{"paper_id":"f0d17818-968e-4222-9b59-13711060ef3f","body_text":"Review began\n 09/23/2026 \nReview ended\n 10/05/2026 \nPublished\n 10/07/2026\n© Copyright \n2026\nShaikh et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.117578\nRobotic Versus Laparoscopic Surgery for\nColorectal Endometriosis: A Systematic Review\nand Meta-Analysis of Comparative Observational\nCohorts\nZoya Shaikh \n, \nMohammed Razeen Shaikh \n1.\n Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, GBR \n2.\n General Surgery, Milton\nKeynes University Hospital, Milton Keynes, GBR\nCorresponding author: \nZoya Shaikh, \nmedicarehub247@gmail.com\nAbstract\nThis review compares perioperative and selected postoperative outcomes between robotic-assisted surgery\nand conventional laparoscopy in females undergoing surgical treatment for colorectal or rectosigmoid\nendometriosis. This systematic review and meta-analysis followed the PRISMA 2020 guidelines. PubMed,\nWeb of Science, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and\nAfrican Journals Online (AJOL) were searched from January 2020 to August 2026 for comparative\nobservational studies evaluating robotic-assisted versus conventional laparoscopic surgery specifically for\ncolorectal or rectosigmoid endometriosis. Manual bibliographic searches of the reference lists of relevant\narticles were also conducted to identify additional eligible studies. Studies involving general, superficial,\novarian, or deep endometriosis without separately identifiable colorectal disease were excluded. Study\nselection, data extraction, and risk-of-bias assessment were performed independently by two reviewers,\nwith disagreements resolved by discussion. Risk of bias was assessed using the Newcastle-Ottawa Scale\n(NOS), and random-effects meta-analysis was undertaken only for outcomes with sufficiently comparable\nand non-duplicated data. Eight comparative observational reports met the eligibility criteria. Across studies\nreporting operative duration, robotic-assisted surgery was generally associated with longer operative time\nthan conventional laparoscopy, although the magnitude and statistical significance of this difference varied\nbetween cohorts. Estimated blood loss, overall postoperative complications, conversion to open surgery, and\nmost other perioperative outcomes were broadly comparable between approaches. Length of hospital stay\nshowed inconsistent findings across studies, while selected reports suggested possible differences in voiding\ndysfunction, reoperation, recurrence, postoperative opioid use, and other longer-term outcomes.\nConsiderable clinical and methodological heterogeneity was present because of differences in colorectal\nlesion complexity, extent of bowel surgery, associated pelvic procedures, institutional experience, follow-up\nduration, and outcome definitions. Potential overlap between several reports from the same specialist centre\nwas addressed at the outcome level to avoid duplicate contribution of participants to pooled estimates.\nOverall, robotic-assisted surgery appears to be a feasible alternative to conventional laparoscopy for\ncolorectal endometriosis, but current evidence does not demonstrate a consistent perioperative superiority\nof either approach. Because all available evidence is observational and susceptible to selection bias, residual\nconfounding, temporal effects, and cohort overlap, causal conclusions cannot be drawn. Further prospective,\nmulticentre, independently recruited comparative studies with standardized perioperative and long-term\noutcome reporting are required.\nCategories:\n General Surgery, Oncology, Gastroenterology\nKeywords:\n endometriosis surgery, general and colorectal surgeon, laparoscopic colon resection, robotic, robotic\nsurgical procedures\nIntroduction And Background\nRobotic surgery has emerged as an increasingly used minimally invasive approach for complex\nendometriosis surgery, particularly when disease involves anatomically restricted areas of the pelvis.\nEndometriosis affects approximately 10% of women of reproductive age and is an important cause of\nchronic pelvic pain, infertility, and impaired quality of life \n[1]\n. The disease is characterized by endometrial-\nlike glands and stroma outside the uterine cavity, accompanied by inflammatory, fibrotic, neuroangiogenic,\nand hormonal processes that contribute to progressive tissue distortion and organ involvement \n[2]\n. Among\nits most technically challenging forms is colorectal endometriosis, in which deep lesions involve the rectum,\nrectosigmoid junction, sigmoid colon, or adjacent bowel and may require advanced pelvic dissection or\nbowel resection.\nColorectal involvement is an important form of deep endometriosis because surgery must balance adequate\ndisease excision against preservation of bowel, urinary, neurological, reproductive, and sexual function.\nDepending on lesion size, depth of bowel-wall infiltration, circumference involved, multifocality, and\ndistance from the anal verge, surgical treatment may consist of rectal shaving, discoid excision, or\n1\n2\n \nOpen Access Review Article\nHow to cite this article\nShaikh Z, Shaikh M (October 07, 2026) Robotic Versus Laparoscopic Surgery for Colorectal Endometriosis: A Systematic Review and Meta-\nAnalysis of Comparative Observational Cohorts. Cureus 18(10): e117578. \nDOI 10.7759/cureus.117578\n\nsegmental colorectal resection. These procedures carry recognized risks, including anastomotic leakage,\nrectovaginal fistula, pelvic abscess, haemorrhage, bowel stenosis, urinary dysfunction, and the possible need\nfor temporary or permanent stoma formation \n[3]\n. For this reason, colorectal endometriosis surgery is\ncommonly performed in specialist referral centres with experience in advanced minimally invasive and\nmultidisciplinary pelvic surgery.\nConventional laparoscopy has long represented the principal minimally invasive approach for colorectal\nendometriosis. Robotic-assisted surgery has subsequently been introduced as an alternative, offering\npotential technical advantages such as three-dimensional magnified visualization, articulated wristed\ninstruments, tremor filtration, improved surgeon ergonomics, and greater instrument dexterity within the\nconfined deep pelvis. Whether these technical advantages translate into clinically meaningful benefits,\nhowever, remains uncertain. A systematic review and meta-analysis comparing robotic and conventional\nlaparoscopic endometriosis surgery found no significant differences in blood loss, hospital stay, or\ncomplication rates, although robotic procedures tended to require longer operative time \n[4]\n. A later\nsystematic review similarly found no demonstrable overall clinical advantage of robotic-assisted\nlaparoscopy over conventional laparoscopy in endometriosis surgery \n[5]\n.\nThe applicability of these broader findings to colorectal disease is uncertain because many earlier reviews\ncombined superficial, ovarian, urinary, deep pelvic, and bowel endometriosis despite substantial differences\nin operative complexity \n[5]\n. A colorectal-specific systematic review and meta-analysis subsequently\nreported longer operative duration with robotic-assisted surgery but no significant differences in estimated\nblood loss, hospital stay, conversion to laparotomy, or overall postoperative complications compared with\nconventional laparoscopy \n[6]\n. Similarly, reviews addressing deep endometriosis more broadly, including\nbowel disease, reported that robotic surgery was a safe and feasible alternative with longer operative times,\nwhile hospital-stay findings differed between reviews \n[7,8]\n. These findings indicate that the comparative\nvalue of the two platforms remains uncertain, particularly when differences in bowel procedure, lesion\nseverity, surgeon experience, and institutional practice are considered \n[9,10]\n.\nThis systematic review and meta-analysis was therefore undertaken to update and synthesize comparative\nobservational evidence involving women undergoing robotic-assisted versus conventional laparoscopic\nsurgery specifically for colorectal or rectosigmoid endometriosis. Eight eligible comparative observational\nreports \n[11-18]\n were identified across the updated review period. Unlike broader reviews incorporating\nheterogeneous forms of endometriosis, the present review was restricted to studies in which colorectal\ninvolvement constituted the defined surgical population and both robotic-assisted and conventional\nlaparoscopic groups were directly compared. Particular attention was given to potential overlap among\npublications originating from the same specialist centre and to differences in colorectal lesion complexity\nand procedure type.\nAlthough a colorectal-specific meta-analysis was published in 2025 \n[6]\n, important evidence has continued to\nemerge, including newer comparative observational studies. The present review was therefore undertaken to\nprovide an updated synthesis of the available comparative evidence, with particular attention to\nperioperative outcomes and the clinical outcomes reported across contemporary studies. We restricted the\nsearch to publications from 2020 onward to focus on contemporary surgical practice and the recent\nexpansion of comparative evidence on robotic-assisted surgery for colorectal endometriosis. This period also\ncaptures the studies published after earlier systematic reviews and reflects the more recent adoption and\nevaluation of robotic techniques.\nEligibility was restricted to direct robotic-versus-laparoscopic comparisons involving colorectal or\nrectosigmoid endometriosis. Studies without separately identifiable bowel involvement were excluded to\nmaintain a strictly colorectal evidence base.\nReview\nMethodology\nEight comparative observational reports were included in this systematic review and meta-analysis \n[11-18]\n.\nAll directly compared robotic-assisted surgery with conventional laparoscopy in women undergoing surgical\ntreatment for colorectal or rectosigmoid endometriosis. Studies of general, superficial, ovarian, urinary, or\ndeep endometriosis were excluded unless a clearly identifiable colorectal population was reported\nseparately. Not every report contributed to every pooled outcome because outcome definitions, statistical\nreporting, follow-up duration, and availability of extractable data differed between studies. Potential\noverlap among reports from the same specialist centre was specifically considered before quantitative\npooling.\nSearch Strategy\nA systematic literature search was performed in PubMed, Web of Science, Embase, Scopus, Cumulative\nIndex to Nursing and Allied Health Literature (CINAHL), and African Journals Online (AJOL). Reference lists\nof relevant systematic reviews and eligible primary studies were also checked manually to identify additional\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n2\n of \n16\n\ncomparative reports. The search covered publications from January 2020 to August 2026, with the final\nsearch update performed on 31st August 2026. Searches were limited to human studies published in English.\nSearch syntax was adapted to each database, and its own subject headings were used where available.\nThe PubMed search was: (\"colorectal endometriosis\"[tiab] OR \"rectosigmoid endometriosis\"[tiab] OR \"rectal\nendometriosis\"[tiab] OR \"bowel endometriosis\"[tiab] OR \"deep infiltrating endometriosis\"[tiab] OR\n(Endometriosis[MeSH] AND (colorectal[tiab] OR rectal[tiab] OR rectosigmoid[tiab] OR bowel[tiab]))) AND\n(\"robotic surgery\"[tiab] OR \"robot-assisted\"[tiab] OR \"robotic-assisted\"[tiab] OR \"Robotic Surgical\nProcedures\"[MeSH]) AND (laparoscop*[tiab] OR Laparoscopy[MeSH]), with filters applied for 2020/01/01 to\n2026/08/31, humans, and English.\nThe Scopus search was: TITLE-ABS-KEY((\"colorectal endometriosis\" OR \"rectosigmoid endometriosis\" OR\n\"rectal endometriosis\" OR \"bowel endometriosis\" OR \"deep infiltrating endometriosis\") AND (\"robotic\nsurgery\" OR \"robot-assisted\" OR \"robotic-assisted\") AND laparoscop*) AND PUBYEAR > 2019 AND PUBYEAR\n< 2027 AND LANGUAGE(English).\nThe Web of Science search was: TS=((\"colorectal endometriosis\" OR \"rectosigmoid endometriosis\" OR \"rectal\nendometriosis\" OR \"bowel endometriosis\" OR \"deep infiltrating endometriosis\") AND (\"robotic surgery\" OR\n\"robot-assisted\" OR \"robotic-assisted\") AND laparoscop*), limited to 2020-2026 and English.\nThe Embase search was: ('endometriosis'/exp OR 'colorectal endometriosis' OR 'rectosigmoid endometriosis'\nOR 'bowel endometriosis') AND ('robotic surgery'/exp OR 'robot-assisted' OR 'robotic-assisted') AND\n('laparoscopy'/exp OR laparoscop*), limited to 2020-2026, humans, and English.\nThe CINAHL search was: (MH \"Endometriosis\" OR \"colorectal endometriosis\" OR \"rectosigmoid\nendometriosis\" OR \"bowel endometriosis\") AND (MH \"Robotic Surgery\" OR \"robot-assisted\" OR \"robotic-\nassisted\") AND (MH \"Laparoscopy\" OR laparoscop*), limited to 2020-2026 and English.\nAJOL does not support Boolean searching, so it was searched separately using the phrases \"colorectal\nendometriosis robotic,\" \"rectal endometriosis laparoscopy,\" and \"bowel endometriosis robotic surgery,\" and\nthe results were screened manually.\nFinally, the reference lists of the included studies and of relevant systematic reviews were hand-searched to\nidentify anything missed by database searches.\nStudy Selection\nStudies were eligible if they included women undergoing surgery for confirmed colorectal, rectal, or\nrectosigmoid endometriosis and directly compared robotic-assisted surgery with conventional laparoscopic\nsurgery within the same study. Eligible designs included prospective cohort studies, retrospective\ncomparative cohorts, retrospective analyses of prospectively collected data, and propensity-matched\nobservational studies. Studies had to report at least one relevant perioperative, postoperative, or longer-\nterm clinical outcome.\nStudies were excluded if they evaluated general endometriosis without separately extractable colorectal\ndata, involved only superficial or ovarian disease, or focused mainly on non-bowel deep endometriosis.\nSingle-arm robotic studies, single-arm laparoscopic series, case reports, conference abstracts, editorials,\nletters, reviews, previous meta-analyses, and studies without a clearly identifiable conventional\nlaparoscopic comparator were excluded.\nTitles and abstracts were screened independently by two reviewers against the eligibility criteria. The full\ntexts of potentially eligible articles were then retrieved and assessed independently by the same two\nreviewers. Disagreements at either stage were resolved by discussion. Eight comparative observational\nreports ultimately met the inclusion criteria \n[11-18]\n. Table \n1\n summarizes the PICOST (Population,\nIntervention, Comparator, Outcomes, Study design, and Time) eligibility framework \n[19]\n used for study\nselection.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n3\n of \n16\n\nPICOST component\nEligibility criteria applied in this review\nPopulation (P)\nWomen undergoing surgical treatment for confirmed colorectal, rectal, or rectosigmoid endometriosis. Studies of\ngeneral, superficial, ovarian, urinary, or deep endometriosis were eligible only when the colorectal population was\nclearly identifiable and separately reported.\nIntervention/Exposure\n(I)\nRobotic-assisted laparoscopic surgery (RAS) for colorectal or rectosigmoid endometriosis, including rectal\nshaving, discoid excision, segmental colorectal resection, colectomy, or other clearly defined minimally invasive\ncolorectal procedures.\nComparator (C)\nConventional laparoscopic surgery (LPS) performed for the same colorectal or rectosigmoid endometriosis\nindication within the same comparative study.\nOutcomes (O)\nPrimary outcomes: operative time, estimated blood loss, length of hospital stay, and overall postoperative\ncomplications. Secondary outcomes: intraoperative complications, major complications, conversion to open\nsurgery, anastomotic leakage or fistula, reoperation or surgical revision, readmission or rehospitalization, voiding\ndysfunction, postoperative pain, analgesic or opioid use, recurrence, pregnancy/fertility-related outcomes, and\nother relevant postoperative or long-term clinical outcomes.\nStudy design (S)\nComparative observational studies, including prospective cohorts, retrospective cohorts, retrospective analyses of\nprospectively collected data, and propensity-matched comparative observational studies. Single-arm case series,\ncase reports, conference abstracts, reviews, meta-analyses, editorials, letters, and studies without a conventional\nlaparoscopic comparison group were excluded.\nTime (T)\nStudies published from January 2020 to August 2026 were eligible. The final eight included comparative\nobservational reports were published between 2020 and 2026 \n[11-18]\n.\nTABLE\n 1: PICOST criteria used for eligibility and study selection in the systematic review and\nmeta-analysis.\nPICOST: Population, Intervention, Comparator, Outcomes, Study design, and Time; RAS: robotic-assisted surgery; LPS: conventional laparoscopic\nsurgery.\nData Extraction and Critical Appraisal\nData were extracted from the full-text versions of the eight included reports \n[11-18]\n using a structured data-\nextraction form. Information collected included author and publication year, country, study centre or\ndatabase, study design, recruitment period, number of patients in each surgical group, baseline\ncharacteristics, colorectal lesion characteristics, type of bowel procedure, associated pelvic procedures,\nfollow-up duration, and reported outcomes.\nData extraction was performed independently by two reviewers using a pre-piloted form. The extracted data\nwere then compared, and discrepancies were resolved by discussion. Where key data were unclear or\nmissing, the original publication was rechecked.\nThe principal numerical outcomes extracted were operative time, estimated blood loss, length of hospital\nstay, and postoperative complications. Secondary outcomes included intraoperative complications, major\npostoperative complications, conversion to open surgery, reoperation or surgical revision, readmission or\nrehospitalization, anastomotic leakage or fistula, voiding dysfunction, postoperative pain, analgesic or\nopioid consumption, recurrence, pregnancy-related outcomes, and other longer-term clinical endpoints\nwhere reported.\nManagement of Potentially Overlapping Cohorts\nSpecial attention was given to possible overlap between reports originating from the same specialist centre.\nLe Gac et al. \n[11]\n, Ferrier et al. \n[13]\n, Crestani et al. \n[14]\n, and Crestani et al. \n[16]\n originated from the Tenon\nHospital research stream and had partly overlapping recruitment periods. These publications were retained\nbecause they addressed different clinical questions and reported different outcomes, but they were not\nautomatically treated as independent datasets in the same meta-analysis.\nFor each outcome, the most appropriate report was selected when substantial overlap was suspected.\nPreference was given to the larger, later, or more complete dataset for that specific endpoint. An overlapping\npublication could still contribute to a different outcome if it provided unique data not reported elsewhere.\nThis approach reduced the risk of double-counting patients and artificially narrowing confidence intervals.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n4\n of \n16\n\nOutcome Variables\nFour outcomes were defined as primary: operative time, estimated blood loss, length of hospital stay, and\noverall postoperative complications. Operative time was recorded in minutes using the closest measure of\nactual surgical duration reported by each study. When both total operating-room occupancy time and\nsurgical time were available, surgical time was preferred. Estimated blood loss was recorded in millilitres,\nand hospital stay in days.\nOverall postoperative complications were treated as a dichotomous outcome. Major complications were\nrecorded separately when the original study used a recognized severity system such as Clavien-Dindo grade\nIII or higher.\nSecondary outcomes included intraoperative complications, conversion to laparotomy, anastomotic leakage\nor fistula, reoperation or revision, readmission or rehospitalization, voiding dysfunction, pain, analgesic or\nopioid use, recurrence, pregnancy-related outcomes, and other longer-term clinical outcomes reported by\nthe included studies.\nRisk of Bias Assessment\nAs all included studies were observational, methodological quality was assessed using the Newcastle-Ottawa\nScale (NOS) for cohort studies \n[20]\n. The NOS evaluates three domains: selection of participants,\ncomparability of treatment groups, and assessment of outcomes, with a maximum score of nine stars.\nEach study was scored independently by two reviewers. Scores were compared, and disagreements were\nresolved by consensus or by consultation with a third reviewer.\nParticular attention was given to non-random treatment allocation, disease complexity, lesion size and\nlocation, associated pelvic procedures, surgeon preference, institutional experience, calendar period, and\nextent of bowel resection. These factors were important because they could influence both the choice of\nsurgical platform and the outcomes independently of the platform itself. Propensity matching or\nmultivariable adjustment, when reported, was considered during the comparability assessment.\nData Synthesis and Statistical Analysis\nQuantitative pooling was undertaken only when populations, outcome definitions, and statistical data were\nsufficiently comparable and when duplicate contribution from overlapping cohorts could reasonably be\navoided. Continuous outcomes reported on the same scale were summarized using mean differences with\n95% confidence intervals. Dichotomous outcomes were summarized using odds ratios or other appropriate\ncomparative measures with 95% confidence intervals where sufficiently consistent data were available.\nA random-effects model was used because the studies differed in disease severity, type of bowel surgery,\nsurgeon experience, and follow-up. Mean differences (robotic minus laparoscopic) were calculated from the\nreported means, standard deviations, and group sizes. Studies were weighted by inverse variance. All\nanalyses were performed using RevMan version 5.4 (Cochrane Collaboration, London, UK). Heterogeneity\nwas assessed using the Q test and I² statistic, and I² above 50% was considered substantial. Studies reporting\nmedians and interquartile ranges were not pooled and were summarized narratively.\nA two-sided P-value below 0.05 was considered statistically significant. Non-significant findings were\ninterpreted as absence of evidence for a statistically detectable difference and not as proof of equivalence.\nWhen pooling was inappropriate because too few independent datasets were available, outcome definitions\ndiffered substantially, data were reported in incompatible statistical formats, or overlapping cohorts could\nnot be separated safely, findings were summarized narratively. Funnel plots, Egger’s regression, and meta-\nregression were not considered reliable because fewer than 10 independent studies contributed to individual\npooled outcomes.\nEthical Considerations\nThis systematic review used only previously published, anonymized, group-level data and involved no direct\npatient contact or access to individual medical records. Formal institutional ethical approval and individual\ninformed consent were therefore not required. The review was conducted and reported according to the\nPRISMA 2020 recommendations \n[21]\n.\nResults\nThe included evidence comprised eight comparative observational reports \n[11-18]\n evaluating robotic-\nassisted surgery versus conventional laparoscopy in women undergoing surgical treatment specifically for\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n5\n of \n16\n\ncolorectal, rectal, or rectosigmoid endometriosis. All available evidence was non-randomized; therefore,\nobserved differences were interpreted as associations rather than causal treatment effects.\nFigure \n1\n shows the PRISMA-based study selection process. A total of 574 records were identified through\ndatabase searching. About 187 full-text articles were assessed for eligibility, with 179 excluded for\npredefined reasons, including non-colorectal populations, absence of a direct robotic-versus-laparoscopic\ncomparison, or ineligible study design. Ultimately, eight observational studies met the eligibility criteria and\nwere included in the systematic review.\nFIGURE\n 1: PRISMA 2020 flow diagram of the study selection process.\nSystematic review\nOperative Time\nLonger operative duration with robotic surgery was observed in several earlier studies. Le Gac et al. \n[11]\nreported 221 ± 94 versus 163 ± 83 minutes (P=0.03), Ferrier et al. \n[13]\n reported 208 ± 90 versus 169 ± 81\nminutes (P=0.01), and Crestani et al. \n[16]\n reported 216 ± 78 versus 190 ± 76 minutes (P=0.027). Raimondo et\nal. \n[12]\n also reported a numerically longer robotic operative time, although the difference was not\nstatistically significant (207 ± 79 vs. 177 ± 63 minutes; P=0.171).\nThe 2026 Krentel study \n[17]\n showed the same numerical direction but no statistically significant difference:\nmedian skin-to-skin operative time was 225 minutes (IQR, 150-292) with robotic surgery versus 201 minutes\n(IQR, 146-251) with conventional laparoscopy (P=0.188), despite greater anatomical complexity in the\nrobotic group. Because these data were reported as medians and interquartile ranges, they were not directly\ncombined with the mean-and-standard-deviation data used in the exploratory mean-difference analysis.\nBecause Le Gac et al. \n[11]\n, Ferrier et al. \n[13]\n, and Crestani et al. \n[16]\n potentially contained overlapping Tenon\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n6\n of \n16\n\nHospital patients, they were not pooled simultaneously. The later and more complete Crestani et al.'s\ndataset (2024) \n[16]\n was used to represent the Tenon stream, together with the independent Raimondo cohort\n[12]\n. Random-effects pooling of these two mean-based independent datasets produced a mean difference of\n27.03 minutes, indicating longer operative time with robotic surgery (95% CI, 5.61-48.45; P=0.013).\nHeterogeneity was I²=0% (Q=0.03; df=1; P=0.87). Because only two datasets contributed to this pooled\nestimate, both the summary effect and heterogeneity statistic were regarded as exploratory.\nEstimated Blood Loss\nLe Gac et al. \n[11]\n reported mean estimated blood loss of 130 ± 86 mL with robotic surgery and 108 ± 99 mL\nwith conventional laparoscopy. Raimondo et al. \n[12]\n reported 184 ± 214 versus 144 ± 101 mL, with no\nstatistically significant difference. Ferrier et al. \n[13]\n and Crestani et al. \n[16]\n also reported no meaningful\noverall differences.\nKrentel et al. \n[17]\n subsequently reported median blood loss of 100 mL in both groups (P=0.075), further\nsupporting the absence of a clear difference, although their median-based data were not combined directly\nwith the mean-based studies.\nUsing the two independent datasets with directly usable mean and standard-deviation data \n[11,12]\n,\nexploratory random-effects pooling produced a mean difference of 25.94 mL (95% CI, −20.33 to 72.21;\nP=0.27). Heterogeneity was I²=0% (Q=0.10; df=1). The confidence interval crossed the null value and\ntherefore provided no evidence of a statistically detectable difference in estimated blood loss.\nLength of Hospital Stay\nHospital stay showed inconsistent findings. Le Gac et al. \n[11]\n reported a numerically longer stay after robotic\nsurgery (8.0 ± 4.4 vs. 6.5 ± 2.6 days; P=0.18), while Raimondo et al. \n[12]\n similarly reported 8 ± 7 versus 6 ± 2\ndays (P=0.291). In contrast, Crestani et al. \n[16]\n found shorter mean hospital stay following robotic surgery (7\n± 4 vs. 8 ± 5 days; P=0.03).\nKrentel et al. \n[17]\n also reported significantly shorter hospitalization after robotic surgery, with a median stay\nof five days (IQR, 4-6) versus six days (IQR, 4-7) (P=0.008). Because the study reported medians and\ninterquartile ranges, it was retained in the narrative synthesis rather than combined directly with the mean-\nbased pooled estimate.\nUsing the independent Raimondo \n[12]\n and Crestani (2024) \n[16]\n datasets, the exploratory random-effects\npooled mean difference was 0.20 days (95% CI, −2.68 to 3.07; P=0.89). Heterogeneity was substantial\n(I²=66.8%; Q=3.01; df=1; P=0.083), reflecting opposite directions of effect. Because only two studies\ncontributed, the heterogeneity estimate was interpreted cautiously. Overall, no consistent hospital-stay\nadvantage could be established.\nOverall Postoperative Complications\nOverall complication rates were broadly similar between approaches. Le Gac et al. \n[11]\n, Ferrier et al. \n[13]\n, and\nCrestani et al. \n[16]\n found no significant overall differences. Raimondo et al. \n[12]\n reported postoperative\ncomplications in 18% of robotic patients and 5% of laparoscopic patients (P=0.345).\nKrentel et al. \n[17]\n similarly reported overall complications in 10.2% of robotic patients and 12.9% of\nconventional laparoscopic patients (P=0.80), despite greater disease complexity in the robotic group.\nA pooled overall complication estimate was not calculated because definitions differed, several Tenon\nreports potentially overlapped, and sufficiently homogeneous independent event data were not consistently\navailable. Results were therefore synthesized narratively.\nIntraoperative Complications\nIntraoperative complications were uncommon. Le Gac et al. \n[11]\n found no statistically significant difference\nbetween groups. Ferrier et al. \n[13]\n reported fewer intraoperative complications in the robotic group among\nwomen undergoing discoid excision or segmental resection (2% vs. 14%; P=0.04). Crestani et al. \n[16]\nsubsequently reported similar overall intraoperative complication rates.\nKrentel et al. \n[17]\n likewise found no clear overall safety disadvantage with robotic surgery despite more\ncomplex disease. Because procedure definitions and populations differed, no quantitative synthesis was\nundertaken.\nMajor Complications\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n7\n of \n16\n\nMajor postoperative complications were uncommon, and no consistent platform-related difference was\nestablished. Le Gac et al. \n[11]\n reported grade III complications in 13% of robotic patients compared with\nnone of the conventional laparoscopic patients (P=0.17). Crestani et al. \n[16]\n found broadly similar Clavien-\nDindo complication profiles.\nKrentel et al. \n[17]\n reported severe complications classified as Clavien-Dindo grade ≥IIIa in 1.7% of robotic\npatients and 6.9% of laparoscopic patients; the difference was not statistically significant (P=0.26). No grade\nIV or V complications occurred.\nConversion to Open Surgery\nConversion to laparotomy was rare. Raimondo et al. \n[12]\n reported one robotic conversion following an\ninternal iliac vein injury and none after conventional laparoscopy. Krentel et al. \n[17]\n similarly reported one\nrobotic conversion (1.7%) and none among 101 laparoscopic procedures (P=0.37).\nElhadi et al. \n[18]\n excluded patients converted to open surgery and therefore did not provide an unbiased\ncomparison of conversion risk. Because events remained very uncommon and reporting differed between\nstudies, conversion was not quantitatively pooled.\nReoperation/Surgical Revision\nFerrier et al. \n[13]\n found no significant difference in surgical revision between approaches. Krentel et al. \n[17]\nreported reoperation in 1.7% of robotic patients compared with 6.9% of laparoscopic patients, although the\ndifference was not statistically significant (P=0.26).\nOther reports used differing definitions of reintervention and serious complications. Therefore, no pooled\nestimate was calculated, and the available evidence did not establish a consistent difference in reoperation\nrisk.\nReadmission/Rehospitalization\nFerrier et al. \n[13]\n reported no significant difference in rehospitalization. Krentel et al. \n[17]\n similarly found\ncomparable early readmission rates (6.8% vs. 5.9%; P=1.00).\nElhadi et al. \n[18]\n provided longer-term database-based information and reported fewer emergency\nreadmissions in the robotic cohort at five years (26.7% vs. 35.1%). Because the study evaluated a different\ntime horizon and outcome definition, these data were not combined with early postoperative readmission\noutcomes.\nAnastomotic Leakage or Fistula\nVolodarsky-Perel et al. \n[15]\n found that robotic versus laparoscopic surgery was not independently associated\nwith anastomotic leakage or fistula after multivariable adjustment (adjusted odds ratio (aOR), 1.2; 95% CI,\n0.3-4.0).\nKrentel et al. \n[17]\n reported no anastomotic or suture leakage among 59 robotic procedures and two events\namong 101 laparoscopic procedures (0% vs. 2.0%; P=0.55). Both leakage cases required temporary stoma\nformation. Event numbers and procedural definitions were insufficient for reliable quantitative pooling.\nVoiding Dysfunction\nVoiding dysfunction showed variable results. Le Gac et al. \n[11]\n and Ferrier et al. \n[13]\n reported no significant\noverall differences. Volodarsky-Perel et al. \n[15]\n found no independent association between surgical platform\nand bladder dysfunction after multivariable adjustment (aOR, 0.5; 95% CI, 0.1-1.8). Crestani et al. \n[16]\n,\nhowever, reported significantly less persistent voiding dysfunction following robotic surgery (5% vs. 25%;\nP=0.01).\nKrentel et al. \n[17]\n reported temporary voiding dysfunction in three patients following conventional\nlaparoscopic segmental rectal resection. Elhadi et al. \n[18]\n found no significant longer-term differences in\nurinary dysfunction or urinary incontinence between propensity-matched groups. Differences in definitions,\nduration of follow-up, and surgical subgroups precluded pooling.\nPostoperative Pain and Analgesic and Opioid Use\nCrestani et al. \n[14]\n reported greater total tramadol consumption after robotic surgery than conventional\nlaparoscopy (322 (222) vs. 242 (292) mg; P=0.04). However, major changes in analgesic prescribing across\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n8\n of \n16\n\ncalendar years substantially confounded this comparison.\nRaimondo et al. \n[12]\n reported improvement in pain and bowel symptoms after both approaches at 12\nmonths. Elhadi et al. \n[18]\n found lower recorded long-term opioid utilization after robotic colectomy at three\nyears (68.4% vs. 89.3%; RR, 0.77; 95% CI, 0.72-0.82), with a similar pattern at five years (68.0% vs. 90.3%).\nConversely, no significant differences were observed for pelvic or perineal pain, dysmenorrhea, or\ndyspareunia. Because these outcomes represented substantially different constructs and time periods, they\nwere summarized narratively.\nRecurrence and Pregnancy-Related Outcomes\nLong-term recurrence and pregnancy-related outcomes were principally reported by Elhadi et al. \n[18]\n. At\nthree years, recorded pregnancy achievement was higher after robotic colectomy (7.2% vs. 2.9%; RR, 2.50;\n95% CI, 1.36-4.59), whereas recorded recurrence was lower (4.3% vs. 20.1%; RR, 0.21; 95% CI, 0.14-0.34). At\nfive years, pregnancy achievement remained numerically higher (7.8% vs. 3.3%) and recurrence lower (4.7%\nvs. 18.5%) in the robotic cohort.\nThese findings were considered hypothesis-generating rather than evidence of causal benefit, because the\nstudy was retrospective, fertility intention was unavailable, and residual differences in follow-up and\nunmeasured clinical characteristics could remain despite propensity-score matching.\nOverall Synthesis\nAcross the eight comparative observational reports \n[11-18]\n, robotic-assisted colorectal endometriosis\nsurgery was generally associated with longer or numerically longer operative duration, although this\ndifference was not statistically significant in all cohorts. Estimated blood loss and overall perioperative\ncomplication rates were generally comparable between platforms. Hospital stay was inconsistent across the\nearlier evidence but was shorter after robotic surgery in two more recent reports \n[16,17]\n. Selected studies\nsuggested potentially favourable robotic associations for persistent voiding dysfunction \n[16]\n, procedure-\nspecific intraoperative complications \n[13]\n, and selected longer-term outcomes \n[18]\n, but these findings were\nnot consistently reproduced across independent populations.\nThe updated evidence base remains limited by observational treatment allocation, residual confounding,\ndifferences in colorectal procedure and anatomical complexity, varying statistical formats and follow-up\nperiods, and potential population overlap among several Tenon Hospital publications \n[11,13,14,16]\n.\nAccordingly, the findings support robotic surgery as a feasible alternative to conventional laparoscopy but\ndo not establish causal superiority of either platform.\nTable \n2\n summarizes the publication and methodological characteristics of the eight comparative\nobservational reports included in the review. It presents country, journal, study design, sample size,\nrecruitment period, and follow-up information. The evidence spans 2020-2026 and includes European\nsingle- and multicentre cohorts together with a large propensity-matched United States database analysis.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n9\n of \n16\n\nAuthor\nCountry\nJournal\nStudy design\nSample size\nRecruitment/Follow-up\nLe Gac et al.,\n2020 \n[11]\nFrance\nJ Gynecol\nObstet Hum\nReprod\nProspective comparative cohort\n48; RAS 23, LPS\n25\nMar-Sep 2019; short\npostoperative follow-up\nRaimondo et al.,\n2021 \n[12]\nItaly\nActa Obstet\nGynecol Scand\nMulticentre prospective\nobservational cohort\n44; RAS 22, LPS\n22\nSep 2018-Sep 2019; 12\nmonths\nFerrier et al.,\n2022 \n[13]\nFrance\nInt J Med Robot\nProspective comparative cohort\n122; RAS 61,\nLPS 61\n18-month recruitment period\nCrestani et al.,\n2023 \n[14]\nFrance\nJ Robot Surg\nRetrospective comparative cohort\n162; RAS 89,\nLPS 73\nFeb 2019-Dec 2021;\nhospitalization outcomes\nVolodarsky-Perel\net al., 2023 \n[15]\nFrance\nColorectal Dis\nRetrospective cohort using\nprospectively collected data\n548; RAS 97,\nLPS 451\nPostoperative complication\nfollow-up\nCrestani et al.,\n2024 \n[16]\nFrance\nJ Robot Surg\nRetrospective comparative cohort\n152; RAS 90,\nLPS 62\n2019-2023; postoperative\noutcomes\nKrentel et al.,\n2026 \n[17]\nGermany\nJ Robot Surg\nRetrospective single-centre\nsequential comparative cohort\n160; RAS 59,\nLPS 101\n2022-2025; perioperative\noutcomes\nElhadi et al.,\n2026 \n[18]\nUnited\nStates\nJ Robot Surg\nRetrospective multicentre\npropensity-score-matched database\ncohort\n974 matched;\nRAS 487, LPS\n487\nOct 2013-Oct 2025; outcomes\nassessed at 3 and 5 years\nTABLE\n 2: General methodological and publication characteristics of comparative observational\nstudies evaluating robotic-assisted versus conventional laparoscopic surgery for colorectal\nendometriosis.\nRAS: robotic-assisted surgery; LPS: conventional laparoscopic surgery.\nSample sizes represent the participants included in each published comparative analysis. For Elhadi et al. \n[18]\n, the numbers represent the final\npropensity-matched cohorts.\nTable \n3\n describes the colorectal disease populations and operative procedures represented across the eight\nreports. All studies specifically evaluated colorectal, rectal, rectosigmoid, or bowel deep endometriosis\nrather than mixed general endometriosis populations. Operative complexity ranged from shaving and\nmucosa-sparing excision to segmental resection and colectomy, contributing importantly to clinical\nheterogeneity.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n10\n of \n16\n\nAuthor\nDefined study population\nRobotic\ngroup\nLaparoscopic\ngroup\nColorectal\nprocedures/Characteristics\nImportant clinical feature\nLe Gac et\nal., 2020\n[11]\nColorectal endometriosis requiring\nsurgery\n23\n25\nRectal shaving, discoid\nexcision, segmental\nresection\nBaseline characteristics generally\nsimilar; trend toward more associated\nurinary/digestive procedures with RAS\nRaimondo\net al., 2021\n[12]\nRectosigmoid endometriosis\n22\n22\nSurgical excision of\nrectosigmoid disease\nMore hysterectomies and bilateral\nuterosacral ligament excisions in RAS\ngroup; adjusted analysis performed\nFerrier et\nal., 2022\n[13]\nColorectal endometriosis\n61\n61\nShaving, discoid excision,\nsegmental resection\nEqual group sizes; specific analysis of\ndiscoid/segmental procedures\nCrestani et\nal., 2023\n[14]\nColorectal endometriosis\nundergoing surgery\n89\n73\nShaving, discoid resection,\nsegmental resection\nMain focus was postoperative analgesic\nconsumption\nVolodarsky-\nPerel et al.,\n2023 \n[15]\nRectal endometriotic nodule >3\ncm (ENZIAN C3)\n97\n451\nRectal shaving, disc\nexcision, colorectal resection\nLarge cohort restricted to large rectal\nnodules\nCrestani et\nal., 2024\n[16]\nColorectal endometriosis requiring\nbowel-wall excision/resection\n90\n62\nDiscoid excision or\nsegmental colorectal\nresection\nConsecutive cohort restricted to more\nextensive colorectal procedures\nKrentel et\nal., 2026\n[17]\nHistologically confirmed\nsymptomatic colorectal\nendometriosis\n59\n101\nComplete mucosa-sparing\nnodular resection or\nsegmental rectal resection\nwith anastomosis\nRAS group had significantly greater\nEnzian-defined anatomical complexity,\nincluding more advanced rectal and\nmulticompartmental disease\nElhadi et\nal., 2026\n[18]\nAdult women undergoing\nminimally invasive colectomy for\ncolorectal deep infiltrating\nendometriosis\n487\n487\nRobotic versus conventional\nlaparoscopic colectomy\nTriNetX network of 72 US healthcare\norganizations; 1:1 propensity matching;\nconversions to open surgery were\nexcluded\nTABLE\n 3: Disease characteristics and colorectal surgical procedures in the eight included\ncomparative observational reports.\nRAS: robotic-assisted surgery; LPS: conventional laparoscopic surgery; ENZIAN C3: colorectal endometriotic involvement classified within compartment C\nwith lesions >3 cm; CNR = complete mucosa-sparing nodular resection; SRR: segmental rectal resection.\nTable \n4\n presents the NOS \n[20]\n assessment for the eight comparative observational reports. The NOS\nevaluates cohort selection, comparability of treatment groups, and outcome ascertainment. Methodological\nquality varied because of non-randomized treatment allocation, residual confounding, temporal changes in\npractice, differences in disease complexity, and limitations inherent to retrospective database-based\nanalyses.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n11\n of \n16\n\nAuthor\nSelection/4\nComparability/2\nOutcome/3\nTotal/9\nQuality\ninterpretation\nMain methodological considerations\nLe Gac et\nal., 2020\n[11]\n4\n1\n2\n7\nHigher quality\nProspective comparative cohort; same-source\ncomparator; broadly similar baseline\ncharacteristics; limited adjustment and short\npostoperative follow-up\nRaimondo\net al., 2021\n[12]\n4\n2\n3\n9\nHigher quality\nMulticentre prospective design; clearly defined\nrectosigmoid population; adjusted analysis;\nstructured 12-month follow-up\nFerrier et\nal., 2022\n[13]\n4\n1\n2\n7\nHigher quality\nProspective design; equal group sizes; objective\noutcomes; limited formal adjustment for treatment-\nselection confounding\nCrestani et\nal., 2023\n[14]\n3\n1\n2\n6\nModerate\nquality\nRetrospective design; marked calendar-year\nchange in analgesic protocols; temporal\nconfounding despite regression analysis\nVolodarsky-\nPerel et al.,\n2023 \n[15]\n4\n2\n2\n8\nHigher quality\nLarge defined rectal cohort; prospectively\ncollected data; multivariable adjustment for major\ncomplication predictors\nCrestani et\nal., 2024\n[16]\n4\n1\n2\n7\nHigher quality\nConsecutive retrospective cohort; clearly defined\ncolorectal procedures; objective outcomes; limited\nadjustment for residual confounding\nKrentel et\nal., 2026\n[17]\n4\n0\n3\n7\nHigher\nquality*\nConsecutive single-centre cohort with objective\nperioperative outcomes, but sequential non-\nrandomized treatment allocation and substantially\ngreater anatomical complexity in the RAS group\nwithout formal risk-adjusted comparison\nElhadi et\nal., 2026\n[18]\n4\n2\n2\n8\nHigher\nquality*\nLarge multicentre database cohort with 1:1\npropensity matching and long-term outcomes;\nresidual unmeasured confounding, database\ncoding limitations, differential follow-up,\nunavailable fertility intention, and exclusion of\nconversions remain important limitations\nTABLE\n 4: Newcastle-Ottawa Scale assessment of methodological quality across the eight\nincluded comparative observational reports.\nNOS: Newcastle-Ottawa Scale.\nThe selection domain has a maximum of four stars, comparability a maximum of two stars, and outcome a maximum of three stars, giving a maximum\ntotal of nine. In this review, scores ≥7 were categorized as higher methodological quality and scores <7 as moderate/lower quality.\nFigure \n2\n presents overlap-aware quantitative comparisons of robotic-assisted surgery with conventional\nlaparoscopy for colorectal endometriosis. Robotic surgery demonstrated longer operative time in the mean-\nbased exploratory analysis, whereas estimated blood loss and hospital stay showed no statistically\nsignificant pooled differences. Krentel et al. \n[17]\n was synthesized narratively because key continuous\noutcomes were reported as medians and interquartile ranges, while Elhadi et al. \n[18]\n principally contributed\nlonger-term outcomes that were not directly comparable with the perioperative datasets. Complications,\nconversion, anastomotic events, voiding dysfunction, analgesic or opioid use, recurrence, and pregnancy-\nrelated outcomes were therefore primarily summarized narratively.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n12\n of \n16\n\nFIGURE\n 2: Forest plot of quantitative comparisons of robotic-assisted\nsurgery versus conventional laparoscopy for colorectal endometriosis.\nMean differences are robotic minus laparoscopic.\nRAS: robotic-assisted surgery; LPS: conventional laparoscopic surgery; MD: mean difference; CI: confidence\ninterval.\nRandom-effects model with inverse-variance weighting and the DerSimonian–Laird estimator.\nDiscussion\nComparison With Previous Literature\nThis systematic review and meta-analysis evaluated eight comparative observational reports \n[11-18]\nexamining robotic-assisted versus conventional laparoscopic surgery specifically for colorectal or\nrectosigmoid endometriosis. The updated evidence generally showed longer or numerically longer operative\nduration with robotic surgery, whereas estimated blood loss and overall perioperative complication rates\nwere broadly comparable between approaches. Hospital stay was inconsistent across earlier studies,\nalthough two more recent reports \n[16,17]\n found shorter hospitalization after robotic surgery. Selected\nstudies also suggested potentially favourable robotic associations for intraoperative complications,\npersistent voiding dysfunction, recurrence, pregnancy-related outcomes, and long-term opioid use;\nhowever, these findings were not consistently reproduced across independent datasets and should not be\ninterpreted as evidence of causal superiority.\nThe operative-time pattern remains broadly consistent with the earlier colorectal-specific meta-analysis,\nwhich reported a pooled weighted mean difference of 21.51 minutes longer with robotic surgery and no\nsignificant differences in blood loss, hospital stay, conversion, or overall complications \n[6]\n. The present\nreview extends that evidence through 2026 and incorporates two additional comparative reports \n[17,18]\n.\nKrentel et al. \n[17]\n found numerically longer robotic operative time despite greater Enzian-defined\nanatomical complexity in the robotic group, while Elhadi et al. \n[18]\n expanded the evidence toward longer-\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n13\n of \n16\n\nterm outcomes through propensity-matched US data.\nInterpretation of safety outcomes is complicated by the heterogeneity of bowel surgery itself. Rectal\nshaving, discoid excision, and segmental colorectal resection differ substantially in operative complexity\nand postoperative risk. A comparative series of 364 women with rectosigmoid endometriosis reported more\nsevere postoperative complications after segmental resection than after more conservative procedures \n[22]\n.\nA separate systematic analysis likewise found lower major-complication rates with conservative shaving or\ndiscoid excision than with segmental bowel resection, while emphasizing the limited quality and\nheterogeneity of the evidence \n[23]\n. These findings reinforce the importance of procedure type and disease\nseverity as potential confounders in robotic-versus-laparoscopic comparisons. The lower procedure-specific\nintraoperative complication rate reported by Ferrier et al. \n[13]\n is therefore clinically interesting but cannot\nalone establish a platform advantage.\nPostoperative urinary dysfunction illustrates this difficulty particularly well. Le Gac et al. \n[11]\n and Ferrier et\nal. \n[13]\n found no clear overall difference, Volodarsky-Perel et al. \n[15]\n found no independent association after\nmultivariable adjustment, and Crestani et al. \n[16]\n reported less persistent dysfunction with robotic surgery.\nThe 2026 evidence similarly did not establish a consistent platform effect. An updated systematic review of\ncolorectal deep endometriosis found substantially less postoperative voiding dysfunction following rectal\nshaving than segmental resection, suggesting that extent of bowel and autonomic-nerve dissection may be\nmore influential than surgical platform alone \n[24]\n.\nTaken together, the updated literature supports robotic surgery as a technically feasible alternative rather\nthan a clearly superior treatment. Potential benefits may be most relevant in complex deep-pelvic disease,\nbut the present observational evidence does not demonstrate a consistent reduction in blood loss, major\ncomplications, conversion, or other core perioperative outcomes.\nLimitations of the Study\nSeveral limitations remain. All eight reports were observational, so treatment allocation could have been\ninfluenced by surgeon preference, robotic availability, calendar period, lesion complexity, previous surgery,\nassociated procedures, and anticipated technical difficulty. Krentel et al. \n[17]\n, for example, included greater\nanatomical complexity in the robotic group, while propensity matching in Elhadi et al. \n[18]\n could address\nonly measured confounders. Residual confounding therefore remains unavoidable.\nThe quantitative analyses also contained very few independent datasets. Operative time and hospital stay\nwere pooled from two independent mean-based datasets, while the blood-loss analysis likewise included\nonly two studies. Estimates of heterogeneity are therefore imprecise, and non-significant results cannot be\ninterpreted as evidence of equivalence. In addition, Krentel et al. \n[17]\n reported several continuous outcomes\nas medians and interquartile ranges, and were therefore synthesized narratively rather than directly\ncombined with mean-based estimates.\nOutcome definitions varied considerably. Operative time, total operating-room time, complication severity,\nurinary dysfunction, pain, opioid exposure, recurrence, and fertility-related outcomes were not measured\nuniformly. Elhadi et al. \n[18]\n also assessed substantially longer-term outcomes than most earlier reports and\nexcluded conversions to open surgery, limiting direct comparability. Publication bias could not be reliably\nassessed because fewer than 10 independent studies contributed to any pooled outcome.\nClinical Implications and Future Research\nFor clinical practice, the current evidence does not justify selecting robotic surgery solely on the expectation\nof lower perioperative morbidity. Conventional laparoscopy remains an established minimally invasive\napproach, while robotic assistance may be particularly useful in selected anatomically complex cases. Choice\nof platform should therefore incorporate disease extent, planned bowel procedure, surgeon experience,\ninstitutional expertise, and available resources.\nEconomic considerations are also important. A detailed public-sector cost analysis demonstrated substantial\nimplementation, maintenance, consumable, and procedure-related expenditure associated with robotic\nprogrammes \n[25]\n. Where clinical outcomes are broadly comparable, these costs become particularly relevant\nin resource-limited health systems.\nFuture research should prioritize independent multicentre recruitment, transparent reporting of overlapping\npopulations, standardized operative definitions, and adjustment for lesion complexity and surgical\ntechnique. Broader robotic-surgery evidence has shown substantial variability in study quality, outcome\nreporting, and transparency, including repeated publications derived from common underlying populations\n[26]\n. Future studies should clearly identify prior publication of participants and stratify results by shaving,\ndiscoid excision, and segmental resection.\n \n2026 Shaikh et al. Cureus 18(10): e117578. DOI 10.7759/cureus.117578\n14\n of \n16\n\nPatient-centred outcomes should also be standardized. The international endometriosis core outcome set\nincludes pain, improvement in the most troublesome symptom, quality of life, adverse events, satisfaction,\nand reproductive outcomes. For colorectal surgery, long-term bowel function, urinary function, recurrence,\nanastomotic morbidity, reoperation, fertility, and quality of life should additionally be reported consistently\n[27]\n.\nConclusions\nThis updated systematic review of eight comparative observational reports suggests that robotic-assisted\ncolorectal endometriosis surgery is generally associated with longer or numerically longer operative\nduration, while estimated blood loss and overall perioperative safety are broadly comparable with\nconventional laparoscopy. Hospital stay and selected secondary outcomes showed inconsistent or study-\nspecific differences.\nAlthough newer studies extend the evidence toward more complex disease and longer-term outcomes, the\nliterature remains limited by non-randomized treatment allocation, residual confounding, heterogeneous\ncolorectal procedures, inconsistent outcome definitions, and overlap among several institutional reports.\nThe available evidence therefore does not establish superiority or equivalence of either platform. Robotic\nsurgery should presently be regarded as a feasible alternative, with selection individualized according to\ndisease complexity, planned bowel procedure, surgical expertise, and institutional resources. Larger\nindependent prospective multicentre studies with standardized outcomes are required.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nZoya Shaikh, Mohammed Razeen Shaikh\nAcquisition, analysis, or interpretation of data:\n  \nZoya Shaikh, Mohammed Razeen Shaikh\nDrafting of the manuscript:\n  \nZoya Shaikh, Mohammed Razeen Shaikh\nCritical review of the manuscript for important intellectual content:\n  \nZoya Shaikh, Mohammed Razeen\nShaikh\nDisclosures\nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors declare the\nfollowing: \nPayment/services info:\n All authors have declared that no financial support was received from\nany organization for the submitted work. \nFinancial relationships:\n All authors have declared that they have\nno financial relationships at present or within the previous three years with any organizations that might\nhave an interest in the submitted work. \nOther relationships:\n All authors have declared that there are no\nother relationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nZondervan KT, Becker CM, Missmer SA: \nEndometriosis\n. 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