Assessing the role of robotic surgery versus laparoscopic surgery in patients with a diagnosis of endometriosis: A meta-analysis

Ten% to 15% of reproductive-age women are affected by endometriosis. When endometriotic tissue penetrates deeper than the peritoneal surface, it is considered deep endometriosis (DE) [ 1 – 3 ] More than 90% of all occurrences of bowel endometriosis are due to colorectal endometriosis, a severe form of DE that is linked to chronic pelvic discomfort, reduced quality of life, and infertility. [ 4 – 6 ] When medicinal treatment for endometriosis fails or causes unwanted side effects, or when ART has been unsuccessful, colorectal surgery may be an option for some people. [ 7 ] Surgery in this scenario, however, puts patients at risk for serious postoperative sequelae include rectovaginal fistula and postoperative voiding dysfunction. [ 8 , 9 ] For surgical treatment of DE, laparoscopy has surpassed laparotomy as the gold standard due to its reduced risk of postoperative complications, improved management of digestive and general symptoms, and no impact on fertility. [ 7 , 10 ] Surface (or peritoneal) endometriosis, ovarian endometrioma, deep endometriosis (defined as infiltrating lesions bigger than 5 mm in depth) are the 3 main types. [ 11 , 12 ] Infiltrating nodules (>5 mm) of deep infiltrating endometriosis can be found in the uterosacral ligaments, pouch of Douglas, vagina, intestine, bladder, and ureter. [ 13 , 14 ] Symptoms, medical response, fertility status are typically taken into account when recommending a course of treatment. [ 3 , 15 ] Surgical excision of deep infiltrating endometriosis has been shown to reduce pain and enhance quality of life in a number of trials. [ 15 ] The past decade has seen the rise of robot-assisted laparoscopy as a viable alternative to traditional laparoscopy. [ 16 ] Even though its superiority over normal laparoscopy has not been shown, authors typically highlight the technical advantages of the robotic approach (vision magnification, better mobility range, and reduced surgeon tremor). Robotic surgery has been shown to be an effective alternative to traditional laparoscopy for endometriosis surgery, according to a recent meta-analysis. [ 17 ] Unfortunately, there is a lack of information comparing robotic to traditional laparoscopy in the context of colorectal endometriosis. Despite the longer surgical time associated with robotic surgery, pilot research indicated that the outcomes were comparable between the 2 methods. [ 18 ] This meta-analysis aims to evaluate and compare the impact of robotic and standard laparoscopic techniques in endometriosis regarding the clinical outcome (operation and hospitalization time, blood loss, rehospitalization, and rate of complications and conversion).

Conceptualization: Shaobin Wei, Zhihua Song, Songtao Li, Hanzhi Zhong. Data curation: Shaobin Wei, Zhihua Song, Songtao Li, Mei Luo, Hongjun Li, Hanzhi Zhong. Formal analysis: Shaobin Wei, Zhihua Song. Investigation: Mei Luo, Hongjun Li. Methodology: Zhihua Song, Songtao Li, Hongjun Li. Project administration: Shaobin Wei, Mei Luo, Hanzhi Zhong. Software: Zhihua Song. Validation: Songtao Li, Mei Luo. Writing – original draft: Shaobin Wei, Zhihua Song, Songtao Li, Mei Luo, Hongjun Li, Hanzhi Zhong. Writing – review & editing: Shaobin Wei, Zhihua Song, Songtao Li, Mei Luo, Hanzhi Zhong.

The meta-analyses of clinical trials were a part of the epidemiological declaration and adhered to a predetermined study procedure. For the purposes of data collection and analysis, a wide number of databases, such as OVID, PubMed, the Cochrane Library, Embase, and Google Scholar, were accessed. These databases were used to collect studies that focused on evaluating and comparing the impact of robotic and standard laparoscopic techniques in endometriosis regarding the clinical outcome (operation and hospitalization time, blood loss, rehospitalization, and rate of complications and conversion). Comparing robotic and standard laparoscopic techniques for the management of endometriosis resulted in a number of clinical outcomes. These outcomes included operation and hospitalization time, blood loss, rehospitalization, and rate of complications and conversion. The main inclusion parameters were these outcomes. During the screening process and the selection of studies to include, language restrictions were not taken into account, and only research on people was considered. There were no restrictions imposed on the possible sample sizes of the studies that were recruited. Because they do not include an intervention, reviews, editorials, and letters are not included in this synthesis that we have presented. The entirety of the process of study identification is illustrated in Figure 1 . Schematic diagram of the study procedure. An investigation of the effects, both positive and negative, that robotic and traditional laparoscopic methods have on the clinical outcome of endometriosis patients was conducted. Only publications that reported the influence of interventions on the occurrence of problems (both intra- and postoperative), the quantity of blood loss, the length of time spent operating and in the hospital, and the rate of rehospitalization were included in the sensitivity analysis. In order to do sensitivity and subclass analyses, the interventional groups were compared to a wide variety of subject types. The criteria for inclusion in the meta-analysis were as follows: a comparison of the outcomes of robotic surgery with laparoscopic surgery in patients affected by endometriosis; an evaluation of operative time, intra- and postoperative complication, blood loss, and time of hospitalization. The expression of the outcome should be in the appropriate output to be included in statistical analysis. Studies that were not comparative in the design of the evaluation of surgical technique on clinical outcomes were excluded. In addition, letters, books, review articles, and book chapters were also excluded from the current study. A protocol of search strategies was devised and specified as follows in accordance with the PICOS principle, which states: P (population) endometriosis cases; Surgical procedure is the “intervention” or “exposure”; C (comparison): the comparative effectiveness and safety of robotic and traditional laparoscopic surgery. O (outcome): operation time, blood loss, hospitalization time, conversion rate, intraoperative problems, postoperative complications, and rehospitalization; S (design of the study): retrospective and prospective studies. We did an exhaustive search of the databases PubMed, Cochrane Library, Embase, OVID, and Google Scholar up until September 2022 using the keywords and associated phrases specified in Table 1 (Search techniques for different databases). A review was conducted on the titles and abstracts of all of the articles that had been compiled into a reference managing program, as well as any research that did not correlate the type of surgical treatments with clinical outcomes. The 2 writers, Z.S. and S.L., also served as reviewers for the purpose of finding studies that were appropriate. Database Search Strategy for inclusion of studies. The following criteria were used to reduce the amount of data: study and subject features presented in a standardized format; the surname of the study’s first author; the period and year of the study; the country in which the study was conducted; and the gender ratio; the population type that was recruited for the studies; the total number of subjects; qualitative and quantitative evaluation methods; demographic data; clinical and treatment characteristics; information sources; and outcome evaluations. Two anonymous reviewers looked at the possibility of bias in each study as well as the quality of the methods used in the studies that were chosen for further investigation. The methodology of each study was evaluated in a separate manner by 2 different reviewers. In the current meta-analysis, the mean difference (MD) with a 95% confidence interval (CI) was determined using dichotomous and continuous random-effect models. Due to substantial heterogeneity in certain groups and inconsistent technique in other groups, all groups were evaluated using the random model, whereas utilizing the fixed models needs proof of high similarity between the included studies and low heterogeneity ( I 2 ) level. The I 2 index, a numeric value between 0 and 100, was computed (%). I 2 = 0 indicates that there is no heterogeneity, whereas higher I 2 values suggest greater heterogeneity. As indicated previously, subcategory analysis was performed by stratifying the first evaluation into result categories. Publication bias was analyzed quantitatively using Begg and Egger test, and it was deemed present if P > .05. The p-values were determined using a test with 2 tails. Using Jamovi 2.3, the statistical analyses and graphs were produced.

Eight studies published between 2013 and 2022 were included in the meta-analysis because they fit the inclusion criteria following a review of 613 relevant studies. [ 18 – 25 ] Table 2 (characteristic of included studies including Author, year, country, number of recruited patients, and study design) summarizes the findings of these investigations. Characteristics of studies. Six studies were included in the time of operation analysis (Fig. 2 ). The analysis findings revealed a significant difference in operation time ( P = .01) between robotic surgery and standard laparoscopic surgery. The laparoscopic surgery showed less operative time, MD = 0.66, CI 95%, [0.11, 1.21], I ² = 91 %). Neither the rank correlation nor the regression test indicated any publication bias ( P = .27 and P = .71, respectively). Forest plot showing the impact of robotic and laparoscopic techniques on operation time. Five studies were included in the hospitalization time analysis (Fig. 3 ). It was clear that the hospitalization time of laparoscopic surgery is significantly ( P = .03) lower than that of robotic surgery, MD = 0.16, CI 95%, [0.01, 0.30], I ² = 0%). Neither the rank correlation nor the regression test indicated any publication bias ( P = .82 and P = .67, respectively). Forest plot showing the impact of robotic and laparoscopic techniques on hospitalization time. Six studies were included in the analysis of blood loss during both interventions (Fig. 4 ). Results of the analysis showed a nonsignificant ( P = .27) difference between robotic and laparoscopic surgery regarding the amount of blood lost during the procedure, MD = 0.08, CI 95%, [−0.06, 0.21], I ² = 0%). Neither the rank correlation nor the regression test indicated any publication bias ( P = .47 and P = .50, respectively). Forest plot showing the impact of robotic and laparoscopic techniques on blood loss. Seven studies were included in the analysis of postoperative complications for both techniques (Fig. 5 a). The results of this analysis showed a nonsignificant ( P = .88) difference between robotic and laparoscopic surgery for endometriosis, MD = −0.04, CI 95%, [−0.55, 0.47], I ² = 7%). Neither the rank correlation nor the regression test indicated any publication bias ( P = .77 and P = .28, respectively). Forest plot showing the impact of robotic and laparoscopic techniques on postoperative (a) and intraoperative complications (b). Seven studies were included in the analysis of intraoperative complications between both groups (Fig. 5 b). A nonsignificant difference between both interventions ( P = .72), MD = 0.71, CI 95%, [−0.32, 1.74, I ² = 25%). Neither the rank correlation nor the regression test indicated any publication bias ( P = .77 and P = .09, respectively). Eight studies were included in the analysis of the conversion rate between robotic and standard laparoscopic surgery (Fig. 6 a). According to the results of the analysis, there was no significant ( P = .18) difference between both techniques, MD = −0.21, CI 95%, [−0.95, 1.38), I 2 = 0%. Neither the rank correlation nor the regression test indicated any publication bias ( P = .4 and P = .85, respectively). Forest plot showing the impact of robotic and laparoscopic techniques on conversion rate (a) and rehospitalization (b). Three studies were included in the analysis of rehospitalization between the 2 groups after surgery (Fig. 6 b). According to the results of the analysis, there was no significant ( P = .48) difference between both techniques, MD = −0.39, CI 95%, [−0.69, 1.47), I 2 = 0%. Neither the rank correlation nor the regression test indicated any publication bias ( P = 1 and P = .52, respectively).

Eight studies from 2013 to 2022 were recruited for the current analysis including 1741 patients with endometriosis. The studied data revealed a statistically significant ( P = .01) lower operation time related to laparoscopic surgery compared with the robotic technique. In addition, the hospitalization time of laparoscopic surgery is significantly ( P = .03) lower than that of robotic surgery. On the other hand, blood loss, rehospitalization, postoperative and intraoperative complications, and conversion rates were not significantly different between both techniques. Heterogeneity values were variable according to the analysis factor, from 0% to 91%. The treatment of endometriosis that is considered to be the gold standard is minimally invasive surgery. This century has seen the advent of robotic-assisted laparoscopy (RAS) in the treatment of a variety of gynecologic illnesses, most notably malignant ones. In more recent years, a number of scientists have proposed that RAS may possibly have a role in endometriosis. [ 26 , 27 ] In accordance with the findings of Chen study, we discovered that robotic surgery is not clinically inferior to laparoscopic surgery. In addition, the findings of this meta-analysis showed that the robotic surgery technique required a longer mean operating time than the standard laparoscopic technique, despite the fact that there was no significant difference between the 2 groups in terms of the amount of blood lost, the number of complications, or the conversion rate. RAS has been shown to be an effective and safe treatment for endometriosis in a number of trials, [ 27 – 30 ] but the majority of these research took a retrospective approach. RAS surgical procedures include radical treatment of the most severe, surgically demanding, painful [ 31 ] form of the disease, which is deeply inflating endometriosis involving the bowel or the urinary tract. This form of endometriosis can only be successfully treated by a surgeon with extensive experience. RCT investigations, which included patients who were operated on using RAS and patients who were operated on using laparoscopic surgery by the same surgical team, did not indicate any significant advantage of the former procedure over the latter technique, despite the fact that these results appear to be encouraging. In fact, the only differences that were statistically significant in favor of laparoscopic surgery were a shorter operating time and a decreased hospital stay. [ 23 ] These were the only benefits of laparoscopic surgery. On the other hand, the majority of comparative studies were carried out in retrospect, and they did not include sufficient follow-up. Because the comparison between robotic surgery and laparoscopic surgery in these studies has been limited to perioperative outcomes, it has not been possible to draw any conclusions about the most important outcomes, such as long-term relief of pain, pregnancy rates in infertile women, and variation in health-related quality of life. Because of this limitation, it has not been possible to draw any conclusions about any of these outcomes. These difficulties can only be clarified through well-conducted randomized studies that compare the efficacy of RAS and laparoscopic surgery in the treatment of endometriosis. The cost of the procedure is frequently cited as a disadvantage of robotic surgery. [ 32 ] There is a possibility that an appropriate evaluation of costs and benefits in patients who are affected by severe endometriosis and who are subjected to a multidisciplinary approach could play an essential role in these circumstances as well. To properly assess these facets, additional research is required. According to Gac et al, [ 18 ] regardless of the length of the operation, the incidence of complications is the most important factor to consider when contrasting robotic versus conventional laparoscopy. When using the Clavien–Dindo classification system, it was shown that both the intraoperative and postoperative complication rates were comparable amongst the groups. On the other hand, the robotic group had a significantly greater incidence of grade III complications (13% vs 0%), although this difference did not achieve statistical significance. As for the length of the operation, this could be explained by both the frequency of associated procedures and the limited experience of surgeons in robotic surgery. As a result, there was a trend for a slight increase in the length of time patients spent in the hospital (8.0 days as opposed to 6.5 days) and the number of patients who required readmission (9% as opposed to 0%). In addition, our rate of complications is consistent with that of a recent meta-analysis on laparoscopic colorectal resection for endometriosis, [ 33 ] which included 38 series with a total of 3079 patients. This study looked at complications after laparoscopic colorectal resection for endometriosis.

In terms of blood loss, rehospitalization, conversion rate, and rate of complications, and robotic and traditional laparoscopic methods produce results that are comparable to 1 another. Although the major difference between the 2 approaches was in favor of routine laparoscopic surgery in terms of the amount of time spent in the operating room and in the hospital, further updates of the data from the meta-analysis will need to be done in order to incorporate additional randomized trials in order to improve the clinical practice evidence.