{"paper_id":"5b7b3921-1aaf-4636-b316-03257b85cd01","body_text":"Abstract\nThis study compared surgical approaches and perioperative outcomes of nerve-sparing modified radical hysterectomy (NSmRH) for deep endometriosis (DE) using the da Vinci SP and Xi systems. This retrospective cohort study included consecutive patients who underwent robot-assisted NSmRH for DE at a single tertiary referral center between March 2020 and October 2025. Disease severity was evaluated using the revised American Society for Reproductive Medicine (rASRM) and #Enzian classifications, and perioperative outcomes—including operative time (OT), console time (CT), docking time (DT), estimated blood loss (EBL), and complications—were compared. The analysis included 100 patients: 32 in the SP group and 68 in the Xi group. Advanced disease was prevalent in both cohorts, with rASRM stage IV observed in 72% of the SP group and 70% of the Xi group. The distribution of #Enzian classifications was comparable between groups. Median OT and CT did not differ significantly between groups (OT: 159 [123–196] vs. 144 [122–164] min, p = 0.16; and CT: 144 [101–180] vs. 130 [108–153] min, p = 0.22), whereas DT was shorter in the SP group (1.8–2.0 vs. 2.0–3.0 min, p = 0.0036). EBL was significantly lower in the SP group (5 vs. 15 mL; p = 0.0015). No intraoperative injuries, severe postoperative complications, or voiding dysfunction were observed in either group. NSmRH for DE was performed safely using both SP and Xi systems. These findings indicate that the SP system represents a feasible alternative robotic platform for selected high-complexity nerve-sparing procedures in DE.\nSimilar content being viewed by others\nData availability\nThe data supporting the findings of this study are not publicly available owing to sensitivity reasons and are available from the corresponding author upon reasonable request.\nReferences\nChapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, Vieira M, Hasan W, Bricou A (2006) Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod 21(7):1839–1845. https://doi.org/10.1093/humrep/del079\nZondervan KT, Becker CM, Missmer SA (2020) Endometriosis. N Engl J Med 382(13):1244–1256. https://doi.org/10.1056/NEJMra1810764\nAs-Sanie S, Mackenzie SC, Morrison L, Schrepf A, Zondervan KT, Horne AW, Missmer SA (2025) Endometriosis: a review. JAMA 334(1):64–78. https://doi.org/10.1001/jama.2025.2975\nChoi S, Roviglione G, Chou D, D’Ancona G, Ceccaroni M (2024) Nerve-sparing surgery in deep endometriosis: has its time come? Best Pract Res Clin Obstet Gynaecol 96:102506. https://doi.org/10.1016/j.bpobgyn.2024.102506\nBarra F, Ferrero S, Zorzi C, Evangelisti G, Perrone U, Valente I, Capezzuoli T, D’Ancona G, Bogliolo S, Roviglione G, Ceccaroni M (2024) From the tip to the deep of the iceberg’: parametrial involvement in endometriosis. Best Pract Res Clin Obstet Gynaecol 94:102493. https://doi.org/10.1016/j.bpobgyn.2024.102493\nCeccaroni M, Clarizia R, Bruni F, D’Urso E, Gagliardi ML, Roviglione G, Minelli L, Ruffo G (2012) Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 26(7):2029–2045. https://doi.org/10.1007/s00464-012-2153-3\nIanieri MM, Raimondo D, Rosati A, Cocchi L, Trozzi R, Maletta M, Raffone A, Campolo F, Beneduce G, Mollo A, Casadio P, Raimondo I, Seracchioli R, Scambia G (2022) Impact of nerve-sparing posterolateral parametrial excision for deep infiltrating endometriosis on postoperative bowel, urinary, and sexual function. Int J Gynaecol Obstet 159(1):152–159. https://doi.org/10.1002/ijgo.14089\nBecker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N ESHRE Endometriosis Guideline Group, ESHRE guideline (2022) ESHRE guideline: endometriosis. Hum Reprod Open 2022(2):hoac009. https://doi.org/10.1093/hropen/hoac009\nRestaino S, Mereu L, Finelli A, Spina MR, Marini G, Catena U, Turco LC, Moroni R, Milani M, Cela V, Scambia G, Fanfani F (2020) Robotic surgery vs laparoscopic surgery in patients with diagnosis of endometriosis: a systematic review and meta-analysis. J Robot Surg 14(5):687–694. https://doi.org/10.1007/s11701-020-01061-y\nCsirzó Á, Kovács DP, Szabó A, Fehérvári P, Jankó Á, Hegyi P, Nyirády P, Sipos Z, Sára L, Ács N, Szabó I, Valent S (2024) Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: a systematic review and meta-analysis. Surg Endosc 38(2):529–539. https://doi.org/10.1007/s00464-023-10587-9\nFerrari FA, Youssef Y, Naem A, Ferrari F, Odicino F, Krentel H, Moawad G (2024) Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward? Front Med (Lausanne) 11:1387036. https://doi.org/10.3389/fmed.2024.1387036. (eCollection)\nMikhail E, Pavlovic ZJ, Al Jumaily M, Kheil MH, Moawad GN, Soares T (2022) Robot-assisted surgery for endometriosis current and future perspectives. Surg Technol Int 40:197–202. https://doi.org/10.52198/22.STI.40.GY1562\nHebert T (2024) Robotic assisted laparoscopy for deep infiltrating endometriosis. Best Pract Res Clin Obstet Gynaecol 92:102422. https://doi.org/10.1016/j.bpobgyn.2023.102422\nTerho AM, Mäkelä-Kaikkonen J, Ohtonen P, Uimari O, Puhto T, Rautio T, Koivurova S (2022) Robotic versus laparoscopic surgery for severe deep endometriosis: protocol for a randomised controlled trial (ROBEndo trial). BMJ Open 12(7):e063572. https://doi.org/10.1136/bmjopen-2022-063572\nRenso M, Bendifallah S, Estrade JP, Merlot B, Roman H, Vidal F, Collinet P (2025) Robot-assisted versus standard laparoscopic approach of total hysterectomy for deep infiltrating endometriosis and adenomyosis (ENDORAS TRIAL): study protocol for a randomised controlled trial. BMJ Open 15(11):e108125. https://doi.org/10.1136/bmjopen-2025-108125\nIntuitive Surgical FDA clears Intuitive’s single port platform for urologic and otolaryngology procedures, Press release (2018) http://intuitive.com/news-releases/news-release-details/fda-clears-intuitives-single-port-platform-urologic-and\nIntuitive S (2022) Japan Regulatory Agency (PMDA) clears Intuitive’s single port robotic-assisted surgery system. Investor relations press release. https://investor.intuitivesurgical.com/news-releases/news-release-details/japan-regulatory-agency-clears-intuitives-single-port-robotic\nSurgical I (2024) Single-Port DV (SP) system receives CE mark for endoscopic abdominopelvic and thoracoscopic procedures Medical product outsourcing (MPO). https://www.mpo-mag.com/breaking-news/intuitives-da-vinci-single-port-surgical-robot-grabs-eu-approval. (Accessed 2025 Dec 20)\nMisal M, Magtibay PM, Yi J (2021) Robotic LESS and reduced-port hysterectomy using the da VINCI SP surgical system: A single-institution case series. J Minim Invasive Gynecol 28(5):1095–1100. https://doi.org/10.1016/j.jmig.2020.08.009\nvon Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, Initiative STROBE (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596):1453–1457. https://doi.org/10.1016/S0140-6736(07)61602-X\nKanno K, Andou M, Aiko K, Yoshino Y, Sawada M, Sakate S, Yanai S (2021) Robot-assisted nerve plane-sparing eradication of deep endometriosis with double-bipolar method. J Minim Invasive Gynecol 28(4):757–758. https://doi.org/10.1016/j.jmig.2020.07.018\nKanno K, Yanai S, Sawada M, Sakate S, Andou M (2024) Nerve-sparing deep endometriosis surgery with rectal discoid resection using da VINCI SP. Fertil Steril 122(4):758–760. https://doi.org/10.1016/j.fertnstert.2024.07.015\nKanno K, Andou M, Aiko K, Yoshino Y, Sawada M, Sakate S, Yanai S (2021) Fertility- and nerve-sparing laparoscopic eradication of deep endometriosis with total posterior compartment peritonectomy: the Kurashiki method. J Minim Invasive Gynecol 28(2):170–171. https://doi.org/10.1016/j.jmig.2020.05.028\nQuerleu D, Cibula D, Abu-Rustum NR, Fanfani F, Fagotti A, Pedone Anchora L, Ianieri MM, Chiantera V, Bizzarri N, Scambia G (2024) International expert consensus on the surgical anatomic classification of radical hysterectomies. Am J Obstet Gynecol 230(2):235.e1-235.e8. https://doi.org/10.1016/j.ajog.2023.09.099\nBarry MJ, Fowler FJ Jr, O’Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WK, Cockett AT (1992) The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 148(5):1549–1557 discussion 1564. https://doi.org/10.1016/s0022-5347(17)36966-5\nCanis M, Donnez JG, Guzick DS, Halme JK, Rock JA, Schenken RS, Vernon MW (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67(5):817–821. https://doi.org/10.1016/s0015-0282(97)81391-x\nKeckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, Krentel H, Janschek E, Exacoustos C, Malzoni M, Mueller M, Roman H, Condous G, Forman A, Jansen FW, Bokor A, Simedrea V, Hudelist G (2021) The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 100(7):1165–1175. https://doi.org/10.1111/aogs.14099\nDindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae\nPark SY, Cho EH, Jeong K, Yoo HK, Lee JH, Moon HS (2023) Robotic single-port hysterectomy versus robotic multisite hysterectomy in benign gynecologic diseases: a retrospective comparison of clinical and surgical outcomes. J Obstet Gynaecol Res 49(11):2746–2752. https://doi.org/10.1111/jog.15778\nHeo JE, Han HH, Lee J, Choi YD, Jang WS (2024) Single-port robot-assisted pyeloplasty using the da Vinci SP system versus multi-port pyeloplasty: Comparison of outcomes and costs. Asian J Surg 47(9):3841–3846. https://doi.org/10.1016/j.asjsur.2024.03.175\nCheon JH, Kim HE, Park SH, Yoon ES (2022) Ten-year experience of robotic latissimus muscle flap reconstructive surgery at a single institution. J Plast Reconstr Aesthet Surg 75(10):3664–3672. https://doi.org/10.1016/j.bjps.2022.06.009\nKanno K, Yanai S, Masuda S, Ochi Y, Sawada M, Sakate S, Andou M (2024) Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis. Arch Gynecol Obstet 310(3):1677–1685. https://doi.org/10.1007/s00404-024-07674-0\nZhao D, Li B, Wang Y, Liu S, Zhang Y, Yuan G (2020) Clinical outcomes in early cervical cancer patients treated with nerve plane-sparing laparoscopic radical hysterectomy. J Minim Invasive Gynecol 27(3):687–696. https://doi.org/10.1016/j.jmig.2019.04.025\nLi K, He X, Tong S, Zheng Y (2021) Nerve plane: an optimal surgical plane for laparoscopic rectal cancer surgery? Med Hypotheses 154:110657. https://doi.org/10.1016/j.mehy.2021.110657\nAleksandrov A, Smith AV, Botchorishvili R, Rabischong B (2022) How to dissect the pelvic nerves: from microanatomy to surgical rules. An evidence-based clinical review. Facts Views Vis ObGyn 14(1):17–29. https://doi.org/10.52054/FVVO.14.1.011\nHiguchi N, Kanno K, Onji H, Masuda S, Taniguchi R, Ochi Y, Kurose Y, Sawada M, Yanai S, Hoshiba T, Andou M (2025) Comparing approaches to benign hysterectomy using conventional multi-port and newer single-port robots: a propensity score matching analysis of surgical outcomes and literature review. J Robot Surg 19(1):320. https://doi.org/10.1007/s11701-025-02448-5\nSeon KE, Lee YJ, Lee JY, Nam EJ, Kim S, Kim YT, Kim SW (2023) Comparing surgical outcomes of da VINCI SP and da VINCI Xi for endometrial cancer surgical staging in a propensity score-matched study. Sci Rep 13(1):11752. https://doi.org/10.1038/s41598-023-37659-z\nVizza E, Giannini A, Bruno V, Baiocco E, Mancini E, Vizza R, Uccella S, Raspagliesi F, Bogani G (2025) Robotic-assisted single-port and multi-port surgical staging in early-stage endometrial cancer: a propensity matched comparison. Eur J Surg Oncol 51(9):110269. https://doi.org/10.1016/j.ejso.2025.110269\nKanno K, Andou M, Sawada M, Yanai S (2025) Segmental Bowel Resection for Rectal Endometriosis Using the da Vinci SP. J Minim Invasive Gynecol 32(1):14. https://doi.org/10.1016/j.jmig.2024.08.005\nKanno K, Andou M, Sawada M, Hoshiba T (2025) Ureteroneocystostomy for Ureteral Endometriosis Using the da Vinci SP. J Minim Invasive Gynecol 32(10):859–860. https://doi.org/10.1016/j.jmig.2025.03.024\nHsiao SM, Lin HH, Kuo HC (2013) International Prostate Symptom Score for assessing lower urinary tract dysfunction in women. Int Urogynecol J 24(2):263–267. https://doi.org/10.1007/s00192-012-1818-8\nImboden S, Bollinger Y, Härmä K, Knabben L, Fluri M, Nirgianakis K, Mohr S, Kuhn A, Mueller MD (2021) Predictive factors for voiding dysfunction after surgery for deep infiltrating endometriosis. J Minim Invasive Gynecol 28(8):1544–1551. https://doi.org/10.1016/j.jmig.2021.01.009\nBenoit L, Dabi Y, Bazot M, Thomassin-Naggara I, Ferrier C, Puchar A, Owen C, Touboul C, Darai E, Bendifallah S (2022) Parametrial endometriosis: A predictive and prognostic factor for voiding dysfunction and complications. Eur J Obstet Gynecol Reprod Biol 276:236–243. https://doi.org/10.1016/j.ejogrb.2022.07.035\nSong T, Cho J, Kim TJ, Kim IR, Hahm TS, Kim BG, Bae DS (2013) Cosmetic outcomes of laparoendoscopic single-site hysterectomy compared with multi-port surgery: randomized controlled trial. J Minim Invasive Gynecol 20(4):460–467. https://doi.org/10.1016/j.jmig.2013.01.010\nAcknowledgements\nWe would like to thank Editage (www.editage.jp) for English language editing.\nFunding\nThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\nAuthor information\nAuthors and Affiliations\nContributions\nAll authors contributed to the study conception, study design, and data collection. The study design, project management, data collection, data analysis, and manuscript drafting and editing were carried out by Kiyoshi Kanno. All authors reviewed and provided comments on previous versions of the manuscript. All authors have read and approved the final version of the manuscript.\nCorresponding author\nEthics declarations\nCompeting interests\nThe authors declare no competing interests.\nEthics approval\nThis study was approved by the Institutional Review Board of the Kurashiki Medical Center (No. 861).\nConsent to Participate and Publish\nWritten informed consent was obtained from all the participants included in this study.\nAdditional information\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nSupplementary Information\nBelow is the link to the electronic supplementary material.\nSupplementary Material 1\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nKanno, K., Kashiwabara, T., Iwata, T. et al. Comparative analysis of nerve-sparing modified radical hysterectomy for deep endometriosis using the da Vinci SP versus Xi systems. J Robotic Surg 20, 354 (2026). https://doi.org/10.1007/s11701-026-03274-z\nReceived:\nAccepted:\nPublished:\nVersion of record:\nDOI: https://doi.org/10.1007/s11701-026-03274-z","source_license":"public-domain-us","license_restricted":false}