{"paper_id":"57cc8097-f58f-48af-9670-e0ee66f6bcb6","body_text":"Clin. Exp. Obstet. Gynecol. 2023; 50(1): 13\nhttps://doi.org/10.31083/j.ceog5001013\nCopyright: © 2023 The Author(s). Published by IMR Press.\nThis is an open access article under the CC BY 4.0 license .\nPublisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nReview\nRobotic Surgery and Deep Infiltrating Endometriosis Treatment: The\nState of Art\nCarlo Alboni1, Ludovica Camacho Mattos 2,*, Antonio La Marca 3, Diego Raimondo 4,5,\nPaolo Casadio4, Renato Seracchioli 4,5, Giorgia Gaia 6\n1Minimally Invasive Gynecologic Surgery Unit, University Hospital of Modena, 41124 Modena, Italy\n2Ospedale Civile di Sassuolo, Ostetricia e Ginecologia, 41049 Modena, Italy\n3Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, 41124 Modena, Italy\n4Gynecology and Human Reproduction Physiopatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy\n5Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy\n6Department of Obstetrics and Gynecology, San Paolo Hospital Medical School, ASST Santi Paolo e Carlo, 20142 Milan, Italy\n*Correspondence: ludovica.camacho@gmail.com (Ludovica Camacho Mattos)\nAcademic Editor: Christos Iavazzo\nSubmitted: 22 July 2022 Revised: 19 September 2022 Accepted: 22 September 2022 Published: 12 January 2023\nAbstract\nObjective: Surgical treatment of endometriosis, when indicated, has demonstrated to be effective in reducing painful symptoms and\nimprove quality of life of patients affected with endometriosis. The minimally invasive approach via laparoscopy is the preferred method\nwhen compared with laparotomy but in the last two decades another minimally invasive approach has become available, the robotically\nassisted laparoscopic surgery. Robotic technology is widely used in different surgical branches, such as general surgery and urology.\nMoreover, the use of robotic surgery is already accepted for different gynecological procedures either for benign and for oncological\ndiseases. The advantages of robotic surgery such as improve dexterity of movements, avoided tremor, increased magnification of 3-\ndimensional vision seem strategic in the context of a complex surgery as is deep endometriosis eradication. However, to date there is\nno unanimous consensus on whether robotically assisted procedures are a valid and safe alternative to laparoscopy in the treatment of\nendometriosis. Mechanism: In this narrative review we analyze the available literature assessesing the robotic treatment of all types\nof endometriosis and specifically deep infiltrating endometriosis, compared to the outcomes of conventional laparoscopy. Findings\nin Brief : Indeed, the evidence of safety and effectiveness of robotically assisted laparoscopy in endometriosis treatment is strong and\nalmost unanimous. There is no clear superiority of one approach to the other but robotic-related advantages and future prospective are\npromising to be able to improve operative outcomes, reduce surgeon’s fatigue and provide a technology easy to implement with a fast\nlearning curve. Conclusions: Robotic technology applied to laparoscopy in the treatment of endometriosis could be seen as an effective\nand safe alternative to the conventional laparoscopic treatment.\nKeywords: robotic surgery; deep endometriosis; laparoscopy\n1. Introduction\nEndometriosis is a very common gynecological dis-\nease, which affects nearly 10% of the female population\nin reproductive age [ 1–3], accounting for 38% of women\nwith infertility and 71–87% of women with chronic pelvic\npain [ 4]. Moreover, it is estimated that about 20% of pa-\ntients with endometriosis are affected by deep infiltrating\nendometriosis (DIE), which is correlated with worse symp-\ntoms and quality of life [ 5].\nTreatment options are multiple and different but even\nmore variable is the response of the patients to each treat-\nment, being it dependent to age, body characteristics, fer-\ntility status, patient compliance and patient’s desires. Two\nmain approaches have been described for endometriosis\ntreatment, not excluding one another: medical hormonal\ntherapy and surgery. It is widely accepted that endometrio-\nsis should be considered as a chronic disease that requires\na life-long management plan with the goal of maximizing\nthe use of medical treatment and avoiding repeated surgical\nprocedures [ 6]. Nevertheless, surgical excision of the en-\ndometriotic lesions can significantly reduce painful symp-\ntoms and improve the quality of life of patients [ 7–10].\nMoreover, some clinical conditions represent a\nmandatory indication for surgery. These comprehend those\nconditions in which an organ’s function is at risk, such as\nthe presence of bowel occlusion or subocclusion due to a\ndeep nodule, a reduced kidney function or hydronephrosis\ncaused by ureteral stenosis. In addition, surgery should be\nproposed to all symptomatic patients who do not respond or\nhave contraindication to the use of medical therapy.\nSince the first reports of application of laparoscopy\nin the diagnosis and treatment of endometriosis, the min-\nimally invasive approach has demonstrated to be the pre-\nferred method when compared with laparotomy [ 10,11]. In\nthe last two decades, the robotically assisted laparoscopic\n\nsurgery (RALS), has become available in different special-\nties. This approach has gradually become a frequent choice,\neven in gynecology, demonstrating good results in terms\nof reducing trauma and shortening the length of hospital\nstay [ 12]. Specific advantages of RALS try to overcome\nspecific limits of conventional laparoscopy, such as the im-\nproved dexterity and coordination RALS provides thanks to\nthe seven degrees of freedom of the instruments, the filter-\ning of physiologic tremor, the increased magnification with\nits 10X view/three-dimensional vision and, not least, the de-\ncrease of surgeon’s fatigue [ 13–16]. In the context of DIE\nsurgery, these advantages may facilitate the correct dissec-\ntion of planes and complete eradication of endometriosis,\nthus improving the success of the procedures [ 17,18].\nOn the other hand, to date there is no large consen-\nsus on the feasibility, safety and effectiveness of robotic\nsurgery for endometriosis although many experiences have\nbeen published.\nThis is a narrative review of the available literature\non the implementation of robotic technology in the surgical\ntreatment of deep infiltrating endometriosis, summarizing\nthe evidence and shedding light on the “blind spots”, on the\naspects that are still unclear or not fully investigated.\n2. Materials and Methods\nA comprehensive literature review was performed us-\ning electronic databases (PubMed, Cochrane, Embase).\nAll languages studies regarding robotically-assisted la-\nparoscopy and endometriosis have been evaluated along\nwith their references from April 2005, when the Food and\nDrug Administration (FDA) has granted the use of robotic\ntechnology to perform laparoscopic gynecological proce-\ndures, to March 2022. The following key words were used\nin the search: “robotic surgery”, “endometriosis”, “gyne-\ncology”. Reviews, case reports and case series with less\nthan 10 patients were excluded, obtaining 26 articles for the\nqualitative synthesis (Table 1,Ref. [ 19–31] ; Table 2, Ref.\n[17,32–43]). PRISMA guidelines were followed during the\nselection process [44,45] (Fig. 1).\n3. Feasibility and Safety\nFeasibility and safety of a new surgical technique are\nthe first aspects to take into account while assessing its\nvalidity. Different articles advocate to this purpose, with\neither retrospectively and prospectively designed studies.\nThe Laparoscopy vs. Robotic Surgery for Endometriosis\n(LAROSE) trial [ 19] is the first multicenter randomized\ncontrolled trial comparing laparoscopic vs robotic surgery\nfor endometriosis at all stages. The study population was\nrecruited between three centers in USA and surgeries were\nperformed by experienced surgeons in each center. Women\nwere randomly assigned to the laparoscopic or to the RALS\narm. All patients were affected by endometriosis but those\ncases with need for bowel resection and/or ureteral reanas-\ntomosis were excluded from the study. RALS and conven-\nFig. 1. PRISMA flow chart for studies selection.\ntional laparoscopic procedures showed no difference as for\noperative time, with mean operative time being 106.6 ±\n48.4 minutes and 101.6 ± 63.2 minutes respectively. Dif-\nferences were not found neither in terms of blood loss and\noperative and postoperative complication when adjusted for\nthe number and type of procedures performed, nor in terms\nof rate of histologic confirmation of endometriosis.\nA large retrospective single center cohort study has\nbeen published by Huang et al. [ 32] demonstrating the fea-\nsibility of robotic single-site surgery for treatment of en-\ndometriosis at all stages. Data from 334 surgeries were ana-\nlyzed along with perioperative outcomes. At least one addi-\ntional port was placed in 41 (12%) patients, in cases of more\ncomplex lesions that demanded greater precision of instru-\nments and a wider surgical field. The median estimated\nblood loss was very low (25–50 mL) and lower than that\nof traditional RALS and conventional laparoscopy [ 19,33],\nsuggesting that robotic single site laparoscopic surgery does\nnot increase the amount of blood loss. As for the complica-\ntion rate, 20 (6%) postoperative complications occurred of\nwhich only 2 (0.6%) of grade III by the Clavien-Dindo clas-\nsification [46,47]; the other 4 complications were grade I or\nII. This rate is similar to that reported for traditional RALS\nand conventional laparoscopy [19,33,47–50]. No umbilical\nhernia due to large umbilical incision was reported in this\ncohort.\nFurthermore, other studies adressed the effectiveness\nof RALS treatment specifically in patients with severe en-\ndometriosis, defined as stage III or IV of the American So-\nciety for Reproductive Medicine (ASRM) [ 51]. Two retro-\n2\n\n\nTable 1. Studies with comparison of robotically-assisted laparoscopic surgeries and conventional laparoscopic surgeries for endometriosis.\nAuthors Y ear of pub-\nlication\nReference\nn.\nStudy design n° of patients Type of endometriosis Complications Folow-up\nDulemba JF et al. 2013 [27] Retrospective cohort study 180 RALS, 100 LPS all RALS 1.1% (1 intraoperative + 1 C-D grade I) vs\nLPS 0%\n2 weeks\nNezhat FR et al. 2014 [20] Retrospective cohort study 32 RALS, 86 LPS ASRM stage III–IV RALS: 10% C-D grade II (3), 6.2% C-D grade 3b\n(2) vs LPS: 5.8% C-D grade II (5), 1.2% C-D grade\n3b (1)\n1 month\nNezhat CR et al. 2015 [21] Retrospective cohort study 147 RALS, 273 LPS ASRM stage III–IV RALS: 0% vs LPS: 0% (only C-D grade III and IV\nconsidered)\nN/A\nLe Carpentier M et al. 2016 [26] Retrospective cohort study 15 RALS, 22 LPS bladder endometriosis RALS: 7% conversion (1), 27% C-D grade II (4),\n33% C-D grade III (5) vs LPS: 0% conversion,\n18.2% C-D grade II (4), 14% C-D grade III (3)\n1, 3, 6, 12 months\nSoto E et al. 2017 [19] Randomized controlled trial 35 RALS, 38 LPS all RALS: 28.5% C-D grade II (10) vs LPS: 36.8% C-\nD grade II (14)\n6 weeks, 6 months\nMosbrucker C et al. 2017 [28] Randomized controlled trial 50 RALS, 48 LPS all N/A N/A\nMoon H et al. 2018 [29] Retrospective cohort study 68 RALS, 52 LPS all RALS: 0% vs LPS: 0% 6 months\nVizzielli G et al. 2020 [22] Retrospective multicenter co-\nhort study\n20 RALS, 27 LPS ASRM stadio III–IV RALS: 5% C-D grade II (1), 5% C-D grade IIIb (1)\nvs LPS: 7.4% C-D grade II (2) e 3.7% C-D grade\nIIIb (1)\nN/A\nLe Gac M et al. 2020 [23] Prospective cohort study 23 RALS, 25 LPS colorectal endometrio-\nsis\nRALS: 9% C-D grade III (2), 4% C-D grade IV (1)\nvs 0% C-D grade III (0), 16% C-D grade IV (4)\nN/A\nLee HJ et al. 2020 [30] Retrospective cohort study 40 RALS, 54 LPS ovarian endometriosis N/A 3, 6 months\nGupta N et al. 2020 [31] Retrospective cohort study 36 RALS, 49 SS-\nRALS, 44 LPS\nall RALS: 8.3% intraoperative (3), 0% postoperative\nvs SSRALS 4% intraoperative (2), 4% postopera-\ntive (2) vs LPS 2.3% intraoperative (1), 2.3% post-\noperative (1)\nN/A\nDi Maida F et al. 2020 [25] Retrospective cohort study 46 RALS, 28 LPS urinary tract en-\ndometriosis\nRALS: 4.3% C-D grade II (2), 2.1% C-D grade\nIII (1) vs LPS: 14.2% C-D grade II (4), 3.5% C-\nD grade III (1)\n30 months\nRaimondo D et al. 2021 [24] Prospective multicenter co-\nhort study\n22 RALS, 22 LPS colorectal endometrio-\nsis\nRALS, 4.5% C-D grade I (1), 4.5% C-D grade II\n(1), 9% C-D grade III (2) vs LPS 4.5% C-D grade\nI (1)\n12 months\nRALS, robotically-assisted laparoscopic surgery; LPS, laparoscopy; SSRALS, single-site robotically-assisted laparoscopic surgery; ASRM, American Society for Reproductive Medicine; C-D, Clavien-Dindo\nclassification; N/A, not applicable.\n3\n\nTable 2. Studies with assessment of robotically-assisted laparoscopic surgeries for endometriosis without comparison to conventional laparoscopy.\nAuthors Y ear of pub-\nlication\nReference\nn.\nStudy design n° of patients Type of endometriosis Complications Folow-up\nMagrina JF et al. 2015 [33] Retrospective cohort study 493 ASRM stage III–IV 0.6% conversions (3), 0.4% intraoperative (2),\n2.8% C-D grade II (14), 1% C-D grade IIIb (5)\n42 days\nAbo C et al. 2017 [36] Prospective cohort study 35 DIE 3% C-D grade IIIb (1) 24 ± 8 months\nErcoli A et al. 2017 [37] Prospective cohort study 31 colorectal endometriosis 3% C-D grade IIIb (1), 6% C-D grade I (2) 3, 6, 12 months\nTamura VG M et al. 2018 [34] Retrospective cohort study 274 all + other gynecological\ndiseases\n1.1% conversions (3), 0.8% C-D grade III (2) N/A\nRiley K et al. 2018 [40] Randomized controlled trial 73 superficial endometriosis N/A 6 , 12 months\nGiannini A et al. 2018 [17] Retrospective single center\ncase series\n31 urinary tract endometrio-\nsis\n16.2 C-D grade III (5) 3, 6 months\nPoujois J et al. 2019 [35] Retrospective single-center\ncase series\n20 all 5% conversions (1), 5% C-D grade I (1), 5% C-D\ngrade IIIa (1)\nN/A\nGraham A et al. 2019 [38] Retrospective single-center\ncase series\n15 colorectal endometriosis 26.6% C-D grade III (4) 1, 3 months\nDiez SP et al. 2019 [41] Experimental 19 not specified N/A N/A\nZhang Y et al. 2021 [42] Retrospective case series 33 all 3% conversions (1), 12.2% C-D grade II (4) 3 weeks\nPhilip CA et al. 2021 [39] Retrospective multicenter co-\nhort study\n232 urinary tract endometrio-\nsis\n18% C-D grade I (44), 7% C-D grade III (16), 0.4%\nC-D grade IV (1)\n3 months\nHuang Y et al. 2021 [32] Retrospective cohort study 334 all 5% C-D grade III (18), 1% C-D grade IV (2) N/A\nDelgado SI et al. 2021 [43] Restrospective cohort study 158 all N/A 3 weeks\nASRM, American Society for Reproductive Medicine; DIE, Deep Infiltrating Endometriosis; C-D, Clavien-Dindo classification; N/A, not applicable.\n4\n\n\nspective cohort studies compared RALS and conventional\nlaparoscopy in the treatment of advanced endometriosis.\nNezhat FR. et al. [ 20] compared operative time, blood loss,\nintraoperative and postoperative complications and hospi-\ntal stay in a cohort of 32 patients treated with RALS and 86\npatients treated by conventional laparoscopy. They found\nno differences in terms of blood loss, complications and\nhospital stay; RALS showed longer operative time than la-\nparoscopy but after stratification for patient’s BMI, the dif-\nference in operative time remained significant for obese pa-\ntients only with RALS procedures being longer than con-\nventional laparoscopy. In this study patients were not ran-\ndomly assigned to one or other technique but the choice\nwas made according to surgeon’s preference. Therefore,\nthe apparent longer operative time for RALS procedures in\nobese patients could be the result of a selection bias and\npoints out the need for cohort randomization in this kind of\ncomparison. Nezhat CR. et al . [ 21] considered the same\nperioperative outcomes in a cohort of 147 patients under-\ngoing RALS and 273 patients undergoing conventional la-\nparoscopy for advanced endometriosis; the patients were\nassigned to RALS or laparoscopy based on the availability\nof the operating room only, so that no surgeon’s choice bias\nwas present. There were no significant differences in blood\nloss or complication rate between the two groups but RALS\noperative time was significantly longer (mean 196 minutes)\nthan laparoscopy group (mean 135 minutes); also, hospi-\ntal stay was longer for RALS patients than laparoscopy pa-\ntients. Studies on surgical treatment of other gynecolog-\nical diseases evidence this discrepancy in operative time\nbetween robotic-assisted surgeries and laparoscopy with\nlonger operative time using RALS [ 52–54] but this is not\nconsistent with all the literature. Magrina et al . [ 33] de-\nscribe the surgical treatment of endometriosis stage III and\nIV in 493 patient, 331 undergoing RALS and 162 under-\ngoing conventional laparoscopy. After multivariate analy-\nsis considering age, blood loss and number of procedures\nperformed, operative time was shorter for RALS than la-\nparoscopy. Moreover, the authors concluded that the type\nof procedure, RALS or laparoscopy, do not influence hos-\npital stay or complication rate. A longer operative time is\nthe only significant variable influencing a higher compli-\ncation rate and longer hospital stay. Thus, implying that\nthe implementation of time-saving strategies, such as the\nstandardization of surgical steps in endometriosis surgery,\neither laparoscopic and robotic, would be able to reduce the\ncomplication rate and improve outcomes.\nComplication rates have been demonstrated to be\ncomparable for both techniques, either when assessing all\ntypes of endometriosis and when evaluating severe en-\ndometriosis (ASRM stage III–IV) [ 19,22].\nAccounting for feasibility of the procedure, all se-\nlected studies describe RALS for endometriosis treatment\nas feasible and effective. Only one study [21] highlights the\nlimits of RALS while approaching cases of extrapelvic en-\ndometriosis such as diaphragmatic endometriosis, because\nof the need for different trocar positioning and difficult\nrobotic branches mobilization. Overall, available literature\nis not unanimous regarding operative time in RALS proce-\ndures compared to conventional laparoscopy and it seems\nreasonable that the differences between the experiences are\ndue to the wide variety of surgical expertise and procedures\nimplemented which are hardly comparable between studies.\n4. Learning Curve\nThe majority of the studies included in this review re-\nports the results of surgical procedures implemented by ex-\nperienced surgeons in the field of RALS. This aspect en-\nsures the possibility to compare results between centers but\nit does not provide the fundamental information regarding\nthe learning curve of the new technique. Indeed, feasibility\nand safety are the first aspect to consider, but the prospect\nof an effective surgical approach which is also easy and fast\nto learn is even more alluring. On one hand, the learning\nperiod for laparoscopic complex procedures such as radical\nhysterectomy and lymph node dissection is long, account-\ning for at least 40 cases needed to achieve a turning point\nin the operative duration and complication rates [ 55]. On\nthe other hand, RALS in gynecology has been reported to\nbe characterized with a shorter learning curve, with 12 to\n18 procedures needed to gain equivalent expertise [ 56].\nGomes et al . [ 34] compared perioperative outcomes\nof patients operated by experienced and beginner robotic\nsurgeons assisted by an experienced proctor. In this retro-\nspective study, 274 different kind of gynecological robotic\nsurgeries were analyzed, being endometriosis treatment the\nmost frequent (57%). No difference in terms of need for\ntransfusion, complications rates and conversion rates was\nobserved between the two groups, pointing out the safety\nof introduction of RALS procedures in a less experienced\nteam with the supervision of a proctor.\nThe learning curve of RALS for deep endometriosis\ntreatment is addressed by a single-center retrospective study\nfrom Poujois et al . [ 35]. In this study, 20 patients under-\nwent a RALS procedure for eradication of endometriosis\nperformed by gynecologysts who were trained for laparo-\nscopic complex gynecological procedures but not for DIE\nsurgery nor for robotic-assisted procedures. Perioperative\noutcomes were evaluated and compared to the available\nliterature on RALS for DIE. According to operative time,\nblood loss, performed procedures, complications and hospi-\ntal stay, no significant differences were identified, meaning\nthat the learning phase for RALS in the study setting had no\nimpact on perioperative outcomes. This could imply that it\nis easier to approach to RALS when having already some\nlaparoscopic experience. However, it does not demonstrate\nthat RALS for the treatment of DIE is actually the easier\nroute for the surgeon.\nIn order to effectively compare the learning curve of\nthe two surgical approaches in the treatment of DIE, ran-\n5\n\ndomized studies comparing the two techniques performed\nby surgical teams with little experience either in conven-\ntional laparoscopy and robot-assisted procedures would be\nneeded.\n5. Deep Endometriosis\nDifferent studies investigated the role of robotic-\nassisted surgery specifically for the treatment of deep en-\ndometriosis, which is the type of endometriosis mostly cor-\nrelated with severe symptoms and more complex surgical\nprocedures [ 57]. In 2017, Abo et al . [ 36] published a\nprospective cohort study assessing the feasibility of RALS\nfor the treatment of deep endometriosis localizations, trying\nto outline benefits and limits. Thirty-five patients under-\nwent a RALS procedure for different DIE lesions, includ-\ning colorectal and urinary tract nodules. Effectiveness of\nthe treatment was evaluated by the presence of recurrence\nat one-year follow up and by preoperatively and postopera-\ntively administering questionnaires on bowel function and\nquality of life. Overall, no recurrence was found at fol-\nlow up and self questionnaires revealed a significant de-\ncrease in pain symptoms in most patients. Two case se-\nries reported a single institution experience on colorectal\nendometriosis treated robotically. The first from Ercoli et\nal. [ 37] evaluated perioperative outcomes in 35 patients\nwho had undergone nerve-sparing nodulectomy of a recto-\nsigmoid endometriotic nodule. They define robotic nod-\nulectomy as a safe and feasible procedure, independently\nfrom the nodule’s dimension, thanks to the precision ob-\ntainable by combining the 3D vision with freeness of move-\nment of robotic instruments. On the other hand, Graham\net al . [ 38] describe the implementation of robotically-\nassisted segmental resection and disk resection in 15 pa-\ntients with colorectal endometriosis. In their experience the\nprocedure was feasible but burdened by a substantial num-\nber of post-operative pelvic abscesses (33%), probably be-\ncause an extensive shaving and disk excisions may have led\nto diffuse tissue devitalization. Two more recent studies\ncompared laparoscopic and robotically-assisted treatment\nof colorectal endometriosis. A prospective cohort study by\nLe Gac et al . [ 23] reports similar perioperative outcomes\nin 23 patients treated with RALS and 25 patients treated\nby conventional laparoscopy except for longer operative\ntime in RALS group, defining RALS an adequate alterna-\ntive to laparoscopy for the treatment of deep endometrio-\nsis. In a prospective multicenter observational study, Rai-\nmondo et al . [ 24] compared perioperative outcomes and\nendometriosis-related symptoms trend in 44 patients treated\nfor rectosigmoid endometriosis, with 22 patients under-\ngoing RALS and 22 patients undergoing conventional la-\nparoscopy. Operative room occupancy time was the only\nparameter which differed between the two groups but oper-\native time (from skin incision to suture), blood loss, com-\nplication rate and hospital stay was comparable. All pa-\ntients in both groups reported significant improvement in\npain symptoms 12 months after surgery.\nAll studies assessing robotic surgery for urinary tract\nendometriosis have a retrospective design. Giannini et al .\n[17] report a series of 31 cases of robotically-assisted erad-\nication of ureteral endometriosis with a follow up period of\n3 and 6 months. They conclude that RALS allows complete\nradical excision of ureteral endometriosis even in complex\ncases, but with not negligible rate of urinary tract complica-\ntions (16%). Similar results were shown by the work of Di\nMaida et al. [ 25] in 2020 and Philip et al. [ 39] in 2021. The\nonly study comparing robotically-assisted procedures with\nconventional laparoscopy in the eradication of urinary tract\nendometriosis is a retrospective cohort study from le Car-\npentier et al. [ 26]. The authors describe 37 cases of bladder\nendometriosis, 15 treated by RALS and 22 treated by con-\nventional laparoscopy. Their results show no differences\nin terms of blood loss, operative time and hospital stay be-\ntween the two techniques; complication rate was higher for\nthe RALS group (33% vs 14%) but RALS group included\npatients with bigger and deeper lesions, with median size\nof resected lesion being 30 mm for RALS group and 23.5\nmm for laparoscopy group. The specific advantage of the\nuse of RALS in urinary tract endometriosis surgery is the\nimproved degree of freedom of movements even in small\nspaces such as the prevescical, paravescical and pararec-\ntal spaces compared to those allowed by conventional la-\nparoscopy. However, whether robotic assistance may im-\nprove the outcomes of patients with urinary tract DIE re-\nmains to be explored, especially when surgery should gain\na functional outcome such as procedures of ureteral anasto-\nmosis or ureteral reimplantation.\n6. Quality of Life\nImprovement of quality of life must be the end goal\nfor each and every surgery aiming to treat endometrio-\nsis [ 58]. Quality of life is a less quantitative and more\nqualitative parameter, thus it is more difficult to assess in\nan objective manner. As a matter of fact, very few of\nthe available studies on endometriosis surgery by RALS\naddress the topic. In a prospective cohort study [ 36],\n35 patients undergoing RALS for treatment of deep en-\ndometriosis were administered pre- and postoperatively\nquestionnaires evaluating quality of life and digestive func-\ntion. Particularly, gastrointestinal symptoms were in de-\ntail evaluated through Gastrointestinal Quality of Life In-\ndex (GIQLI) [ 59], the Knowles-Eccersley-Scott-Symptom\nQuestionnaire [ 60], the Fecal Incontinence Quality of\nLife Index [ 61] and the Bristol stool scale [ 62]. Also,\nendometriosis-related pain symptoms such as dysmenor-\nrhea and dyspareunia were evaluated using an 11-point Vi-\nsual Analogue Scale (V AS). Self questionnaires revealed\na significant decrease in pain symptoms related to en-\ndometriosis in most patients and the values of several items\nof gastrointestinal standardized questionnaires were signifi-\ncantly improved. The LAROSE trial [ 19] measured quality\n6\n\n\nof life changes before and after surgery by administering\nthe patients the 12-Item Short Form Health Survey (SF-12)\n[63] and the Endometriosis Health Profile (EHP-30) [ 64]\nquestionnaires at baseline and 6 weeks and 6 months af-\nter surgery. The results are particularly interesting because\nfor the first time quality of life after endometriosis-surgery\nis compared between conventional laparoscopy and robot-\nassisted procedures. According to the SF-12 question-\nnaires, there were no differences in scores between the two\ntechniques and between baseline, 6 weeks and 6 months.\nOn the other hand, improvement was shown compared with\nbaseline according to EHP-30 questionnaire results, which\ninvestigated, pain scores, control/powerlessness, emotions,\nsocial support, self-image, work, children, sexual inter-\ncourse, medical profession and treatment. No statistical\ndifferences were found between the laparoscopy and the\nRALS group.\nOne other study investigated the effect of surgery for\ndeep endometriosis, comparing conventional laparoscopy\nwith robot-assisted laparoscopy [ 24]. Endometriosis-\nrelated symptoms were pre- and postoperatively evaluated\nwith an 11-item Visual Analogue Scale (V AS). Consis-\ntent with the other studies available, all patients in both\ngroups reported a significant improvement of pain and\nbowel symptoms after surgery at 12-months follow up.\nA recent study investigated one other aspect which\ncould be included in a wide meaning of quality of life, the\ncosmetic satisfaction after surgery [ 65]. The authors report\nthe results of a survey on 64 patients who underwent ei-\nther robot-assisted or conventional laparoscopy for benign\ngynecological disease. Every skin incision was closed in\nthe same manner and by the same surgeon but the posi-\ntion and width of the incisions were different according to\nthe technique used. According to the results of the survey,\nthe cosmetic satisfaction rate was higher in the laparoscopic\ngroup than in the robotic group. Obviously, cosmetic satis-\nfaction cannot be the decisive parameter to choose one sur-\ngical route or another. Nevertheless, site of skin incision\nand possible esthetic concerns should be part of the preop-\nerative counseling with the patient.\n7. Conclusions\nRobotic surgery has spread rapidly in the last decade.\nA 2020 cohort study published on Journal of the American\nMedical Association (JAMA) [ 66] reports that the use of\nrobotics in general surgery increased from 1.8% in 2012 to\n15.1% in 2018, and for certain procedures, the magnitude\nof the increase was greater. This trend is generalized even\nin other specialties, particularly urology and gynecology.\nIn the context of a generalized need of optimization:\nof resources, of manpower, of money, of therapy, it is top-\nical to assess whether a specific treatment is not only ef-\nfective and safe but also timely indicated, widely available\nand cost-worthy. Surprisingly, more than two decades af-\nter the first robotic platform was introduced to assist la-\nparoscopic surgery, this kind of evaluation regarding en-\ndometriosis surgery is still far from being easy and handy.\nOn one hand, the available literature demonstrates with-\nout a doubt the feasibility of endometriosis eradication via\nrobotically-assisted laparoscopy. Also, safety of RALS for\nendometriosis could be cautiously assumed from the stud-\nies with widest casuistry, which show comparable compli-\ncation rates and perioperative outcomes between conven-\ntional laparoscopy and RALS. There are very few studies\nwhich report a slightly higher complication rate for RALS\nprocedures, especially for deep urinary tract endometriosis;\nanyway, the comparison of the results from all studies is dif-\nficult because of the extreme variability in design, the low\nnumber of cases reported and the lack of standardization of\nthe surgical technique for robotic procedures. Indeed, more\nreliable evidence would be gained from studies with largest\ncohorts and well standardized clinical parameters and tech-\nnical steps for the procedures.\nOn the other hand, costs related to the use of robotic\nsurgeries instead of laparoscopy should be thouroughly\ntaken into account. Health care costs for endometriosis are\nsubstantial, with 29% of the cost attributed to the surgical\nprocedure and 18% to hospitalization [ 67]. Whether the\nadvantages related to robotic procedures, such as shorter\noperative time for some studies, faster recover and shorter\nhospital stay would compensate the increase in the cost of\nthe surgical procedure itself, is yet to be determined. How-\never, this evaluation would constantly need to be updated\non the available technology, which is tending towards eas-\nier systems with faster docking and instrument interchange.\nMoreover, the effort in developing new robotic systems has\nbeen huge in the last few years, with new platforms try-\ning to overcome some limits of the already available sys-\ntems. Indeed, also the competition between brands is a good\npremise to speed up technological advances and bring down\nthe costs associated to robotic surgery. Besides, technical\ninnovations are going to improve safety and effectiveness\nof procedures, by providing systems able to reduce the com-\nplication rate and to speed up the learning curve, such as the\nintegration of preoperative imaging with the surgical field\n(augmented reality).\nUndoubtably, there is an impellent need for random-\nized studies with comparison of the most recent avail-\nable technologies in a parametrizable manner, in order to\nfound the ground on which standardized guidelines could\nbe made. However, as it is known, innovation cannot be\nefficient at first and great innovations are the result of im-\nplementation and correction of small everyday changes.\nRobotic technology applied to laparoscopy in the treatment\nof endometriosis could be seen as an effective and safe alter-\nnative to the conventional treatment but also as a promising\ntool for future achievements.\n7\n\nAuthor Contributions\nAll authors named on this submission made substan-\ntial contributions to the study. Material preparation and data\ncollection were made by LCM, DR and PC, analysis was\nmade by ALM and RS. The first draft of the manuscript was\nwritten by CA and LCM. GG and all authors commented on\nprevious versions of the manuscript and approved the final\nmanuscript.\nEthics Approval and Consent to Participate\nNot applicable.\nAcknowledgment\nNot applicable.\nFunding\nThis research received no external funding.\nConflict of Interest\nThe authors declare no conflict of interest. GG is serv-\ning as one of the Guest editors of this journal. DR and PC\nare serving as one of the Editorial Board members of this\njournal. We declare that GG, DR and PC had no involve-\nment in the peer review of this article and has no access to\ninformation regarding its peer review. Full responsibility\nfor the editorial process for this article was delegated to CI.\nReferences\n[1] Giudice LC, Kao LC. Endometriosis. The Lancet. 2004; 364:\n1789–1799.\n[2] Ballweg ML. Impact of endometriosis on women’s health: com-\nparative historical data show that the earlier the onset, the more\nsevere the disease. Best Practice & Research Clinical Obstetrics\n& Gynaecology. 2004; 18: 201–218.\n[3] Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman\nG, Greb R, et al. ESHRE guideline for the diagnosis and treat-\nment of endometriosis. Human Reproduction. 2005; 20: 2698–\n2704.\n[4] Practice bulletin no. 114: management of endometriosis. 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