{"paper_id":"57da5f2a-e6e1-4c31-8118-eece37d045da","body_text":"Copyright © 2020 Society of Korean Robotic Gynecologic Surgery\n36\nReview\neISSN 2672-1481\nhttps://doi.org/10.36637/grs.2020.00045\n Gyne Robot Surg 2020;1(2):36-49\n• Received: June 28, 2020   • Revised: September 13, 2020   • Accepted: September 14, 2020\n•  Correspondening author: Tae-Joong Kim\nDepartment of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, \nKorea\nE-mail: tj28.kim@gmail.com\n This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/\nlicenses/by-nc/4.0)  which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.\nINTRODUCTION\nEndometriosis is a common gynecologic disorder defined \nas the presence of endometrial glands and stroma outside \nthe uterine cavity, with an estimated incidence of 11% in \nthe population [1]. It commonly affects the pelvic organs \nand can also be found outside the pelvic cavity. Although \npatients with endometriosis can be asymptomatic, 35–50% \nof them suffer from severe pelvic pain, infertility, and other \nsymptoms that depend on the location of the lesion [2,3]. \nEndometriosis can also decrease quality of life (QOL) and \nincrease overall healthcare costs [4].\nSurgical resection of all visible lesions using laparoscopy \nhas been considered the gold standard for treating endo-\nmetriosis when medical treatment fails [5,6]. A complete re-\nsection of endometriosis is important to prevent disease \nrecurrence, relieve pain, and improve fertility. However, in \ncomplex cases of endometriosis, e.g., stage III or IV accord-\ning to the revised American Society for Reproductive Medi-\ncine classification, achieving that goal through laparoscopy \nThe role of robotic surgery for endometriosis\nJun-Hyeok Kang, Tae-Joong Kim\nDepartment of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea\nEndometriosis is a chronic gynecologic disorder characterized by chronic pelvic pain and infertility that affects \napproximately 11% of reproductive-aged women. Medical or surgical treatment is essential to manage symptoms and \nreduce recurrence. When surgical treatment is needed, laparoscopy is considered the gold standard treatment. However, \nthe severity of the disease varies from simple endometrioma to bowel and urinary tract endometriosis, which require \nradical surgery. With severe endometriosis, even experienced surgeons often need to use laparotomy because of the \ntechnical limitations of laparoscopy. Robotic surgery (RS) can be an alternative treatment option because of the advanced \nvisualization, wristed instruments, and ergonomic positioning that it offers to the surgeon. We reviewed previous studies \nto evaluate the role of RS for endometriosis. Compared with conventional laparoscopy, RS shows similar surgical outcomes, \nincluding blood loss and perioperative complications, but it is generally a more time-consuming procedure. RS has no \nadded value for the treatment of early stage endometriosis. However, it does seem to have considerable advantages in \ncomplex endometriosis surgery, such as that for advanced stage, bowel, and urinary tract endometriosis, although that \nhas not been shown statistically due to a lack of study. RS can also help prevent conversion to laparotomy and reduce the \ntraining period required for inexperienced surgeons. We cannot yet define the definitive role of RS in endometriosis due to \nits short history, but we note its value for complex surgery. Therefore, RS should be considered in selected patients.\nKey Words: Endometriosis; Deep infiltrating endometriosis; Robotic surgical procedures; Laparoscopy\n\n\n  Robot surgery for endometriosis | Kang JH, et al.\n Gyne Robot Surg 2020;1(2):36-49 37\ncan be technically difficult even for experienced surgeons. \nThe technical limitations of laparoscopy, such as the sur-\ngeon’s dexterity, surgical precision, coordination, and visual-\nization, can cause major complications (e.g., bowel perfora-\ntion, bladder injury, or ureter injury) during surgical \ndissection [7-9]. For these reasons, some surgeons hesitate \nto perform laparoscopic surgery, and some surgeons prefer \nto perform a laparotomy for severe endometriosis. \nThe introduction of robotic surgery (RS) has helped some \nsurgeons circumvent the technical challenges of laparosco-\npy. RS is now used widely in gynecology for hysterectomy, \nmyomectomy, adnexal surgery, sacrocolpopexy, and malig-\nnancy staging, which require extensive suturing and precise \ncontrol [10,11]. The benefits of a robotic system can espe-\ncially help in the surgical management of severe, advanced-\nstage endometriosis that requires complex pelvic dissec-\ntion, which involves a long operation time and a high risk of \nintraoperative complications.\nThis review article provides background information on \nusing RS for endometriosis and reviews the literature on \nthis topic. A literature search was performed in PubMed \nwith the key words “endometriosis,” “advanced,” “robotic \nsurgery,” “laparoscopy,” and “deep infiltrating endometrio-\nsis.”\nRS FOR ENDOMETRIOSIS COMPARED \nWITH CONVENTIONAL LAPAROSCOPY \n(CL)\nThe goal of endometriosis surgery is to excise all visible \nendometriosis lesions and associated adhesions and restore \nnormal anatomy (Fig. 1) [12]. It is well known that complete \nresection of endometriosis lesions is the only reliable treat-\nment to reduce the recurrence rate and pain [13]. Superfi-\ncial endometriosis can easily be treated by laparoscopy. \nHowever, the altered tissue planes and dense adhesions \ncaused by deep infiltrating endometriosis (DIE) makes it dif-\nficult to do a complete resection using laparoscopy. Be -\ncause of the many technical limitations of laparoscopy, in-\ncomplete resections and major complications occur \nfrequently during complex endometriosis surgery. In fact, \nthe conversion rate to laparotomy is approximately 10%, \neven among skilled surgeons [6,14].\nSince the introduction of robot systems, the technology \nof robot surgery has developed rapidly. RS provides 3-di-\nmensional and magnified visualization, wristed instruments, \nmotion scaling, and ergonomic positioning for the surgeon. \nThese technological advances enable a surgeon to do pre-\ncise and careful dissections, such as clearing the rectovagi-\nnal space, pelvic side wall dissection, ureter dissection, and \nresection of densely adherent endometrioma. Moreover, \nduring RS, the surgeon sits at a console away from the sur-\nFig. 1. (A) Severe pelvic adhesion among endometrioma, the rectum, and the pelvic peritoneum in the posterior cul-de sac. (B) Successfully \nperformed endometriosis surgery using robotic surgery (RS).\nBA\n\nGynecologic Robotic Surgery | Vol 1, No. 2, September 2020\nhttps://doi.org/10.36637/grs.2020.00045\n38\nTable 1. Summary of studies comparing RS and CL\nStudy Design\nPatient rASRM stage Operation time \n(minutes) EBL (mL) HS (days)\nConversion \nto \nlaparotomy\nMajor Cx.\nRemarks\nRS CL I/II III/IV RS CL RS CL RS CL RS CL RS CL\nNezhat et \nal. [18] \n(2010)\nRetrospective 40 38 61 17 191 \n(135–295)\n159\na)\n \n(85–320)\n60  \n(0–350)\n65  \n(0–500)\nN/A N/A 0 0 0 0\nChu et \nal. [19] \n(2011)\nRetrospective 25 96 Severe \nendome- \ntriosis\nSevere \nendome- \ntriosis\n238 \n(120–630)\n190\na)\n \n(71–674)\nNo \nsignificant \ndifference\nNo \nsignificant \ndifference\nNo \nsignificant \ndifference\nNo \nsignificant \ndifference\n0 0 No \nsignificant \ndifference\nNo \nsignificant \ndifference\nDulemba \net al. \n[20] \n(2013)\nRetrospective 180 100 148 132 7 7.4±41 . 672.0±28.5 29.2±43.2 24.9±24.3 N/A N/A 0 0 1 0 Analysis for \npathologic \nconfirmation \nrate\nNezhat \nand \nSirota \n[21] \n(2014)\nRetrospective 32 86 0 118 250 \n(176–328)\n173\na)\n \n(123–237)\n100 \n(50–200)\n100 \n(50–200)\n1 1 0 0 2 1 Analysis of \nthe relation \nbetween \nobesity and \nOP. tim e\nNezhat et \nal. [22] \n(2015)\nRetrospective 147 273 0 420 196 135\na)\n40 25 >1 1\na)\nN/A N/A 0 0 Analysis of \nreasons for \nthe longer \nOP. time of \nRS\nMagrina \net al. \n[23] \n(2015)\nRetrospective 331 162 0 493 139 \n(40–531)\n113\na)\n \n(28–347)\n92 \n(10–2500)\n82  \n(70–700)\n1.1 0.7\na)\n2 1 6 1\nSoto et \nal. [24] \n(2017)\nRCT 35 38 29 23 106±48 101±63 100±229 43±39 N/A N/A 0 1 0 0 Analysis of \nQOL after \nsurgery\nValues are presented as mean±standard deviation or median (range).\nRS, robotic surgery; CL, conventional laparoscopy; rASRM, revised American Society for Reproductive Medicine; EBL, expected blood loss; HS, duration of hospital \nstay, Cx., complication; N/A, not applicable; OP., operation; RCT, randomized clinical trial; QOL, quality of life.\na)\nP<0.05.\n\n  Robot surgery for endometriosis | Kang JH, et al.\n Gyne Robot Surg 2020;1(2):36-49 39\ngical field and controls the robotic instruments and camera \nvia finger graspers and pedals. The operator can thus feel \ncomfortable and experience less fatigue despite long oper-\native times [11,15]. The near-infrared fluorescence-indocy-\nanine green (NIRF-ICG, firefly) technique of robot surgery \ncan also improve the detection of endometriosis lesions in-\nvisible to the naked eye in white light (WL) illumination \n[16,17]. All of these advantages help robot surgery ensure a \ncomplete resection of endometriosis.\nOur literature review found eight studies comparing RS \nwith CL for the treatment of endometriosis. Among them, \nsix were retrospective comparative studies, one was a ran-\ndomized clinical study, and one was a meta-analysis. The \nyear of publication, study design, and results of all the stud-\nies except the meta-analysis are shown in T able 1.\nThe first study to compare RS and CL for endometriosis \ntreatment was conducted in 2010 by Nezhat et al. [18]. \nThey found no significant differences in perioperative out-\ncomes between the two groups except in operative time \n(mean [range]; RS, 191 [135–295] minutes vs. CL, 159 [85–\n320] minutes; P=0.045). However, most patients in that \nstudy cohort had stage I or II disease; only 22% (27/78) of \npatients had advanced stage endometriosis. They conclud-\ned that RS is feasible and safe for the treatment of endome-\ntriosis but that the superiority of RS for early stage disease \nis unclear. Since then, several studies have evaluated the \nrole of RS in advanced stage endometriosis. Chu and col-\nleagues [19] retrospectively compared RS (n=25) and CL \n(n=96) for the treatment of severe endometriosis. They \nalso found comparable surgical outcomes between the \ngroups and that RS required a longer mean operative time \nthan CL (238 vs. 190 minutes, P=0.05). According to a \nstudy of 280 patients with endometriosis (RS, 180 vs. CL, \n100) performed by Dulemba et al. [20], RS had similar sur-\ngical outcomes including mean operation time (RS, 77 .4 \nminutes vs. CL, 72.3 minutes; P=0.23), in contrast to the \nprevious study results regarding operation time. Interest-\ningly, their group compared the rate of biopsy-confirmed \nendometriosis patients between the two groups and found \nthat the RS group had a higher confirmation rate than the \nCL group (RS, 80% vs. CL, 56.8%; P<0.001) due to its bet-\nter visualization. They revealed that robot surgery can im-\nprove the diagnosis and excision of implanted tissue over \nthat available with CL, with comparable perioperative out-\ncomes. In a study of patients with advanced stage endome-\ntriosis (n=118) by Nezhat and Sirota [21], RS was a more \ntime-consuming procedure than CL, and other surgical out-\ncomes, such as complications and conversion rate, were \ncomparable between the two groups. In particular, they \nevaluated the effect of obesity on surgery. After obesity \nstratification, they found no significant differences in oper-\native time between RS and CL among normal weight and \noverweight patients. In obese patients, however, the opera-\ntive time for RS was longer than that for CL (median [range]; \n282.5 [224–342] vs. 174 [130–270] minutes; P<0.05). They \nargued that RS is a feasible and safe procedure for the \ntreatment of endometriosis but that it should be used only \nfor complex operations that require fine dissection. They \nrevealed that the longer operation time of RS compared \nwith CL is related to obesity.\nTwo large retrospective studies have been done. A study \nby Nezhat et al. [22] of 420 patients who underwent sur-\ngery for advanced stage endometriosis (RS, 147 vs. CL, \n273) found no differences in surgical outcomes between \nthe two groups. However, the RS group had a longer mean \noperative time (196 vs. 135 minutes, P<0.001) and longer \nhospital stay (P<0.001). Their findings were consistent with \nprevious studies in terms of the increase in overall opera-\ntive time with RS. They also analyzed the factors that con-\ntribute to the longer operation time and found that docking \nand undocking time, the size of endometrioma, the fact that \na CO\n2 laser is not available in the RS setting, the presence of \nupper abdomen disease, and the lack of tactile sense with \nRS contributed to the increased operative time. In another \nlarge study of 493 patients with advanced stage endome-\ntriosis (RS, 331 vs. CL, 162) [23], the only difference be -\ntween two groups in surgical outcomes was operation time. \nThose authors explained that the longer operation time \nwith RS stemmed from the higher number of additional \nprocedures and more radical operations performed in the \nrobot group.\nThe only randomized clinical trial (RCT) comparing RS vs. \nCL for advanced endometriosis was conducted with 73 pa-\ntients (RS, 35 and CL, 38) by Soto et al. [24] in 2017 . They \nfound no statistically significant differences between RS \nand CL in surgical outcomes, including operative time \n(mean±standard deviation; 106±48.4 and 101.6±63.2 min-\nutes; P=0.71). That study also compared QOL scores from \n\nGynecologic Robotic Surgery | Vol 1, No. 2, September 2020\nhttps://doi.org/10.36637/grs.2020.00045\n40\nbaseline, 6 weeks, and 6 months after surgery and found no \nsignificant differences between the two groups. Both \ngroups reported significant improvements in QOL at both \npostoperative times compared with their preoperative \nbaseline.\nOne previous meta-analysis by Chen et al. [25] evaluated \nthe safety and efficacy of RS vs. CL for the treatment of ad-\nvanced stage endometriosis. According to that analysis, RS \nhas a significantly longer operation time than CL (P<0.01). \nHowever, they found no difference between RS and CL in \nthe duration of hospital stay, complication rate, or blood loss. \nThey concluded that RS is a safe and efficient alternative to \nCL for the treatment of advanced stage endometriosis, al-\nthough RS is time-consuming and the overall cost remains \nhigh. The benefits of RS for the treatment of advanced en-\ndometriosis thus remain uncertain. \nROBOTIC SINGLE-SITE SURGERY TO \nTREAT ENDOMETRIOSIS\nWith an increase in the demand for minimally invasive \nsurgery (MIS), robotic single site (RSS) surgery has devel-\noped since 2013 as an alternative to RS in various surgical \nfields. RSS surgery requires only a small incision of 3 cm to \nplace a single multichannel port, whereas RS requires the \nplacement of at least four trocars. Therefore, RSS is less in-\nvasive, causes less pain, and offers better cosmesis after \nsurgery than RS [26,27]. Given that most women who suf-\nfer from endometriosis are young and susceptible to scar-\nring, the cosmesis of the surgical scar is an important issue \n[28,29]. Single-port laparoscopy (SPL) is more difficult than \nCL because limitations in space and movement lead to con-\nflicts among instruments. RSS surgery overcomes those \nproblems with crossed and flexible instruments. We thus \nassume that surgeons can remove endometriosis lesions \nmore easily using RSS surgery than SPL and that RSS can \nachieve cosmetic goals better than RS surgery.\nIn our literature review, we found some case reports \nabout the excision of endometriosis using RSS surgery and \none retrospective study comparing the outcomes of RSS \nsurgery and SPL for endometriosis. The first case report of \none patient using RSS surgery for endometriosis was writ-\nten by Guan et al. [16] in 2015. They successfully resected \nadvanced endometriosis using RSS surgery and an ICG in-\njection. Jayakumaran and colleagues [17] reported their ex-\nperience performing RSS surgery for endometriosis in sev-\nen patients. All the visible endometriosis lesions in those \nseven patients were successfully resected without any \ncomplication or the conversion to another surgical method. \nInterestingly, their group compared the number of endo-\nmetriosis lesions found using different endoscopic visualiza-\ntion techniques: laparoscopic WL illumination, robotic WL \nillumination, and NIRF-ICG imaging. The NIRF-ICG imaging \ndetected more endometriosis lesions than the other visual-\nization methods. They argued that RSS surgery combined \nwith this advanced visualization technique facilitated more \ncomplete endometriosis lesion detection and excision. A \nretrospective study in 2018 compared the surgical out -\ncomes from RSS surgery (n=68) with those from SPL \n(n=52) for the treatment of advanced-stage endometriosis \n[30]. RSS surgery showed comparable surgical outcomes, \nincluding duration of hospital stay and perioperative com-\nplications, with SPL except for mean operation time (RSS \nsurgery, 107 .8 minutes vs. SPL, 76.9 minutes; P=0.001) and \nestimated blood loss (106.6 vs. 57 .1 mL, P=0.001). That \nstudy suggested that RSS surgery is feasible, safe, and ef-\nfective for the treatment of advanced stage endometriosis.\nAnother novel single port robotic platform, the da Vinci® \nSP Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) \nuses a single robotic arm that contains an articulating cam-\nera and instruments docked from a single laparoscopic tro-\ncar. Initial reports on this system were published in other \nfields, such as urologic surgery, and they suggested that this \nnew technology is a safe and feasible surgical option com-\npared with prior procedures [31,32]. However, no report \nhas yet been published about the use of this platform for \nendometriosis. \nRS FOR DIE AND EXTRAGENITAL ENDO-\nMETRIOSIS\nDIE is diagnosed when endometriosis occurs more than \n5 mm deep into the peritoneum. Approximately 40% of pa-\ntients with endometriosis have DIE [33]. It is usually found \nin the rectovaginal space (70%), but it also occurs in the \nbowel (12%), urinary tract (9%), and pelvic peritoneum \n[34,35]. The infiltrative nature of DIE can cause dense ad-\nhesions and fibrosis and distort pelvic structures, including \n\n  Robot surgery for endometriosis | Kang JH, et al.\n Gyne Robot Surg 2020;1(2):36-49 41\ngenital organs, the bowel, and urinary tract. This can cause \nsevere pelvic pain. Because DIE lesions are not easily treat-\ned medically, complete radical excision and the restoration \nof normal anatomy to reduce pain and the recurrence rate \nare the most important points in managing such patients. \nTo achieve that goal, particular skills, such as dissecting the \ndeep retroperitoneal space, isolating the ureter and the \nbowel, and suturing technique, are essential. However, \nthose procedures are challenging using CL. Therefore, es-\npecially in DIE and extragenital endometriosis, RS can be a \nstrong, attractive option. \nDIE in bowel\nBowel involvement with deep endometriotic nodules is \nreported 8–12% of endometriosis cases (Fig. 2). Of them, \nthe recto-sigmoid junction (65%) is the most common site, \nfollowed by the rectum (15–20%). Bowel-involved endo-\nmetriosis can cause cyclic bowel symptoms, dyschezia, \nbloating, and rectal bleeding [36-38]. The surgical treat -\nment for bowel endometriosis depends on the depth of \nbowel wall invasion and ranges from shaving to segmental \nresection [39]. Although the current surgical standard is \nbased on laparoscopic surgery, some bowel surgery proce-\ndures are difficult to perform using laparoscopy due to the \npossibility of major complications such as bowel perforation \nand leakage. Therefore, many surgeons abandon laparo -\nscopic surgery when they have to do bowel surgery and \nconvert to laparotomy. Without a doubt, RS offers advan-\ntages over laparoscopy in complex bowel operations.\nSince the introduction of robot systems, many attempts \nhave been made to evaluate the feasibility of RS in treating ad-\nvanced colorectal endometriosis with DIE. Most studies found \nduring our literature search were case reports (Table 2). Ne-\nzhat et al. [40] reported the first two cases of successful RS \nmanagement for bowel endometriosis (segmental bowel \nresection and disc excision of the anterior rectal wall) with-\nout any complications. Since then, many studies have re -\nported surgical outcomes of RS for bowel endometriosis. \nAccording to a study by Lim et al. [41] comparing the surgi-\ncal outcomes of RS (n=8) and laparotomy (n=10) for low an-\nterior resection to treat endometriosis, RS showed similar \nsurgical outcomes with fewer complications than laparoto-\nmy. Although that study included a small number of pa -\ntients, it was the first to compare laparotomy with RS in the \ntreatment of bowel endometriosis. Ercoli et al. [42] used RS \nto perform complete excision from 22 patients who had \nDIE with colorectal involvement (segmental resection, 12 \nand bowel wall shaving, 10). Only one case had a major \npostoperative complication (small bowel obstruction), and \nthere was no conversion to laparotomy. They demonstrat-\ned that using RS for complete debulking of DIE with \ncolorectal involvement is feasible and safe and can be done \nwithout conversion to other surgical methods. Collinet and \ncolleagues [43] reported that their group successfully used \nRS in 96 patients who received segmental rectal resection, \nrectal shaving, and ileocecectomy without any major post-\nFig. 2. (A) Rectum involvement. (B) Sigmoid colon involvement.\nBA\n\nGynecologic Robotic Surgery | Vol 1, No. 2, September 2020\nhttps://doi.org/10.36637/grs.2020.00045\n42\nTable 2. Summary of studies about robot surgery for DIE with bowel and urinary tract involvement \nStudy Design Patient Operation name Major complication\nColorectal DIE\nNezhat et al. [40] (2011) Case report 2 Segmental bowel resection (n=1)\nDisc excision (n=1)\nNo complications\nLim et al. [41] (2011) Comparative\nProspective\n8 Low anterior resection (n=8) No complications\nErcoli et al. [42] (2012) Case series 22 Segmental bowel resection (n=12)\nColorectal wall shaving (n=10)\nSmall bowel obstruction (n=1)\nVitobello et al. [45] \n(2013)\nCase report 7 Segmental bowel resection (n= 7): \nhybrid technique (RS+CL)\nReoperation due to bleeding\nNeme et al. [44] (2013) Case report 10 Segmental bowel resection (n=10) No complications\nSiesto et al. [46] (2014) Case series 42 Rectal shaving (n=23)\nSegmental bowel resection (n=19)\nAnastomosis leakage (n=1)\nReoperation due to bleeding (n=1)\nCollinet et al. [43] (2014) Case series\nRetrospective\nMulticenter\n97 Rectal shaving (n=68)\nSegmental rectal resection (n=24)\nIleocecectomy (n=1)\nAppendectomy (n=3)\nStoma (n=1)\nRectal perforation during rectal \nshaving surgery (n=2)\nPellegrino et al. [47] \n(2015)\nCase series\nProspective\n25 Rectal shaving (n=25) Rectal perforation during rectal \nshaving surgery (n=1)\nAbo et al. [48] (2017) Case series 35 Rectal shaving (n=25)\nDisc excision (n=3)\nSegmental bowel resection (n=3)\nNo complications\nMorelli et al. [49] (2016) Case report 10 Segmental rectal resection (n=6)\nSigmoid-rectal resection (n=4)\nNo complications\nGraham et al. [50] (2019) Case series 57 Segmental rectal resection (n=12)\nDisc excision or rectal shaving (n=42)\nRectovaginal fistula (n=1)\nUrinary tract DIE\nNezhat et al. [40] (2011) Case report 3 Ureteroneocystostomy (n=1)\nSegmental bladder resection (n=1)\nUreterolysis (n=1)\nNo complications\nBot-Robin et al. [53] \n(2011)\nCase report 4 Partial bladder resection (n=4) No complications\nFrick et al. [54] (2011) Case report 2 Ureteroneocystostomy (n=2) No complications\nBrudie et al. [55] (2012) Case report 29 Ureterolysis (n=29) Ureteral transection (n=1)\nCollinet et al. [43] (2014) Case series\nMulticenter\n87 Ureteroneocystostomy(n=3)\nPartial bladder resection (n=22)\nUreterolysis (n=62)\nUreteral fistula (n=2)\nUreter and bladder anastomosis site \nleakage (n=1)\nProlonged self catheterization (n=1)\nSiesto et al. [46] (2014) Case series 7 Bladder resection (n=5)\nUreterolysis (n=2)\nNo complications\nle Carpentier et al. [52] \n(2016) \nRetrospective\nComparative\n37 (RS, 15; \nCL, 22)\nPartial bladder resection (n=37) Vesicovaginal fistula (CL, n=1)\nUreter and bladder anastomosis site \nleakage (RS, n=1) \nDehiscence of bladder (CL, n=1)\n\n  Robot surgery for endometriosis | Kang JH, et al.\n Gyne Robot Surg 2020;1(2):36-49 43\noperative complications. Neme et al. [44] reported that \nthey successfully performed bowel resection using RS in 10 \npatients without any complications or conversion to lapa-\nrotomy. Symptoms related to endometriosis (dysmenor-\nrhea, dyspareunia, dyschezia, intestinal cramping, diarrhea, \nand constipation) had disappeared in all women 12 months \nafter surgery. They also suggested that RS bowel resection \nsurgery for the treatment of deep infiltrating bowel endo-\nmetriosis is feasible, effective, and safe. In addition, Vitobel-\nlo et al. [45], Siesto et al. [46], Pellegrino et al. [47], and Abo \net al. [48] published reports of their successful experiences \nusing RS for bowel endometriosis, including rectal shaving \nand segmental bowel resection. Most cases were success-\nful and without complication, and the authors all argued for \nthe feasibility of RS.\nMorelli et al. [49] reported successful surgical outcomes \nfrom bowel resection using RS (n=10). Unlike previous stud-\nies, they used questionnaires to assess autonomic function \npreservation after surgery, such as urinary function and \nsexual function. According to their study result, dyspareu-\nnia was significantly improved 12 months after surgery. \nUrinary function and other symptoms showed results simi-\nlar to those before surgery. They argued that the better vi-\nsualization and precise control offered by RS can facilitate \nnerve sparing, such as the hypogastric nerve and sacral \nsplanchnic nerve, which can easily be damaged during bow-\nel surgery. They suggested that RS is a better surgical \nmethod for the preservation of urinary and sexual function \nthan laparotomy or laparoscopy. A retrospective analysis of \n57 women who underwent RS for colorectal DIE was pub-\nlished in 2019. Among them, 15 patients received a bowel \nresection and the remaining 42 patients underwent only \nexcision of endometriotic nodules. No intraoperative com-\nplications or conversion to laparotomy was reported [50].\nDIE in the urinary tract \nThe urinary tract, including the ureter, bladder, and kid-\nney, is frequently affected by endometriosis, which can \ncause symptoms such as dysuria, hematuria, urinary fre -\nquency, and ureteral obstruction (Fig. 3). The incidence of \nurinary tract endometriosis is approximately 10% of endo-\nmetriosis patients, and the bladder is the most common site \n[51]. Superficial endometriotic lesions on the bladder and \nureter can easily be treated with simple excision or fulgura-\ntion. However, deep endometriotic lesions, such as an infil-\ntration of the detrusor muscle of the bladder or the muscu-\nlaris, lamina propria, or lumen of the ureter can require \nextensive resection and re-anastomosis. In those surgeries, \nfine dissection to identify the ureter and precise suturing \nfor anastomosis of the resected ureter are the most impor-\ntant techniques, and laparoscopy presents many limitations \nto performing them. Therefore, we assume that RS is well \nsuited to those types of surgical interventions because of \nits advantages, which we’ve already described.\nOur literature review returned several case reports \nabout treating urinary tract endometriosis using RS (Table \n2). However, no RCT studies have been done. All the previ-\nous reports had small sample sizes. A relatively large retro-\nspective multicenter study was conducted by Collinet et al. \n[43]. Their group performed ureterolysis (n=62), uretero-\nneocystostomy (n=3), and partial bladder resections (n=22) \nand reported major complications to the urinary tract in ap-\nproximately 4% of patients. A study by le Carpentier et al. \n[52] compared surgical outcomes between RS and CL for \nbladder endometriosis. RS showed similar surgical out -\ncomes, including perioperative complications and recur -\nStudy Design Patient Operation name Major complication\nAbo et al. [48] (2017) Case series 16 Partial bladder resection (n=3)\nUreterolysis (n=11)\nUreteroneocystostomy (n=2)\nUreteral necrosis and fistula (n=1)\nGiannini et al. [56] (2018) Case series 31 Ureterolysis (n=31) Ureteral fistula (n=2)\nHydronephrosis (n=1)\nUreterovesical reimplantation due to \nureter injury (n=1)\nRS, robotic surgery; CL, conventional laparoscopy; DIE, deep infiltrating endometriosis.\nTable 2. Continued\n\nGynecologic Robotic Surgery | Vol 1, No. 2, September 2020\nhttps://doi.org/10.36637/grs.2020.00045\n44\nFig. 3. (A) Deep infiltrating endometriosis (DIE) on the left distal ureter (magnetic resonance imaging [MRI] imaging). (B) Left hydroureter caused \nby left distal ureter obstruction due to DIE (computed tomography [CT] imaging). (C) Exposed left ureter after dissection of retroperitoneum \nusing robotic surgery. (D) DIE lesion on the left distal ureter. (E) Robotic suturing during ureteroneocystostomy. (F) Successfully performed \nureteroneocystostomy.\nF\nD\nB\nE\nC\nA\n\n  Robot surgery for endometriosis | Kang JH, et al.\n Gyne Robot Surg 2020;1(2):36-49 45\nrence rate. The conclusion of the other case reports was \nthat RS is safe and feasible for urinary tract endometriosis \n[40,53-56].\nDISCUSSION\nSince the introduction of robot surgery, it has been wide-\nly used to treat gynecologic disease. However, in the early \ndays of RS, it was not usually recommended for benign gy-\nnecologic disease. According to the American College of \nObstetrician and Gynecologists (ACOG) Committee Opin-\nion No. 628 announced in 2015, although RS has compara-\nble surgical outcomes, including complications, length of \nhospital stay, rate of conversion to laparotomy compared to \nCL, it requires similar or longer operation times and has \nhigher costs. ACOG thus recommends that operators avoid \nthe use of robot for benign gynecologic disease when it is \nfeasible to use CL or a vaginal approach. However, such \nstatements are mainly based on data from benign gyneco-\nlogic conditions other than endometriosis, which can re -\nquire complex and difficult surgical procedures. In addition, \nthis opinion has now been withdrawn due to technical ad-\nvances and accumulation of much experience, and the value \nof RS in benign gynecologic disease is being reevaluated. \nTherefore, the role of RS for endometriosis needs to be re-\nconsidered.\nWe reviewed documentation from the past 10 years on \nrobot surgery for endometriosis. Most studies were case \nreports, retrospective, observational, and non-compara-\ntive. Due to the short history of RS, only one RCT has com-\npared surgical outcomes between RS and CL. Therefore, \nthere are some limitations in determining the exact role RS \nshould play in endometriosis treatment. Our review has \nfound no evidence indicating that RS is superior to CL for \nthe treatment of endometriosis, similar to previous studies \nevaluating the role of RS in benign gynecologic disease. Of \nseven comparative studies, five studies [18,19,21-23] re-\nported that RS did not show any superiority to CL with re-\nspect to surgical outcomes, and they reported that it in -\nvolves significantly longer operation time regardless of the \nseverity of endometriosis. The one meta-analysis [25] also \nconcluded that RS is a more time-consuming procedure. In \ncontrast, two comparative studies, one retrospective [20] \nand the one RCT [24], reported that RS has an operation \ntime comparable to that of CL. RS has several time-con -\nsuming factors. First is the docking time, which has been \ntraditionally pointed out as time-consuming factor [57]. \nSecond, surgeons cannot be guided by tactile feedback \nduring surgery. The absence of the tactile sense correlates \nwith longer operation times and a higher complication rate \nbecause it is difficult to perform a careful dissection and \ndetect firm endometriosis lesions without it [58]. Third, the \nposition of the robotic camera is fixed on the umbilical port \nand cannot be changed during surgery. The robotic arm \nalso has a limited range of motion. These limitations are not \na critical problem for pelvic surgery, but extrapelvic disease \ncould require redocking of the robot for upper abdomen \nsurgery. However, those processes are increasingly being \nimproved through new docking techniques, advanced visu-\nalization from the camera to compensate for the tactile \nsense, and the da Vinci\n® SP Surgical System, which provides \nan easier approach to the upper abdomen.\nOverall, RS has no statistically proven benefit compared \nwith CL according to recent studies. Does that mean that \nclinicians should refrain from this expensive and time-con-\nsuming procedure when treating endometriosis? Many ex-\nperienced laparoscopic surgeons agree that RS can be ap-\npropriate, especially in treating severe endometriosis that \nrequires difficult surgical procedures. RS has many advan-\ntages over CL in complex surgery, such as precise control, \nmagnified and advanced 3D visualization, ergonomic posi-\ntioning, and a short learning curve. Moreover, these advan-\ntages can reduce operator’s fatigue in complex surgery and \nmay enable to do more cases of surgery at the same time \ncompared to CL. The indications for RS in treating endome-\ntriosis have not been well established. Therefore, it is im-\nportant to use in selecting patients suitable for robot sur-\ngery.\nOur review suggests some conditions that are appropri-\nate for RS. First, patients with severe pelvic adhesions, such \nas posterior cul-de-sac obliteration, that require fine dissec-\ntion and the restoration of normal anatomy can be excellent \ncandidates. Most patients with severe endometriosis feel \nsevere pelvic pain. Removing as many lesions as possible \nand normalizing pelvic anatomy is essential to reduce pain \nand the recurrence rate in such patients. The technical ad-\nvantages of robot surgery, as explained above, enable sur-\ngeons to more completely detect and resect the disease \n\nGynecologic Robotic Surgery | Vol 1, No. 2, September 2020\nhttps://doi.org/10.36637/grs.2020.00045\n46\n[17 ,20]. Second, patients who need bowel and urinary tract \nsurgery that carries high complication rates and conversion \nto laparotomy are good candidates for RS [59,60]. Radical \nsurgery, such as segmental bowel resection, low anterior \nresection, and ureteroneocystostomy, is required in some \npatients. Traditionally, those radical surgeries required con-\nversion to laparotomy. No comparative study has examined \nthe complication rate and conversion rate of CL, laparoto-\nmy, and RS in those cases. Therefore, we cannot draw the \nconclusion that RS is superior to CL during radical surgery. \nHowever, we can speculate that RS has definite advantages \nfor radical surgery. For example, precise dissection and \ngood visualization facilitate the removal of endometriosis \nlesions without nerve injury, especially to the inferior hypo-\ngastric plexus, which is important for postoperative urinary, \nsexual, and bowel function [61,62]. Furthermore, a reduc-\ntion in vessel injury and electrocoagulation during RS con-\ntributes to healing at the anastomosis site and reduces the \npossibility of fistula formation [63]. Finally, surgeons without \nmuch experience doing complex surgeries with CL tech -\nniques might find RS easier and more comfortable. It has \nbeen reported that the learning curve for RS is generally \nshorter than that for CL [64,65]. In particular, suturing tech-\nnique is faster with a robot than in CL [66]. Of course, that \nmight not be an important issue for experienced surgeons; \nhowever, it can be a strong advantage to beginners. Those \nindications for RS are hypothetical. No statistically proven \nindications are available because most published studies \nhave been case reports and not RCTs.\nMIS is another emerging issue in gynecologic surgery. \nPrior robot surgery platforms do not qualify as MIS be -\ncause they require at least four trocars. One disadvantage \nof RS compared with SPL is cosmesis. The development of \na single site platform for robot surgery can overcome the \ncosmetic shortcomings of both previous robot platforms \nand CL. RSS surgery, which is similar to SPL, shows surgical \noutcomes comparable to those of SPL [30]. Furthermore, it \nhas several strengths over SPL when treating endometrio-\nsis. For example, the wristed robotic arm and curved tro-\ncars of RSS help to maintain triangulation, which is a techni-\ncal obstacle for SPL. Second, RSS surgery provides a wider \nrange of motion than SPL. Surgeons can do precise dissec-\ntions and meticulous ovarian suturing in a single-site setting \nwithout collisions between surgical instruments. Further-\nmore, the development of the da Vinci\n® SP system is ex -\npected to provide even more range of motion in the robotic \narm and an easier approach to the upper abdomen than \nRSS surgery platforms. However, no study has considered \nthe use of a single-port robotic system for endometriosis \nbecause of its short history.\nIn conclusion, using RS to treat endometriosis is expected \nto have several technical advantages, but it has no statisti-\ncally proven benefit over CL and is associated with a longer \noperation time and higher cost. Standardized comparative \nresearch designs are difficult due to the diversity of extent \nin endometriosis surgery, which depends on the severity of \nendometriosis and disease location, e.g., from simple cys-\ntectomy of endometrioma to a bowel resection that re -\nquires radical surgery. Furthermore, due to the short histo-\nry of RS, most studies compared laparoscopy performed by \nhighly experienced surgeons with RS performed by sur -\ngeons who were relatively inexperienced in robot surgery. \nRS has no added value for the treatment of early stage en-\ndometriosis. However, it seems that RS could have strong \nadvantages for complex endometriosis surgery. It can also \nhelp to prevent conversion to laparotomy and reduce the \ntraining period for inexperienced surgeons. Most studies \nabout robot surgery for endometriosis have evaluated only \nperioperative outcomes, such as blood loss, operation time, \nand complication rate. Considering that most patients who \nsuffer from this disease are young, reproductive-aged \nwomen, fertility rates and the preservation of ovarian re-\nserve after surgery are other important problems that no \nstudy has investigated. As the proportion of RS increases in \nthe field of MIS, it is expected to play an important role in \ncomplex function-preserving surgeries, including endome-\ntriosis surgery. To make better decisions about its utility, \nlong-term outcome studies and RCTs should be conducted.\nConflict of interest\nNo potential conflict of interest relevant to this article \nwas reported.\nReferences\n  1. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J \nMed 2020;382:1244-56.\n\n  Robot surgery for endometriosis | Kang JH, et al.\n Gyne Robot Surg 2020;1(2):36-49 47\n  2. Sensky TE, Liu DT. Endometriosis: associations with menor -\nrhagia, infertility and oral contraceptives. Int J Gynaecol Obstet \n1980;17:573-6.\n  3. Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, \nBrandes I, et al. The burden of endometriosis: costs and quality of \nlife of women with endometriosis and treated in referral centres. \nHum Reprod 2012;27:1292-9.\n  4. Houston DE. 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