Robotic-assisted compared to conventional laparoscopic surgery for colorectal endometriosis: perioperative outcomes in the context of #Enzian-defined anatomical complexity

The objective of this work was to compare the perioperative safety and operative efficacy of robotic-assisted surgery (RAS) versus conventional laparoscopy surgery (CLS) in women with symptomatic colorectal endometriosis, with particular focus on to the anatomical disease complexity as defined by the #Enzian system. We retrospectively reviewed 160 consecutive cases operated for colorectal endometriosis at a single referral center between 2022 and 2025. Patients were managed by RAS (n = 59) or CLS (n = 101) in a non-randomized, sequential setting, with CLS performed prior to the implementation of RAS at our center. Intraoperative variables (operative time, blood loss, number of trocars, conversion rate) and perioperative outcomes (length of stay, transfusion, intensive-care admission, complications, reoperation, readmission, anastomotic leakage, and C-reactive protein serum levels on postoperative days 1-3 were analyzed. Anatomical disease extent was assessed using the #Enzian classification, including compartments P, O, T, A, B, C and F-compartments (FA, FB, FI, FU, F-nerves, F-diaphragm). Continuous variables were compared using the Mann-Whitney U test and categorical variables using Fisher's exact test, with p < 0.05 considered statistically significant. Complete excision of colorectal endometriosis and additional lesions was achieved with either route in all cases, with a very low overall rate of anastomotic leakage (2/160; 1.3%). Anatomical complexity was significantly higher in the RAS group, with more frequent peritubal/periovarian adhesions (T) (p = 0.002), advanced rectal (C) lesions (p = 0.003), and increased involvement of the bladder (FB) (8.5% vs. 0.0%, p = 0.006), ureter (FU) (11.9% vs. 2.0%, p = 0.013), and diaphragm (10.2% vs. 0.0%, p = 0.002). Despite this, median operative time was comparable between groups (225 [150-292] vs. 201 [146-251] minutes, p = 0.188). Length of hospital stay was significantly shorter after RAS (5 [4-6] vs. 6 [4-7] days, p = 0.008). Overall complication rates were similar (10.2% vs. 12.9%, p = 0.80), and the reoperation rate was numerically lower in the RAS group (1.7% vs. 6.9%, p = 0.26). RAS and CLS are both safe and effective surgical approaches for excision of symptomatic colorectal endometriosis. Despite being used in anatomically more complex cases, RAS achieved perioperative outcomes comparable to CLS, with a shorter length of hospital stay and a numerically lower reoperation rate. These findings underscore the importance of accounting for anatomical complexity and disease extent when comparing outcomes in deep endometriosis surgery. Prospective risk-adjusted or propensity score-matched studies are warranted to confirm these results.What is new? RAS achieves comparable perioperative outcomes to CLS in colorectal endometriosis and is associated to shorter hospitalization, despite being preferentially used in anatomically more complex cases defined by the #Enzian classification.