Outcomes Of Robot-Assisted Versus Laparoscopic and Laparotomic Surgery For Endometrial Cancer: A Meta-Analysis Of Randomized Trials

Outcomes Of Robot-Assisted Versus Laparoscopic and Laparotomic Surgery For Endometrial Cancer: A Meta-Analysis Of Randomized Trials | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 18 January 2025 V1 Latest version Share on Outcomes Of Robot-Assisted Versus Laparoscopic and Laparotomic Surgery For Endometrial Cancer: A Meta-Analysis Of Randomized Trials Authors : Emanuele De Angelis , Roberta Maria Arseni 0009-0007-8808-9183 [email protected] , Ilaria Cuccu , Federica Tomao , Innocenza Palaia , Giorgia Perniola , Ludovico Muzii , Andrea Giannini , Giorgio Bogani , Evangelos Kontopantelis , and Violante Di Donato Authors Info & Affiliations https://doi.org/10.22541/au.173721604.41913752/v1 237 views 144 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background Endometrial cancer is the most common gynecological malignancy in developed countries. Robotic surgery has been widely adopted across various surgical fields, including gynecologic oncology, yet its benefits compared to traditional approaches, such as laparoscopy and laparotomy, remain uncertain. Objective The present study aimed to evaluate surgical and perioperative outcomes of robotic surgery compared to laparoscopy and laparotomy in the treatment of endometrial cancer. Search Strategy A comprehensive search of the literature was performed up to September 2022, across multiple databases including Pubmed, Embase, Cochrane, to retrieve eligible randomized studies. Selection Criteria Literature was searched for publications reporting robotic surgery for endometrial cancer compared to laparoscopy or laparotomy. Only randomized trial were selected. The risk of bias was evaluated using the Risk of Bias in Randomized Trials tool. Data Collection and Analysis A total of 14 relevant articles were retrieved. After applying inclusion criteria, 8 studies were included in the analysis, encompassing 647 patients: 322 underwent robotic surgery, 244 laparoscopic surgery, and 81 laparotomy. Main Results Robotic surgery was associated with a significant reduction in conversion rates to laparotomy compared to laparoscopy (odds ratio [OR] = 0.17, p = 0.03). No significant differences were observed in other perioperative outcomes. Conclusion Robotic surgery significantly reduces conversion rates to laparotomy in endometrial cancer treatment compared to laparoscopy. Outcomes Of Robot-Assisted Versus Laparoscopic and Laparotomic Surgery For Endometrial Cancer: A Meta-Analysis Of Randomized Trials Emanuele De Angelis a , Roberta Maria Arseni a *, Ilaria Cuccu a , Federica Tomao a , Innocenza Palaia a , Giorgia Perniola a , Ludovico Muzii a , Andrea Giannini b , Giorgio Bogani c , Evangelos Kontopantelis d , Violante Di Donato a a. Department of Gynecological, Obstretrical and Urological Sciences, “Sapienza” University of Roma, 00161, Rome, Italy b. Unit of Gynecology, Department of Surgical and Medical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy c. Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy d. Division of Informatics, Imaging and Data Sciences, University of Manchester, Greater Manchester, Manchester, UK. Authors’ E-mail Emanuele De Angelis: [email protected] Ilaria Cuccu: [email protected] Federica Tomao: [email protected] Innocenza Palaia: [email protected] Giorgia Perniola: [email protected] Ludovico Muzii: [email protected] Andrea Giannini: [email protected] Giorgio Bogani: [email protected] Evangelos Kontopantelis: [email protected] Violante Di Donato: [email protected] Corrisponding author: Roberta Maria Arseni Department of Gynecological, Obstretrical and Urological Sciences, “Sapienza” University of Roma, 00161, E-mail: [email protected] Tel: +39 3208193401 Running title: Robot-Assisted vs. Traditional Surgery for Endometrial Cancer Background Endometrial cancer is the most common gynecological malignancy in developed countries. Robotic surgery has been widely adopted across various surgical fields, including gynecologic oncology, yet its benefits compared to traditional approaches, such as laparoscopy and laparotomy, remain uncertain. Objective The present study aimed to evaluate surgical and perioperative outcomes of robotic surgery compared to laparoscopy and laparotomy in the treatment of endometrial cancer. Search Strategy A comprehensive search of the literature was performed up to September 2022, across multiple databases including Pubmed, Embase, Cochrane, to retrieve eligible randomized studies. Selection Criteria Literature was searched for publications reporting robotic surgery for endometrial cancer compared to laparoscopy or laparotomy. Only randomized trial were selected. The risk of bias was evaluated using the Risk of Bias in Randomized Trials tool. Data Collection and Analysis A total of 14 relevant articles were retrieved. After applying inclusion criteria, 8 studies were included in the analysis, encompassing 647 patients: 322 underwent robotic surgery, 244 laparoscopic surgery, and 81 laparotomy. Main Results Robotic surgery was associated with a significant reduction in conversion rates to laparotomy compared to laparoscopy (odds ratio [OR] = 0.17, p = 0.03). No significant differences were observed in other perioperative outcomes. Conclusion Robotic surgery significantly reduces conversion rates to laparotomy in endometrial cancer treatment compared to laparoscopy. Funding None Keywords: “endometrial cancer”, “endometrium”, “hysterectomy”, “robotic”, “laparoscopy”, “randomized “ INTRODUCTION Endometrial cancer is the most common gynecologic cancer with over 417,000 new cases diagnosed in 2020, and it represents a leading cause of mortality among women with nearly 100.000 deaths 1,2 . Most patients present with prognostically favorable characteristics (low stage and grade), therefore the role of surgery is an important determinant of the total disease burden. The choice of the surgical approach for endometrial cancer treatment depends on patient comorbidities, surgical risk, and procedural characteristics 3,4 . Today robotic surgery has been adopted for different surgical fields, including urologic, general, thoracic surgery, and usually is compared with traditional laparoscopic and open surgery in terms of clinical and surgical outcomes 5,6 . In 2005, robotic surgery was approved for use in oncological gynecology, especially for endometrial and cervical cancer. However, there is still no unanimous consensus on benefit of this technique. The aim of the present meta-analysis is to evaluate surgical and perioperative outcomes in randomized controlled trials comparing robotic surgery to laparoscopy or laparotomy for endometrial cancer treatment. METHODS Search Strategy A comprehensive search of the literature was performed up to September 2022 by two authors (EDA, RMA) independently, across multiple databases including MEDLINE, Pubmed, Embase, Cochrane to retrieve eligible randomized studies. The process of evidence acquisition combined the following keywords and their MESH terms: “endometrial cancer”, “endometrium”, “hysterectomy”, “robotic”, “laparoscopy”, “randomized”. Only articles written in English were included. Duplicates were removed as well as irrelevant articles. The search strategy was designed in accordance with PRISMA guidelines, and a flow diagram was created to illustrate the selection process of studies. All studies existing in the literature were considered, focusing specifically on randomized controlled trials that compared robotic hysterectomy with laparoscopic and open approaches in patients with endometrial cancer. Three independent investigators conducted the search to ensure the thoroughness and objectivity of the data collection. Discrepancies among reviewers were resolved through discussion, and a consensus was reached prior to final inclusion. Data Extraction and methodological quality assessment The data were extracted by different authors independently for each eligible study comparing robotic surgery to laparoscopy and laparotomy, in patients with endometrial cancer. The selected studies were comprehensively examined, and relevant data extracted for each paper. The information selected included: authors and year of the study, country, number of patients involved, type of surgery performed, number of patients for each surgery, primary and secondary endpoint (time of surgery, blood loss, length of stay, conversions, peri- and post-operative complications, cost). The authors carried out data extraction and quality assessment from all the retrieved studies based on full-text articles. Discrepancies between the investigators were resolved by consensus. The risk of bias of studies included in the systematic review were assessed according to The Risk of Bias In Randomized Trials 7 . Some of the studies included in the meta-analysis were conducted at the same center which may result in potential overlap in patient populations. Inclusion and exclusion criteria This meta-analysis included only randomized studies that examined robotic surgery for endometrial cancer, specifically those comparing it with laparoscopic or laparotomic surgery. Eligible studies were restricted to full-text articles written in English. Studies were excluded if they addressed benign, cervical, or ovarian pathologies or employed non-randomized designs. Additionally, reviews, letters, editorials, case reports, and articles not published in English were not considered for inclusion. Outcomes This meta-analysis primarily evaluated surgical and perioperative outcomes, comparing robotic surgery to both conventional laparoscopic and laparotomic approaches. The primary outcomes included total operating room time (from entry to exit) and specific operation time (from skin incision to closure), estimated blood loss (ml), length of postoperative stay (days), rate of conversions to open surgery, incidence of perioperative complications and overall cost in dollars or euros. RESULTS Study characteristics The research was conducted until September 2024 using the search strategy described. The study selection is illustrated in Figure 1. In accordance with the search strategy, the initial search identified 244 records. After the removal of duplicate records, the screening of titles and abstracts, and the exclusion of irrelevant topics, the search strategy resulted in 14 relevant articles. A full-text screening of these references led to the exclusion of six articles for the reasons described in Figure 1. A total of eight randomized studies involving 647 patients were included, comparing robotic surgery to laparoscopic or laparotomic approaches (Table S1) 8-15 . Four studies comparing robotic surgery to laparoscopic surgery, for a total of 485 patients 8-11 ; 4 comparing robotic surgery to laparotomic surgery for a total of 162 patients 12-15 . Only randomized trials were considered. The risk of bias assessment for the included studies is detailed in Figure 2. Eight randomized studies were included. Four of these compared robotic surgery to laparoscopy, 4 compared robotic surgery to laparotomy. Unfortunately, it was not possible to perform a meta-analysis for each outcome because not all studies considered report the mean value. Patients Characteristics Only patients undergoing surgery were considered. Of the total of 647 patients, 322 (49,8 %) underwent robotic surgery, 244 (37,7%) underwent laparoscopy, 81 (12,5 %) underwent laparotomy. Of included patients, 320 (49,5%) had endometrioid histotype endometrial cancer, while 109 (17%) had non endometrioid histotype endometrial cancer; for 218 (33,5%) patients histotype was not specified. 211 (32,6%) patients were affected by low/intermediate grade (G1/G2) endometrial cancer and 49 (7,6%) were affected by high grade (G3) endometrial cancer; for 387 (59,8%) patients, grade was not specified. Finally, 298 (46%) patients resulted in FIGO stage I and II endometrial cancer, while 29 (4,5%) resulted in FIGO stage III and IV endometrial cancer; for 320 (49,5%) patients FIGO stage was not specified. Outcomes All studies reported time as median value 8-11 , for this reason, a meta-analysis was not performed. Two studies examined only the “operating room time” 10,11 ; two studies examined both “operating room time” and “operation time” 8,9 . One study 10 showed a median “operating room time” increase in the robotic cohort compared to the laparoscopic one (319,5 vs 248 minutes respectively, p < .001). Contrariwise, 2 authors 8,9 , reported median “operating room time” decrease in Robotic cohort compared to laparoscopic (197 vs 228 minutes respectively, p < .001); moreover, reported a median shorter “operation time”, in the robotic cohort compared with laparoscopy (139 vs 170 minutes respectively, p < .001). Three of four studies reported the median time 13-15 , one reported mean time 12 , making any meta-analysis impracticable. Three studies examined the “operation time” 13-15 ; one study examined both “operating room time” and “operation time” 14 . Both the “operating room time” 14 and the “operation time”, were longer in the robotic cohort (“operation time”: 187 vs 233 minutes, p < .001 13 and 56 vs 70 minutes, p = .048 14 ; “operating room time”: 145 vs 176 minutes, p < .001 14 ). No study specified how blood losses were estimated. Blood losses were reported in ml in all studies considered. Three of four studies reported the median estimated blood loss 8,10,11 making any meta-analysis impracticable. One study was excluded from the analysis because it did not report any data about blood loss 9 . One study reported no difference in terms of blood loss between cohort (robotic surgery vs laparoscopy) 8 , instead, two studies 10,11 reported a higher blood loss in patients treated with robotic surgery compared with laparoscopy (162 vs 105.5 ml and 87.5 vs 50 ml, respectively), although no statistically significant difference was reached in one of these studies (p = .64) 10 . Three of four studies reported the median estimated blood loss 13-15 . Two studies reported no difference in terms of blood loss between groups (robotic surgery vs laparotomy) 14,15 . One study [13] reported a higher significant blood loss in laparotomic vs robotic cohorts (200 vs 78 ml respectively, p < .001). Three studies of four reported the length of stay as median time 8-10 , making any meta-analysis impracticable. One study showed 3 days of hospitalization for both robotic surgery and laparoscopy 10 . Two studies reported a not significant longer hospitalization time for the laparoscopy cohort than the robotic cohort 8,9 . Three studies of four reported the median length of stay 13-15 . One study was excluded from the analysis because it reported no data regarding length of stay 12 . Two studies reported no difference in terms of hospitalization days between groups (robotic vs laparotomy) 14,15 ; one study 13 showed a significantly longer hospitalization for laparotomy cohort compared to robotic cohort (5 vs 2 days respectively, p < .001). Three studies of four reported conversion rate data 8-10 . In all three studies the conversion rate was higher in the laparoscopy cohort. Of the 285 women included in the pooled analysis (142 underwent robotic surgery and 143 underwent laparoscopy), the conversion occurred in 13 (4,6%) women: 1 (0,7%) in robotic surgery and 12 (8,4%) in laparoscopy cohort. The pooled estimated odds ratio (OR) was 0.17 (95% CI 0.04–0.84; p = .03). (Figure 3) Two studies did not report data on complications 9,11 ; however, two studies 8,10 analyzed intra- and postoperative complications, dividing them into severe and minor complications. None of the studies analyzed complications by Accordion or Claviene-Dindo classification. While severe intraoperative complications were slightly more frequent in the laparoscopic cohort, statistical significance was not achieved (p = .056); however, the robotic cohort reported a higher rate of severe postoperative complications than the laparoscopic cohort, statistically not significant (p = .204). Minor complications were more frequent in the robotic cohort than in the laparoscopic cohort (6 vs 2 total minor complications, p = .97 10 ; 8% vs 6% early minor complications, p: 1.000 and 10% vs 4% late minor complications, p = .436 8 ). Mortality, overall survival and disease-free survival were not analyzed by any study. One study reported no data on complications 14 . The Claviene-Dindo classification was used in two studies 12,13 to analyze postoperative complications. Minor complications (grade I, II) were higher in laparotomic surgery than in robotic surgery (25% vs 10.4%, p = .36). Severe complications (grade > 3b) were higher in laparotomic surgery than in robotic surgery. Mortality, overall survival and disease-free survival were not analyzed by any study. Two of the four studies reported cost data 9,10 . Both studies reported an analysis of direct costs (instruments, personnel and hospitalization costs); however, neither analyzed indirect costs (sick leave and informal care). The daily cost of hospitalization was higher for laparoscopic surgery than for robotic surgery (1387 vs 1092 euros respectively, p = .130 9 ; 495 vs 492 US dollars respectively, p = .427 10 ). The costs of employment-personal was higher in robotic surgery (2810.3 vs 2224.6 US dollars, p < .001) in one study 10 , while another study 9 reported lower costs in robotic surgery (896 vs 735 euro, p < .001 and 844 vs 729 euro, p < .001 respectively). Strumentation costs were higher for robotic surgery (1172 vs 232 euro, p < .001 9 ; 1462.35 vs 897.7 US dollars respectively, p < .001 10 ). Two of the four studies reported cost data 13,14 . One study 14 analyzed direct costs (instruments, personnel and hospitalization costs) and indirect costs (sick leave and informal care). Total direct costs were higher for robotic surgery (5770.2 vs 3997.5 euro, based on 300 procedures annually). Total indirect costs were higher for laparotomic surgery (1786 vs 1214 euro, based on 300 procedures annually). The other one 13 analyzed only direct costs, showing a significantly lower total cost for robotic surgery than for laparotomic surgery (15581 vs 16807 euro, p < .05). Excluding the investment cost for the robotic system, the cost of robotic surgery was even lower (14509 euro, p < .001). DISCUSSION Summary of Main Results Robotic surgery in endometrial cancer has shown significant differences in intraoperative conversion rates compared to conventional laparoscopic surgery. The primary finding of the present meta-analyses was a statistically significant reduction in the conversion rate in cohorts of patients treated for endometrial cancer with robotic surgery compared to traditional laparoscopic techniques (OR = 0.17, p = .03). Results in the Context of Published Literature The reduction in conversion to laparotomy during robotic surgery could be attributed to enhanced precision, ergonomic benefits that reduce surgeon fatigue, and better access to complex anatomical areas. The ’tent effect’ created by robotic arms facilitates ventilation minimizing intraperitoneal and intrathoracic pressures, reducing the risk of complications. The advantages, particularly in complex cases, contribute to fewer conversions to laparotomy 16,17 . Conversion to open surgery often occurs in emergencies, where swift decision-making is crucial and often increases the risk of complications. The increased incision in open surgery can heighten the risk of accidental injury to vital organs, including the intestines, bladder, and ureters. Additionally, it can increase the risk of wound infection and prolongs postoperative recovery time 18 . Our findings align with data from the United States, showing that robotic surgery adoption for endometrial cancer reduces conversions to laparotomy and perioperative complications without increasing 30-day costs. Lower complication rates and shorter hospital stays offset robotic technology’s initial costs, with notable benefits for obese patients who experience fewer perioperative complications compared to laparoscopy 19-22 . Our meta-analysis was not able to directly compare surgical outcomes like operating time, blood loss, and length of postoperative stay due to inconsistencies in how these variables were reported across studies, including the use of median versus mean values and varying definitions of surgical times. However, the existing literature and the studies included in our analysis suggest that robotic surgery generally results in longer operating times compared to laparoscopy, along with reduced blood loss and shorter hospital stays compared to laparotomy 23-26 . In our study, it was not possible to perform a direct comparison of cost outcomes due to the variability in how costs were reported across studies, making a meta-analysis of this outcome unfeasible. However, the available data still provide valuable insights into the economic implications of robotic surgery compared to laparoscopy and laparotomy. Although direct costs, particularly those related to instrumentation and personnel, tend to be higher for robotic surgery, the overall financial impact appears more balanced when considering reduced hospitalization times and fewer perioperative complications. This is especially evident in the robotic group, where shorter hospital stays, even if not always statistically significant, suggest an advantage in postoperative recovery efficiency. Moreover, despite the higher upfront costs of robotic surgery, reduced complications and shorter hospital stays may lead to cost-effectiveness in the long term, especially for complex cases 9,10 . This supports the notion that robotic surgery may offer greater cost-effectiveness over time, especially in settings where it is utilized for complex cases or large patient volumes. Additionally, the studies that evaluated indirect costs, such as sick leave and informal care, demonstrated that robotic surgery has the potential to reduce overall treatment costs in the long term, due to faster recovery times and a quicker return to normal activities 14 . In other words, although robotic surgery may involve higher initial costs, the overall economic benefits render it a financially viable option, particularly for patient populations requiring more complex surgical management. Strengths and Weaknesses The strength of this meta-analysis lies in its exclusive evaluation of randomized controlled trials, providing a robust comparison between robotic surgery and traditional laparoscopic or laparotomic approaches. However, a significant limitation is the inability to perform a comprehensive meta-analysis for all considered outcomes. This limitation arises from the fact that many studies reported outcomes as median values, precluding direct comparisons. Implications for Practice and Future Research Future applications of robotic surgery in the management of endometrial cancer could include refining surgical approaches to reduce conversion rates even further, optimizing patient selection for robotic versus laparoscopic procedures, and potentially establishing protocols for use in high-risk populations to improve outcomes. Future objectives should focus on standardizing surgical outcome reporting and developing cost-effectiveness models, including both direct and indirect costs, to provide clearer economic insights. Additionally, research into robotic techniques may explore strategies to further minimize blood loss and operating times, enhancing recovery and reducing overall healthcare burden. CONCLUSION This meta-analysis confirms a statistically significant reduction in laparotomy conversion rates for patients undergoing robotic surgery compared to traditional laparoscopy in endometrial cancer treatment. Although cost data were inconsistent across studies, the available evidence suggests that robotic surgery does not result in higher overall treatment costs when considering shorter hospital stays and fewer complications. However, due to variability in outcome reporting, we were unable to perform a comprehensive comparison of all surgical outcomes. Acknowledgements SAPIENZA University of Rome supported the time and facilities of EDA. Disclosure None Contributors EDA: conceptualization, methodology, software, validation, formal analysis, writing, original draft, visualization, supervision, guarantor, project administration. RMA: investigation, resources, data curation, writing, original draft, visualization. FT: validation, data curation, visualization. IP: validation, data curation, visualization. GP: validation, data curation, visualization. LM: validation, data curation, visualization. AG: validation, data curation, visualization. supervision. GB: validation, data curation, visualization. supervision. VDD: conceptualization, methodology, validation, formal analysis, writing - original draft, visualization, supervision, project administration. Funding None REFERENCES 1. Cronin KA, Scott S, Firth AU, Sung H, Henley SJ, Sherman RL, et al. Annual report to the nation on the status of cancer, part 1: National cancer statistics. Cancer. 2022 Dec 15;128(24):4251-4284. 2. https://www.cancer.gov 3. Clair KH, Tewari KS. Robotic surgery for gynecologic cancers: indications, techniques and controversies. J Obstet Gynaecol Res. 2020 Jun;46(6):828-843. 4. Rivas-López R, Sandoval-García-Travesí FA. Robotic surgery in gynecology: review of literature. Cir Cir. 2020;88(1):107-116. 5. 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Robotically assisted laparoscopic hysterectomy versus total abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecol Oncol. 2008 Dec;111(3):412-7. 26. Boggess JF, Gehrig PA, Cantrell L, Shafer A, Ridgway M, Skinner EN, et al. A case-control study of robot-assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. Am J Obstet Gynecol. 2008 Oct;199(4):357.e1-7. Supplementary Material File (table s1.docx) Download 14.90 KB Information & Authors Information Version history V1 Version 1 18 January 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords carcinoma of the endometrium: surgery gynaecological oncology gynaecological surgery: gynaecological cancer gynaecological surgery: laparoscopy gynaecological surgery: robotic meta-analysis Authors Affiliations Emanuele De Angelis Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Roberta Maria Arseni 0009-0007-8808-9183 [email protected] Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Ilaria Cuccu Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Federica Tomao Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Innocenza Palaia Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Giorgia Perniola Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Ludovico Muzii Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Andrea Giannini Universita degli Studi di Roma La Sapienza Dipartimento di Scienze Medico-Chirurgiche e Medicina Translazionale View all articles by this author Giorgio Bogani Fondazione IRCCS Istituto Nazionale dei Tumori View all articles by this author Evangelos Kontopantelis The University of Manchester Division of Informatics Imaging and Data Sciences View all articles by this author Violante Di Donato Universita degli Studi di Roma La Sapienza Dipartimento Materno Infantile e Scienze Urologiche View all articles by this author Metrics & Citations Metrics Article Usage 237 views 144 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Emanuele De Angelis, Roberta Maria Arseni, Ilaria Cuccu, et al. Outcomes Of Robot-Assisted Versus Laparoscopic and Laparotomic Surgery For Endometrial Cancer: A Meta-Analysis Of Randomized Trials. Authorea . 18 January 2025. DOI: https://doi.org/10.22541/au.173721604.41913752/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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