Authors' objectives: The objective of this technology review was to assess the effectiveness, safety, and cost effectiveness of robotic-assisted surgery for gynaecological disorders.

Authors' results and conclusions: Search results A total of 590 records were identified through the Ovid interface and PubMed while 15 were identified from references of retrieved articles. Thirty-three duplicate references were found; 557 potentially relevant titles were screened using the inclusion and exclusion criteria. Of these, 44 relevant abstracts were retrieved in full text. After reading, appraising, and applying the inclusion and exclusion criteria to the full-text articles, 33 were included while the other 11 were excluded since the studies were included in the systematic reviews, had irrelevant populations and few were narrative reviews. All full-text articles finally selected for this review were 18 systematic review and network meta/meta-analysis, 6 systematic reviews, one HTA, one cohort study, two cross-sectional studies, two qualitative studies, and three cost analyses. Efficacy/ effectiveness Robotic-Assisted Surgery for General Gynaecological Disorders Multiple meta-analyses and systematic reviews demonstrated that robotic-assisted surgery showed comparable effectiveness to conventional laparoscopic and open surgeries for general gynaecological conditions including benign and malignant conditions, with similar clinical outcomes. Although robotic surgery consistently involved longer operative times compared to laparoscopic approaches, it provided notable advantages over open surgery, including reduced length of hospital stay and lower estimated blood loss. Robotic-Assisted Surgery for Myomectomy Evidence from systematic reviews and meta-analyses showed that compared to laparoscopic myomectomy and open myomectomy, robotic-assisted myomectomy significantly reduced estimated blood loss, lowered conversion rates from minimally invasive to open surgery, and shortened hospital stays relative to open myomectomy. However, operative times were consistently longer for robotic-assisted myomectomy compared to laparoscopic myomectomy and open myomectomy. Robotic-Assisted Surgery for Endometriosis Evidence from systematic reviews and meta-analyses indicates that robotic-assisted surgery demonstrates comparable clinical effectiveness to conventional laparoscopic surgery for endometriosis. Robotic surgery showed no significant difference in intraoperative and postoperative complications, conversion rates, or estimated blood loss compared to conventional laparoscopy. However, robotic-assisted surgery consistently involved significantly longer operative times, with mean differences ranging from 28 to 51 minutes compared to laparoscopic surgery. For bowel deep infiltrating endometriosis, robotic surgery was associated with shorter hospital stays and comparable symptomatic relief, despite increased operative durations. Robotic-Assisted Surgery for Hysterectomy Evidence from systematic reviews and meta-analyses indicates that robotic-assisted hysterectomy significantly reduces hospital stays, blood loss, transfusion rates, and conversion rates compared to laparoscopic and open approaches. Robotic single-site hysterectomy also proved safe and feasible, exhibiting short hospital stays, minimal blood loss, and low conversion rates. Despite slightly longer operative times, RAH and RSSH offer clear clinical advantages, particularly beneficial in cases involving larger uteri or prior abdominal surgeries. Robotic-Assisted Surgery for Endometrial Cancer Evidence from multiple systematic reviews and meta-analyses demonstrates that roboticassisted surgery for endometrial cancer offers superior perioperative outcomes compared to laparotomy and conventional laparoscopy, particularly in improving short-term surgical outcomes including significantly reduced blood loss, transfusion rates, and hospital stay, though operative times were longer. While long-term oncologic outcomes such as disease-free and overall survival are comparable across surgical approaches, some studies reported a slight advantage in disease-free survival for robotic-assisted surgery. Robotic-Assisted Surgery for Sacrocolpopexy in Pelvic Organ Prolapse Multiple systematic reviews and meta-analyses consistently showed robotic-assisted sacrocolpopexy is associated with less estimated blood loss, lower conversion rates, and high anatomical success, particularly for apical prolapse. Although it often involves longer operative times and higher costs, multiple systematic reviews and meta-analyses confirm that it achieves excellent anatomical outcomes, with cure rates up to 98.6% and low recurrence and reoperation rates. Robotic-Assisted Surgery for Stress Urinary Incontinence Robotic-assisted artificial urinary sphincter implantation in women with stress urinary incontinence has shown promising effectiveness in multiple recent studies, with continence rates ranging from 72% to 83% and significant improvements in quality-of-life measures. Safety Robotic-Assisted Surgery for General Gynaecological Disorders Multiple systematic reviews and meta-analyses indicate that roboticassisted gynaecologic surgery demonstrates a safety profile comparable to conventional laparoscopic surgery, with no significant differences in overall complication rates. Robotic single-port procedures show acceptable complication rates, predominantly minor, and rare conversion rates. Mortality rates associated with robotic gynaecologic surgery are extremely low, closely mirroring laparoscopic surgery outcomes. Robotic approaches in oncologic cases specifically resulted in significantly lower blood loss compared to open surgery, without increased complication risks. Robotic-Assisted Surgery for Myomectomy Multiple systematic reviews and meta-analyses indicate that roboticassisted myomectomy has a favourable safety profile, showing comparable complication and transfusion rates to laparoscopic myomectomy. However, compared to open myomectomy, robotic procedures demonstrated significantly lower complication rates, reduced transfusion requirements, and decreased blood loss. Robotic-Assisted Surgery for Endometriosis Multiple systematic reviews and meta-analyses indicate that roboticassisted surgery demonstrates comparable safety outcomes to conventional laparoscopy for endometriosis. Specifically, no significant differences were observed between robotic and laparoscopic procedures regarding intraoperative complications, postoperative complications, conversion rates to open surgery, or estimated blood loss. Robotic-Assisted Surgery for Hysterectomy Multiple systematic reviews and meta-analyses indicate that roboticassisted hysterectomy is associated with favourable safety outcomes compared to other surgical approaches. Robotic-assisted hysterectomy showed significantly fewer complications than open hysterectomy, lower transfusion and conversion rates than laparoscopy, and slightly reduced readmission rates. Robotic single-site hysterectomy also demonstrated low intraoperative and postoperative complication rates, minimal blood loss, and no reoperations or readmissions within 30 days. Robotic-Assisted Surgery for Endometrial Cancer Evidence from multiple systematic reviews and meta-analyses consistently indicate that robotic-assisted surgery for endometrial cancer is associated with a favourable safety profile compared to laparotomy and laparoscopy. Robotic-assisted surgery significantly reduces intraoperative and postoperative complications, blood loss, transfusion rates, and conversion to open surgery. In patients with obesity, robotic-assisted surgery maintains low perioperative complication rates and shows reduced conversion rates. Robotic-Assisted Surgery for Sacrocolpopexy in Pelvic Organ Prolapse Multiple systematic reviews have demonstrated that robotic-assisted sacrocolpopexy is consistently associated with lower blood loss, fewer conversions to open surgery, and high anatomical success rates. Although overall complication and transfusion rates are similar between robotic and laparoscopic sacrocolpopexy, robotic sacrocolpopexy shows low rates of mesh-related complications and reoperations. Some evidence indicates increased postoperative pain and analgesic use with RSC, but serious adverse events remain uncommon. Robotic-Assisted Surgery for Stress Urinary Incontinence Evidence from recent studies suggests that robotic-assisted artificial urinary sphincter implantation in women with stress urinary incontinence offers favourable continence outcomes, with pooled rates ranging from 72% to 83%. However, complication rates remain considerable, with intraoperative complications reported in up to 21% of cases and postoperative complications in approximately 20–27%. Economic Implications Multiple studies highlight the substantially higher costs associated with robotic-assisted surgery compared to conventional approaches. Robotic hysterectomy was the most expensive among all hysterectomy types, primarily due to equipment and maintenance costs, while offering clinical benefits in complex cases. In gynaecologic oncology, robotic-assisted surgery demonstrated higher operative and equipment costs, but also yielded lower blood loss, fewer conversions, and shorter hospital stays in some studies. Cost-effectiveness appears limited and may only be achieved in high-volume centres or with cost-saving strategies. Organisational Issues Training Despite widespread availability of robotic systems and simulators in training institutions, formalized curricula for roboticassisted surgery remain limited. Many residents lack faculty-led instruction and hands-on opportunities to serve as primary surgeons. Key barriers include time constraints, limited simulator access, and faculty reluctance. However, most trainees express strong interest in pursuing robotic certification and integrating robotics into future practice, highlighting the need for structured, standardized training programs in residency. Perception of healthcare experts Healthcare professionals generally perceive robotic-assisted surgery as a valuable innovation that enhances clinical performance and hospital reputation. However, adoption remains limited due to financial barriers, training gaps, and infrastructural constraints. While some experts support its selective use in complex cases, others advocate broader implementation due to perceived advantages in precision, ergonomics, and recovery time. Despite favourable views, concerns persist around resident readiness and inconsistent training exposure, suggesting a need for standardized curricula and robust credentialing pathways to support future adoption. Guidelines Numerous international and regional bodies have issued guidelines to support the safe, effective, and standardized implementation of roboticassisted surgery in gynaecology. These guidelines consistently emphasize key areas including appropriate patient selection, surgeon training and credentialing, informed consent, and quality assurance mechanisms. In highincome and regional contexts alike, structured curricula, simulation-based training, and certification processes are promoted to ensure surgical proficiency. Ethical Issues While robotic-assisted surgery offers technological advancements and potential clinical benefits, it raises several ethical concerns. Key issues include ensuring informed consent amidst patient misconceptions, equitable access given the high cost of robotic-assisted surgery, and variability in training that may impact surgical competency and patient safety. Inconsistent evidence of clinical superiority, coupled with significantly higher costs, also raises questions about justifiable resource allocation in public healthcare. Additionally, potential conflicts of interest such as those driven by industry partnerships highlight the need for transparency and evidence-based decision-making to maintain ethical, patient-centered care. CONCLUSION Robotic-assisted surgery for gynaecological disorders demonstrates comparable safety and clinical effectiveness to conventional approaches, with potential advantages in reducing blood loss, shortening hospital stays, and enhancing surgical precision, particularly in complex cases. However, these benefits are accompanied by significantly higher costs, longer operative times, and limited long-term outcome data. Significant organizational challenges were identified, including inconsistent training, limited resident autonomy, and the absence of standardized curricula, all of which may compromise surgical proficiency and patient safety. Although international and regional guidelines emphasize structured education and credentialing, their implementation across settings remains highly variable.

Authors' methods: A systematic search was conducted on the following databases without any restriction on publication language and publication status. The Ovid interface: Ovid MEDLINE(R) and Epub Ahead of Print, InProcess, In-Data-Review & Other Non-Indexed Citations and Daily 1946 to March 3rd, 2025. Searches were also run in Cochrane Embase, PubMed, and INAHTA databases. Google was used to search for additional web-based materials and information. Additional articles were identified by reviewing the references of retrieved articles. The last search was conducted on 3rd March 2025.

Project Status: Completed

URL for project: https://www.moh.gov.my/index.php/database_stores/store_view_page/30/425

Year Published: 2025

URL for published report: https://www.moh.gov.my/index.php/database_stores/store_view_page/30/425

English language abstract: An English language summary is available

Publication Type: Mini HTA

Country: Malaysia

Organisation Name: Malaysian Health Technology Assessment

Contact Address: Malaysian Health Technology Assessment Section, Ministry of Health Malaysia, Federal Government Administrative Centre, Level 4, Block E1, Parcel E, 62590 Putrajaya Malaysia Tel: +603 8883 1229

Contact Name: htamalaysia@moh.gov.my

Contact Email: htamalaysia@moh.gov.my

Copyright: Malaysian Health Technology Assessment Section (MaHTAS)