Robotic versus laparoscopic and open surgery for endometrial cancer: a systematic review of randomized trials and pooled analysis of conversion rates

Clinical Snapshot

Key Findings

• P Value: p = 0.03 for conversion rate comparison (robotic vs laparoscopy)

• Effect Size: Odds Ratio 0.17, favouring robotic over laparoscopic surgery for conversion to open surgery

• Primary Outcome: Conversion to laparotomy: robotic surgery resulted in significantly lower conversion rates compared with conventional laparoscopy (0.7% vs 8.4%)

• Nnt Or Sensitivity: Absolute risk reduction for conversion: approximately 7.7 percentage points (8.4% laparoscopy vs 0.7% robotic); NNT to prevent one conversion ≈ 13. Operative time generally longer with robotics vs laparoscopy; hospital stay shorter with robotics vs laparotomy. Direct procedural costs higher for robotic approach.

• Confidence Interval: Not reported in the abstract — a significant reporting gap

Clinical Application

Robotic surgery requires significant capital investment in robotic platforms, ongoing maintenance contracts, and dedicated surgical training programmes. Operative time is generally longer than laparoscopy, with implications for theatre scheduling and throughput. The higher direct procedural costs identified in this review are a barrier to widespread adoption, particularly in public hospital settings. Feasibility is currently limited to tertiary and quaternary gynaecological oncology centres with established robotic programmes. In Australia, robotic surgery for gynaecological oncology is available at select tertiary centres (predominantly in major metropolitan hospitals) but is not universally accessible. The Therapeutic Goods Administration (TGA) has approved robotic surgical systems for use in Australia. However, robotic procedures are not separately funded under Medicare Benefits Schedule (MBS) item numbers — surgeons bill using standard laparoscopic or open MBS codes, meaning the additional platform costs are absorbed by hospitals. The RANZCOG and ASGO (Australian Society of Gynaecological Oncologists) have not yet issued specific guidelines mandating robotic over laparoscopic approaches for endometrial cancer. The finding of lower conversion rates may be particularly relevant in Australian regional and rural contexts where conversion to open surgery carries greater implications for recovery and access to postoperative care. Cost-effectiveness data from Australian health economic modelling would be required before broader PBS or MBS-funded adoption could be recommended. Women with endometrial cancer (predominantly early-stage, given the surgical context) being considered for minimally invasive hysterectomy with staging. Most applicable to patients at higher risk of intraoperative conversion (e.g., obesity, prior abdominal surgery, complex anatomy) where the lower conversion rate of robotics may confer greatest benefit.

Abstract

To summarize randomized evidence assessing robotic surgery in relation to conventional laparoscopic and open abdominal approaches for endometrial cancer treatment, with particular attention to perioperative outcomes and conversion to open surgery. Randomized controlled trials evaluating robot-assisted surgical treatment of endometrial cancer were identified across major biomedical databases up to December 2025. Eligible studies compared the robotic approach against laparoscopic or open abdominal surgery. Quantitative pooling was undertaken only when outcome reporting was sufficiently consistent across studies. Eight randomized trials including 647 patients met the inclusion criteria. Overall, 322 patients underwent robotic surgery, 244 conventional laparoscopy, and 81 laparotomy. Most perioperative endpoints were reported heterogeneously, limiting formal pooling. Operative time varied across trials when robotics was compared with laparoscopy and was generally longer than laparotomy. Intraoperative blood loss and postoperative hospitalization did not show consistent differences between the two minimally invasive approaches. Compared with laparotomy, the robotic approach was linked to reduced postoperative stay. Conversion to laparotomy occurred less frequently after robotic surgery than after laparoscopy (0.7% vs. 8.4%; OR 0.17; p = .03). Complication reporting was inconsistent, although trials comparing robotics with laparotomy generally favored the robotic approach. Direct procedural costs were higher for robotics, whereas indirect costs favored robotics in the single study evaluating them. The robotic approach resulted in a lower need for open conversion compared with conventional laparoscopy. Other perioperative outcomes appeared broadly comparable between the two minimally invasive approaches, while comparisons with laparotomy suggested shorter hospital stay and fewer postoperative complications, although these findings should be interpreted cautiously because of the limited and heterogeneous randomized evidence.

References

1. 1.De Angelis, E., Arseni, R. M., Cuccu, I., Palaia, I., Perniola, G., Muzii, L., Perrone, E., Bogani, G., Kontopantelis, E., Vizzielli, G., & Di Donato, V. (2026). Robotic versus laparoscopic and open surgery for endometrial cancer: a systematic review of randomized trials and pooled analysis of conversion rates. Journal of Robotic Surgery. Advance online publication. https://pubmed.ncbi.nlm.nih.gov/42474556