\n 28. Nam, G. E. et al. Obesity fact sheet in Korea, 2020: Prevalence of obesity by obesity class from 2009 to 2018. J. Obes. Metab. Syndr. \n30, 141–148. https:// doi. org/ 10. 7570/ jomes 21056 (2021).\n 29. Hales, C. M., Carroll, M. D., Fryar, C. D. & Ogden, C. L. Prevalence of obesity among adults and youth: United States, 2015–2016. \nNCHS Data Brief. 1–8 (2017).\nAuthor contributions\nY .P . and Y .J.K. conceptualized the study. Y .P . wrote the main manuscript text and Y .P . A.S., J.J., N.B., and S.O. \nprepared data. J.S. and Y .J.K. supervised the study. All authors reviewed the manuscript.\nCompeting interests \nThe authors declare no competing interests.\nAdditional information\nCorrespondence and requests for materials should be addressed to Y .J.K.\nReprints and permissions information is available at www.nature.com/reprints.\nPublisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and \ninstitutional affiliations.\n\n8\nVol:.(1234567890)Scientific Reports |         (2024) 14:9099  | https://doi.org/10.1038/s41598-024-59935-2\nwww.nature.com/scientificreports/\nOpen Access  This article is licensed under a Creative Commons Attribution 4.0 International \nLicense, which permits use, sharing, adaptation, distribution and reproduction in any medium or \nformat, as long as you give appropriate credit to the original author(s) and the source, provide a link to the \nCreative Commons licence, and indicate if changes were made. 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