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Robot-assisted laparoscopy for infertility treatment: current views

2014; Elsevier BV; Volume: 101; Issue: 3 Linguagem: Inglês

10.1016/j.fertnstert.2014.01.020

1556-5653

Marie Carbonnel, Julie Goetgheluck, Albane Frati, Marc Even, Jean Marc Ayoubi,

Gynecological conditions and treatments

To determine the interest of using robotic laparoscopic surgery in the management of female infertility, we reviewed our own activity and searched the Medline database for publications on robotic technology in infertility surgery, with the use of the following search words: robotic laparoscopy, tubal anastomosis, myomectomy, deep infiltrating endometriosis, and adnexal surgery. Robot-assisted laparoscopic surgery has seen rapid progression over the past few years. It has been mostly used for myomectomy, proximal tubal reanastomosis, and deep endometriosis surgery. Despite its increased range of indications, no randomized control studies are available. The place of robotic surgery in the management of infertility remains undetermined. To determine the interest of using robotic laparoscopic surgery in the management of female infertility, we reviewed our own activity and searched the Medline database for publications on robotic technology in infertility surgery, with the use of the following search words: robotic laparoscopy, tubal anastomosis, myomectomy, deep infiltrating endometriosis, and adnexal surgery. Robot-assisted laparoscopic surgery has seen rapid progression over the past few years. It has been mostly used for myomectomy, proximal tubal reanastomosis, and deep endometriosis surgery. Despite its increased range of indications, no randomized control studies are available. The place of robotic surgery in the management of infertility remains undetermined. Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/carbonnelm-robotic-assisted-laparoscopy-infertility/ Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/carbonnelm-robotic-assisted-laparoscopy-infertility/ Laparoscopy is the criterion standard in fertility surgery. It reduces both risk of adhesion and blood loss and improves surgical outcome (less pain, shortened hospital stay, and early return to normal active life) with reduced scars compared with laparotomy. According to Muhlstein et al. (1Muhlstein J. Monceau E. Lamy C. Tran N. Marchal F. Judlin P. et al.Contribution of robot-assisted surgery in the management of female infertility.J Gynecol Obstet Biol Reprod (Paris). 2012; 41: 409-417https://doi.org/10.1016/j.jgyn.2012.05.006Crossref PubMed Scopus (4) Google Scholar), laparoscopy is the preferred technique for simple procedures, such as fimbrioplasty, cystectomy, pelvic investigations, and ovarian drilling. In more complex surgery, such as myomectomy, proximal tubal reanastomosis, and deep endometriosis, laparoscopy has not been fully accepted, owing to its technical limitations and lengths of the learning curve and operating time. Telerobotics technologies that have been developed over the past decade are likely to offer a new paradigm in minimally invasive surgery. The first telerobot, called Zeus, was developed in 1995 by combining two operating arms and the Automated Endoscopic System for Optimal Positioning (AESOP) with a voice-activated camera controlled by the surgeon who also controls via a console the two robotic arms (2Jourdan I.C. Dutson E. Garcia A. Vleugels T. Leroy J. Mutter D. et al.Stereoscopic vision provides a significant advantage for precision robotic laparoscopy.Br J Surg. 2004; 91: 879-885Crossref PubMed Scopus (78) Google Scholar). The da Vinci robot was developed in 1998 by Intuitive Surgical on the same concept as Zeus, adding a three-dimensional (3D) stereoscopic vision and the possibility for the two arms to provide rotation of the instruments with seven degrees of freedom. Since then, many improvements of the system have been achieved: a supplementary operating arm in addition to that holding the camera, a new high-definition (HD) visualization, and an expanded range of surgical instruments. Currently, Intuitive Surgical has a monopoly of the market in the field. This technologic advance offers numerous advantages over conventional laparoscopy (Table 1). The surgeon's gesture gains accuracy owing to the robot's ability to filter and reduce physiologic tremor and to transform surgeon's hand movements into more precise micromovements of the jointed-wrist instruments; these operate with seven degrees of freedom and 360° pronosupination amplitude. The improved 3D HD visualization provided by the camera directly controlled by the operator allows accessing deep areas. Sutures gain quality as a result of both continuity and stability of the hand movements, making gesture intuitive. The advantages offered by the robotic technique may be highly valuable in the management of infertility with the assimilation of microsurgery principles into fertility-promoting procedures. It should translate into major benefits, such as the reduction of postoperative adhesions (3Gomel V. The impact of microsurgery in gynecology.Clin Obstet Gynecol. 1980; 23: 1301-1310Crossref PubMed Scopus (16) Google Scholar).Table 1Interest in robotic assistance in laparoscopy.Conventional laparoscopyLaparoscopy with robotic assistance2D visualization3D visualizationMagnification of the operating fieldPhysiologic tremorTremor filtrationInstability of the imageStability of the imageFixed axis of the instrumentsMicro-motion of the instruments360° amplitude, 7° freedomDiscomfort for the surgeonErgonomics, comfortable handling of the consolePoor quality of the dissectionFacilitated dissectionHard access for some areasImproved accessibilityDifficult intracorporeal stitchingEasy suturingLong learning curveShort learning curve Open table in a new tab The da Vinci S or SI HD four-arm system is commonly used for any type of gynecologic surgery. After induction of general anesthesia the patient is put in a dorsal gynecologic position. A uterine-positioning system is used to mobilize the uterus with an intrauterine cannula. Three to four standard quarter-inch incisions are made (depending on the technical difficulty of the procedure) and ports are inserted for the robot's camera and instrument arms. An operating assistant remains beside the patient and is provided with a supplementary 12-mm trocar. Then the robot is docked: The robotic column fitted with four arms (three holding a wide range of surgical instruments—monopolar scissors, bipolar surgical clamps, etc.—and the fourth holding the 3D cameras) is positioned directly over the patient during surgery. The robotic arms are controlled by a computer that replicates exactly the movements of the surgeon who is sitting at the console, operating while looking into a stereoscopic monitor that shows HD 3D views of the surgical field. The surgeon manipulates the four robotic arms by maneuvering two master controls that ensure fingertip precision of the movements. The surgeon also controls a foot switch that provides additional options, such as the ability to switch between two different energy sources (Fig. 1) The main reason for the limited use of robotic surgery is the cost of the device and related expenditures. The cost of the robot is ∼1.6 million U.S. dollars, the system necessitates annual maintenance contracts and requires instruments that cost ∼$2,000 each, with a limited range of ten uses. Laparoscopic and robotic procedures are combined into one current procedural technology (CPT) code, with no opportunity for higher reimbursement for the more expensive technology. In addition, longer operative times translate into significantly higher costs for the operating room and anesthesia. Another limitation is the absence of haptic or tactile feedback. Such lack may be dangerous when manipulating fragile tissues and when tactile sensation is important for the realization of the surgical gesture. It may also be responsible for suture rupture when knot tying is performed with the use of small-caliber thread. The setup time, usually considered to be a limit for the use of a robot, rapidly decreases with the operator's experience as shown by Braumann et al. (4Braumann C. Jacobi C.A. Menenakos C. Ismail M. Rueckert J.C. Mueller J.M. Robotic-assisted laparoscopic and thoracoscopic surgery with the da Vinci system: a 4-year experience in a single institution.Surg Laparosc Endosc Percutan Tech. 2008; 18: 260-266https://doi.org/10.1097/SLE.0b013e31816f85e5Crossref PubMed Scopus (71) Google Scholar) to be reduced from 25.0 minutes to 10.4 minutes after only ten interventions. Uterine fibroid disease affects 20%–30% of women of childbearing age and 70% of those >49 years of age (5Stewart E.A. Uterine fibroids.Lancet. 2001; 357: 293-298Abstract Full Text Full Text PDF PubMed Scopus (874) Google Scholar). Fibroids are responsible for hypofertility, especially when they cause cavity distortion (6Sunkara S.K. Khairy M. El-Toukhy T. Khalaf Y. Coomarasamy A. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta-analysis.Hum Reprod. 2010; 25: 418-429https://doi.org/10.1093/humrep/dep396Crossref PubMed Scopus (210) Google Scholar). In the case of fibroid disease, the sole treatment currently efficient to allow future pregnancy is surgical resection. With increased maternal age and the development of oocyte donation, the surgical management of fertility is needed more than ever. The criterion standard for abdominal myomectomy remains to be defined. Despite the advantages of laparotomy, such as the technical comfort of the procedure and the high quality of suture it provides, compared with laparoscopy laparotomy induces "heavier" postoperative outcomes and a major risk of adhesion likely to jeopardize future spontaneous pregnancy (7Ecker J.L. Foster J.T. Friedman A.J. Abdominal hysterectomy or abdominal myomectomy for symptomatic leiomyoma: a comparison of preoperative demography and postoperative morbidity.J Gynecol Surg. 1995; 11: 11-18https://doi.org/10.1089/gyn.1995.11.11Crossref Scopus (30) Google Scholar). Laparoscopy reduces this risk and offers advantages such as better cosmetic results and postoperative recovery (8Dubuisson J. Botchorishvili R. Perrette S. Bouderl N. Jardon K. Rabischong B. et al.Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic procedures.Am J Obstet Gynecol. 2010; 203: 111.e1-111.e3https://doi.org/10.1016/j.ajog.2010.03.031Abstract Full Text Full Text PDF Scopus (35) Google Scholar), but the quality of suture remains uncertain (9Parker W.H. Einarsson J. Istre O. Dubuisson J.B. Risk factors for uterine rupture after laparoscopic myomectomy.J Minim Invasive Gynecol. 2010; 17: 551-554https://doi.org/10.1016/j.jmig.2010.04.015Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar). Owing to its related technical difficulties, laparoscopy is still infrequently used and is considered to be hardly feasible. In fact, some sutures may be difficult, and the fixed position of the trocars limits access to some areas of myoma location, such as in case of anterior myomas, very posterior ones, or those located in the broad ligament. Myomas >8 cm, too many fibroids, and the necessity for clamping and enucleation constitute further limitations to laparoscopy (10Falcone T. Bedaiwy M.A. Minimally invasive management of uterine fibroids.Curr Opin Obstet Gynecol. 2002; 14: 401-407Crossref PubMed Scopus (73) Google Scholar, 11Daraï E. Dechaud H. Benifla J.L. Renolleau C. Panel P. Madelenat P. Fertility after laparoscopic myomectomy: preliminary results.Hum Reprod. 1997; 12: 1931-1934Crossref PubMed Scopus (105) Google Scholar). Although hard to evaluate, the rate of uterine rupture appears to be ∼1% for both techniques (12Roopnarinesingh S. Suratsingh J. Roopnarinesingh A. The obstetric outcome of patients with previous myomectomy or hysterotomy.West Indian Med J. 1985; 34: 59-62PubMed Google Scholar, 13Dubuisson J.B. Fauconnier A. Deffarges J.V. Norgaard C. Kreiker G. Chapron C. Pregnancy outcome and deliveries following laparoscopic myomectomy.Hum Reprod. 2000; 15: 869-873Crossref PubMed Scopus (234) Google Scholar). Robot-assisted laparoscopic myomectomy is performed with the use of the monopolar scissors and the dipolar grasping device, sometimes with the use of the fourth arm of the robot for myoma traction. After the incision in the uterus, the fibroid is excised and extracted from the surrounding uterine tissue. Finally, the uterus is sutured before removing the robot. The myomectomy site is sutured in one or two myometrial planes, usually by X-shape Vicryl 0 stitches, and the uterine serosa is sutured by monofilament overedge stitches to reduce the risk of adhesion. Then a morcellator is placed and used to cut the fibroid into smaller pieces inside the patient's abdomen after withdrawing the robot arms for more safety. Finally, these pieces are removed through one of the ports. An antiadhesion gel may be applied when the procedure is finished. Both feasibility and safety of robotic myomectomy have been proven since 2004 (14Advincula A.P. Song A. Burke W. Reynolds R.K. Preliminary experience with robotic-assisted laparoscopic myomectomy.J Am Assoc Gynecol Laparosc. 2004; 11: 511-518Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar). In the retrospective study by Advincula et al. (15Advincula A.P. Xu X. Goudeau 4th, S. Ransom S.B. Robotic assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short term surgical outcomes and immediate costs.J Minim Invasiv Gynecol. 2007; 14: 698-705Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar), which compared conventional laparotomy and robotic laparoscopy, the robotic surgery needed longer operating time, 231.38 ± 85.1 minutes vs. 154.41 ± 43.14 minutes (P<.05), but blood loss and length of hospital stay were significantly reduced; laparotomy was associated with higher rates of morbidity. The longer operating time associated with the robotic technique is related to the time necessary to set up the robot and to myoma extraction by morcellation. The results of studies that evaluated robotic myomectomy versus conventional laparoscopic myomectomy showed reduced blood loss and hospital stay, and conversion rates equalled zero when laparoscopy was robot assisted (15Advincula A.P. Xu X. Goudeau 4th, S. Ransom S.B. Robotic assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short term surgical outcomes and immediate costs.J Minim Invasiv Gynecol. 2007; 14: 698-705Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 16Nezhat C. Lavie O. Lemyre M. Gemer O. Bhagan L. Nezhat C. Robotic assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy-a retrospective matched control study.Fertil Steril. 2009; 91: 556-559Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 17Bedient C.E. Magrina J.F. Hsu S. Watson J. Barnett O. Lemyre M. Comparison of robotic and laparoscopic myomectomy.Am J Obstet Gynecol. 2009; 201: 566.e1-566.e2Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 18Pundir J. Pundir V. Walavalkar R. Omanwa K. Lancaster G. Kayani S. Robotic-assisted laparoscopic vs. abdominal and laparoscopic myomectomy: systematic review and meta-analysis.J Minim Invasive Gynecol. 2013; 20: 335-345https://doi.org/10.1016/j.jmig.2012.12.010Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 19Barakat E. Bedaiwy A. Zimberg S. Nutter B. Nosseir M. Falcone T. Robotic assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes.Obstet Gynecol. 2011; 117: 256-265Crossref PubMed Scopus (145) Google Scholar). In 2008, Ascher-Walsh et al. (20Ascher-Walsh C. Capes T. Robot-assisted laparoscopic myomectomy is an improvement over laparotomy in women with a limited number of myomas.J Minim Invasive Gynecol. 2010; 17: 306-310https://doi.org/10.1016/j.jmig.2010.01.011Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar) assessed 75 robot-assisted laparoscopic myomectomies versus 50 conventional laparoscopic myomectomies: Lengthened operating time was reported with the robotic technique (192 minutes vs. 138 minutes), but blood loss was reduced (226 mL vs. 459 mL) and the duration of hospital stay was shorter (0.5 day vs. 3.3 days). Even if short-term benefits of robotic assistance appear to be modest in standard myomectomy, in some complex cases and atypical locations, such as deep intramural fibroids, the advantages of robot-assisted surgery allow overcoming laparoscopy limits (21Lönnerfors C. Persson J. Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas.Acta Obstet Gynecol Scand. 2011; 90: 972-977Crossref PubMed Scopus (39) Google Scholar). With the use of robotic surgery, more fibroids become accessible (broad ligament, uterine isthmus, anterior and posterior locations), and dissection gains thoroughness, inducing less blood loss. Few studies have evaluated long-term outcomes of robot-assisted laparoscopic myomectomy. In 31 patients with endometrial cavity distortion due to interstitial fibroid disease, Lonnersfors et al. showed rates of pregnancy of 68%, with a median time to pregnancy of 10 months; 55% of pregnancies were spontaneous (21Lönnerfors C. Persson J. Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas.Acta Obstet Gynecol Scand. 2011; 90: 972-977Crossref PubMed Scopus (39) Google Scholar). Pitter et al. (22Pitter M.C. Gargiulo A.R. Bonaventura L.M. Lehman J.S. Srouji S.S. Pregnancy outcomes following robot-assisted myomectomy.Hum Reprod. 2013; 28: 99-108Crossref PubMed Scopus (75) Google Scholar) carried out a retrospective study of 872 patients who had undergone robot-assisted myomectomy; 107 of them became pregnant postoperatively. In that study, the authors reported a similar rate of pregnancy compared with conventional laparoscopy and a rate of uterine rupture of 1%; in patients delivered by cesarean section, pelvic adhesions of only 11% were discovered (22Pitter M.C. Gargiulo A.R. Bonaventura L.M. Lehman J.S. Srouji S.S. Pregnancy outcomes following robot-assisted myomectomy.Hum Reprod. 2013; 28: 99-108Crossref PubMed Scopus (75) Google Scholar). Compared with conventional laparoscopy, the rate of uterine rupture appears to be identical with that of the robotic procedure and the rate of pelvic adhesions lower. These figures must be considered with some caution, given the small size of the samples in these studies. Indeed, the main interest remains the quality of the suture, which might be similar to that of laparotomy, easily realizing two or three planes of adequate quality. The cost of robotic myomectomy remains higher than those of conventional laparoscopy and laparotomy. Behera et al. (23Behera M.A. Likes 3rd, C.E. Judd J.P. Barnett J.C. Havrilesky L.J. Wu J.M. Cost analysis of abdominal, laparoscopic, and robotic-assisted myomectomies.J Minim Invasive Gynecol. 2012; 19: 52-57https://doi.org/10.1016/j.jmig.2011.09.007Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar) estimated the mean cost of robot-assisted myomectomy to be $7,299, conventional laparoscopy $6,219, and conventional laparotomy $4,937. Regarding long-term outcome, larger studies are needed to evaluate the rates of pregnancy after myomectomy by robot-assisted laparoscopy versus laparotomy and the risk of secondary uterine rupture. Tubal sterilization is the leading mode of contraception worldwide, involving 17% of reproductive-age women (24Westhoff C. Davis A. Tubal sterilization: focus on the U.S. experience.Fertil Steril. 2000; 73: 913-922Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 25Population Division, Department of Economic and Social Affairs, United Nations. World contraceptive use 2007. Available at: www.un.org/esa/population/publications/contraceptive2007/WallChart_WCU2007_Data.xls. Accessed May 5, 2008.Google Scholar). Provided that no other abnormality of fertility exists, both the good reanastomosis outcome (pregnancy rate ranging from 50% to 88% in the literature) and mean cost by birth are rather favorable with laparoscopic tubal sterilization reversal compared with medically assisted reproduction (26Deffieux X. Morin Surroca M. Faivre E. Pages F. Fernandez H. Gervaise A. Tubal anastomosis after tubal sterilization: a review.Arch Gynecol Obstet. 2011; 283: 1149-1158Crossref PubMed Scopus (20) Google Scholar, 27Tan H.H. Loh S.F. Microsurgical reversal of sterilisation: is this still clinically relevant today?.Ann Acad Med Singap. 2010; 39: 22-26PubMed Google Scholar). Successful reanastomosis depends on several factors, especially patient age and adequate application of microsurgery rules: hydration, anatomic reconstruction with extra mucosa stitches, fine suture, and hemostasis and adequate magnification of the operating field (28HAS. Anastomose tubo tubaire par coelioscopie ou laparotomie. June 2008. Gervaise A, Deffieux X, Fernandez H. Available at: www.has-sante.fr.Google Scholar). The two main techniques that have been described for performing reanastomosis are: 1) four extra mucosa stitches placed at "6, 9, 12, and 3 o'clock" with the use of a thin monofilament nonabsorbable wire; and 2) the one-stitch technique that consists of one single suture placed at the "12 o'clock" site of the antimesenteric border (29Dubuisson J.B. Swolin K. Laparoscopic tubal anastomosis (the one stitch technique): preliminary results.Hum Reprod. 1995; 10: 2044-2046PubMed Google Scholar). For a long time, microscope-aided laparotomy has been the criterion standard for reanastomosis in tubal sterilization reversal, with rates of pregnancy ranging from 54% to 88% and rates of extrauterine pregnancy ranging from 2% to 7% (26Deffieux X. Morin Surroca M. Faivre E. Pages F. Fernandez H. Gervaise A. Tubal anastomosis after tubal sterilization: a review.Arch Gynecol Obstet. 2011; 283: 1149-1158Crossref PubMed Scopus (20) Google Scholar). This technique has been progressively supplanted by laparoscopy, which offers the advantages of minimally invasive surgery in terms of postoperative outcome, scarring, and adhesions reduction. However, laparoscopy does not allow the same quality of suture as in microsurgery: All of the surgeon's physiologic tremor, the 2-dimensional visualization, and the fixed axes and nonarticulation of the instruments make suturing difficult, especially when sutures must be nontraumatic and very precisely positioned, as they must be on the fallopian tube. The outcome, however, is quite the same as in laparotomy, whatever the technique (one single stitch or several stitches): The rate of pregnancy ranges from 31% to 85% and rate of extrauterine pregnancy from 3% to 7% (26Deffieux X. Morin Surroca M. Faivre E. Pages F. Fernandez H. Gervaise A. Tubal anastomosis after tubal sterilization: a review.Arch Gynecol Obstet. 2011; 283: 1149-1158Crossref PubMed Scopus (20) Google Scholar). Mean time to pregnancy ranges from 2.6 to 9 months. Nevertheless, we must underscore the substantial disparity of the data: Apart from the quality of the surgical procedure per se, intraoperative observations, factors of ovarian reserve, and sperm variables constitute biases likely to significantly modify the results. Few studies have compared the two techniques. Wiegerink et al. (30Wiegerinck M.A. Roukema M. van Kessel P.H. Mol B.W. Sutureless re-anastomosis by laparoscopy versus microsurgical re-anastomosis by laparotomy for sterilization reversal: a matched cohort study.Hum Reprod. 2005; 20: 2355-2358Crossref PubMed Scopus (26) Google Scholar) showed the superiority of microsurgical reanastomosis by laparotomy versus glue usage in sutureless reanastomosis by laparoscopy, whereas Cha et al. (31Cha S.H. Lee M.H. Kim J.H. Lee C.N. Yoon T.K. Cha K.Y. Fertility outcome after tubal anastomosis by laparoscopy and laparotomy.J Am Assoc Gynecol Laparosc. 2001; 8: 348-352Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar) observed no significant differences between laparoscopy and laparotomy with four stitches. Robotic tubal reanastomosis is usually performed after resection of the sclerotic area with the use of monopolar scissors and bipolar grasper (only two arms are necessary). End-to-end reanastomosis is carried out with extramucosal stitches of thin nonabsorbable monofilament wire (≤5.0) with the use of adequate needle holders. Tubal methylene blue test is performed at the end of the procedure (Fig. 2). Tremor filtration, microarticulated instruments, and magnification of the operating field allow the realization of several precise extramucosal stitches with a very thin thread as microsurgery in laparotomy. The first case of robot-assisted tubal anastomosis was described by Falcone et al. in 1999 (32Falcone T. Goldberg J. Garcia-Ruiz A. Margossian H. Stevens L. Full robotic assistance for laparoscopic tubal anastomosis: a case report.J Laparoendosc Adv Surgl Techn A. 1999; 9: 107-113Crossref PubMed Scopus (104) Google Scholar). Some studies have assessed robotic reanastomosis versus laparotomy (33Dharia Patel S.P. Steinkampf M.P. Whitten S.J. Malazia B.A. Robotic tubal anastomosis: surgical technique and cost effectiveness.Fertil Steril. 2008; 90: 1175-1179Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 34Rodgers A.K. Goldberg J.M. Hammel J.P. Falcone T. Tubal anastomosis by robotic compared with outpatient minilaparotomy.Obstet Gynecol. 2007; 109: 1375-1380Crossref PubMed Scopus (97) Google Scholar) but included only a small number of patients. They show lengthened operating time, but reduced hospital stay and analgesic consumption, as well as earlier return to normal active life, which is usually associated with minimally invasive surgery. No significant difference is evident in these comparisons between the two techniques regarding the rate of pregnancy at 12 months, with, however, a trend for higher rate with robotic surgery; the small size of the sample may explain the lack of significance of the figures. We identified only one study comparing conventional and robotic laparoscopy: a retrospective study of 10 and 18 cases operated with the use of the Zeus robot, which showed higher pregnancy rate with robotics (50% vs. 37.5%; ns), lengthened operating times, and reduced hospital stay (ns) (35Goldberg J.M. Falcone T. Laparoscopic microsurgical tubal anastomosis with and without robotic assistance.Hum Reprod. 2003; 18: 145-147Crossref PubMed Scopus (82) Google Scholar). The most important study on robot-assisted laparoscopic reanastomosis was published in 2010 by Caillet et al. (36Caillet M. Vandromme J. Rozenberg S. Paesmans M. Germay O. Degueldre M. Robotically assisted laparoscopic microsurgical tubal anastomosis: a retrospective study.Fertil Steril. 2010; 94: 1844-1847Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar); it was a retrospective study of 97 patients, showing 71% pregnancy rate at 24 months and, the results being age stratified, a rate of pregnancy of ∼90% in women <35 years old. In the last procedures, operating times were reduced to a mean value of 110 minutes, which is very close to the figures usually associated with conventional laparoscopy and even laparotomy, reflecting the shorter length of the robotics learning curve compared with that of laparoscopy (37Lenihan Jr., J.P. Kovanda C. Seshadri-Kreaden U. What is the learning curve for robotic assisted gynecologic surgery?.J Minim Invasive Gynecol. 2008; 15: 589-594Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar). No complication specifically related to robotics has been reported in this indication, but we still lack randomized prospective studies allowing potentially conclusive evidence of the advantages of robotics in tubal reanastomosis. However, the relative rarity of this indication makes carrying out such studies difficult. Two downsides have been highlighted in robotics: the lack of haptic feedback and the costs. Regarding the first, a rate of wire rupture at knot tying reaching 11% was reported to be associated with robotic reanastomosis by Caillet et al. (36Caillet M. Vandromme J. Rozenberg S. Paesmans M. Germay O. Degueldre M. Robotically assisted laparoscopic microsurgical tubal anastomosis: a retrospective study.Fertil Steril. 2010; 94: 1844-1847Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar). For the second, studies show a cost per procedure higher than that associated with laparotomy (33Dharia Patel S.P. Steinkampf M.P. Whitten S.J. Malazia B.A. Robotic tubal anastomosis: surgical technique and cost effectiveness.Fertil Steril. 2008; 90: 1175-1179Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 34Rodgers A.K. Goldberg J.M. Hammel J.P. Falcone T. Tubal anastomosis by robotic compared with outpatient minilaparotomy.Obstet Gynecol. 2007; 109: 1375-1380Crossref PubMed Scopus (97) Google Scholar) but a similar cost by birth (34Rodgers A.K. Goldberg J.M. Hammel J.P. Falcone T. Tubal anastomosis by robotic compared with outpatient minilaparotomy.Obstet Gynecol. 2007; 109: 1375-1380Crossref PubMed Scopus (97) Google Scholar). Owing to the heaviness of laparotomy and easier access to medically assisted reproduction, proximal and midtubal surgery for endometriosis and postinfective sclerosis are no longer performed. In fact, tubal surgery remains restricted to reanastomosis for tubal sterilization reversal; however, robotic assistance is likely to modify the field and make such interventions more easily feasible. No study is currently available on this topic. Laparoscopy has a prominent place in the management of deep endometriosis. Endometriosis treatment must be as radical as possible to significantly increase the likelihood of spontaneous pregnancy. Adamson et al. (38Adamson G.D. Pasta D.J. Surgical treatment of endometriosis-associated infertility: meta-analysis compared with survival analysis.Am J Obstet Gynecol. 1994; 171 (discussion 1504–5 Erratum in: Am J Obstet Gynecol 1995 Jun;172(6):1937.): 1488-1504Abstract Full Text PDF PubMed Scopus (155) Google Scholar) have shown an increased rate of postoperative spontaneous pregnancy after surgical treatment of endometriosis-associated infertility: from 22% to 52% in revised American Fertility Society stage 3 and from 3% to 41% in stage 4. Nevertheless, this surgery is complex and requires a well trained, experienced, and often multidisciplinary (urologist, visceral surgeon) surgical team. The associated morbidity is significant owing to the invasion of surrounding organs, nerves, and blood vessels, as well as to the limits of dissection in laparoscopy. The literature reports rates of 3.6% of bladder atony and 15% of digestive fistula in case of rectal resection (39Fedele L. Bianchi S. Zanconato G. Bettoni G. Gotsch F. Long-term follow-up after conservative surgery for rectovaginal endometriosis.Am J Obstet Gynecol. 2004; 190: 1020Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar, 40Darai E. Thomassin I. Barranger E. Detchev R. Cortez A. Houry S. et al.Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis.Am J Obstet Gynecol. 2005; 192: 394-400Abstract Full Text Full Text PDF PubMed Scopus (214) Google Scholar). In addition, the adhesions related to initial endometriosis or induced by the surgery negatively affect the subsequent pregnancy rate (41Canis M. Mage G. Wattiez A. Chapron C. Pouly J.L. Bassil S. Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas.Fertil Steril. 1992; 58: 617-619Crossref PubMed Scopus (143) Google Scholar). Finally, laparoscopic ovarian cystectomy may lead to premature ovarian failure in the case of endometriotic cyst due to the inherent dissection difficulties (42Yazbeck C. Madelenat P. Sifer C. Hazout A. Poncelet C. Ovarian endometriomas: effect of laparoscopic cystectomy on ovarian response in IVF-ET cycles.Gynecol Obstet Fertil. 2006; 34: 808-812Crossref PubMed Scopus (31) Google Scholar). In deep endometriosis, laparoscopic surgery appears to have many drawbacks; consideration should be given to the potential role of robotics in this indication. Very limited literature is available to date, and no recommendations exist regarding potential benefits of robot-assisted surgery in deep infiltrating endometriosis. Robot-assisted techniques might help completing resections in poorly accessible areas, particularly in the cul-de-sac, with greater dexterity (jointed robotic arms) and enhanced precision with the use of smaller instruments, 3D magnification of the operating field, and tremor filtration. Adequate application of microsurgery rules should reduce postoperative adhesions and conserve ovarian reserve in the case of ovarian cystectomy. Some authors report single cases of deep pelvic endometriosis resection. Chammas et al. (43Chammas Jr., M.F. Kim F.J. Barbarino A. Hubert N. Feuillu B. Coissard A. et al.Asymptomatic rectal and bladder endometriosis: a case for robotic-assisted surgery.Can J Urol. 2008; 15: 4097-4100PubMed Google Scholar) describe a partial cystectomy and resection of a rectal lesion with no digestive derivation, performed with robotic assistance, and Liu et al. (44Liu C. Perisic D. Samadi D. Nezhat F. Robotic-assisted laparoscopic partial bladder resection for the treatment of infiltrating endometriosis.J Minim Invasive Gynecol. 2008; 15: 745-748https://doi.org/10.1016/j.jmig.2008.07.002Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar) report a case of partial cystectomy as well. Robot-assisted laparoscopy appears to be feasible in deep endometriosis. Nezhat et al. (45Nezhat C. Lewis M. Kotikela S. Veeraswamy A. Saadat L. Hajhosseini B. et al.Robotic versus standard laparoscopy for the treatment of endometriosis.Fertil Steril. 2010; 94: 2758-2760https://doi.org/10.1016/j.fertnstert.2010.04.031Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar) recently reported a series of 78 cases, comparing robot-assisted laparoscopy (n = 40) with standard laparoscopy (n = 38); lengthened operating duration was observed with the robot-assisted procedure (191 minutes vs. 159 minutes) but with similar rates of complications and blood loss in the two groups. Ercoli et al. (46Ercoli A. d'Asta M. Fagotti A. Fanfani F. Romano F. Baldazzi G. et al.Robotic treatment of colorectal endometriosis: technique, feasibility and short-term results.Hum Reprod. 2012; 27: 722-726https://doi.org/10.1093/humrep/der444Crossref PubMed Scopus (53) Google Scholar) consider robotic surgery to be a revolutionary approach in the treatment of deep infiltrating endometriosis with colorectal involvement; their 14-month study included 22 patients with this disease and showed significant symptom improvement postoperatively and no case of laparoconversion. The long-term follow-up of patients should confirm these short-term results and allow evaluating the outcome in terms of fertility. Very few published data exist on robot-assisted salpingo-oophorectomy. The sole publication reports a retrospective cohort study that compared 85 cases of robotic adnexal surgery with 91 standard laparoscopic procedures; no difference was observed between the two routes regarding blood loss, intraoperative complications, or duration of hospital stay; the operating time was increased by 12 minutes with the robotic approach (47Magrina J.F. Espada M. Munoz R. Noble B.N. Kho R.M. Robotic adnexectomy compared with laparoscopy for adnexal mass.Obstet Gynecol. 2009; 114: 581-584https://doi.org/10.1097/AOG.0b013e3181b05d97Crossref PubMed Scopus (36) Google Scholar). Consequently, it would not be appropriate to recommend robotic assistance for such simple interventions that are easily managed by standard laparoscopy. Robot-assisted laparoscopy seems to be of interest in cases of complex surgical treatment of infertility. Myomectomy, tubal reanastomosis, and deep infiltrating endometriosis appear to be the preferred indications. The main limitation to the diffusion of this technique remains its cost. Further studies are needed to determine the superiority of robotic surgery over other techniques to implement it more commonly in these procedures. Particularly needed are randomized controlled trials, which are still lacking, looking at issues such as operating time, blood loss, and immediate and post-surgical complications. But it will be crucial to have more long-term outcomes regarding fertility: pregnancy rate (natural and IVF), uterine rupture for myomectomy, impact on ovarian reserve, adhesion forming, etc. These results are necessary for showing the real contribution of robot-assisted laparoscopy in gynecology.