PURPOSE: The surgical treatment of endometriosis, which is routinely performed by minimally invasive approach, is developing towards an increasing complexity in deep endometriosis. While RAS appears to be gaining importance, there are few real-life data on its use for patients with endometriosis. The aim of this study is to investigate the current use of RAS in certified endometriosis centers in Central Europe. METHODS: In this international multicentric cross-sectional study, an online branching survey was sent to certified endometriosis centers in Austria, the Czech Republic, Germany, and Switzerland. This survey contained 47 questions including proportion of use, indications, advantages and barriers, technical aspects, and training in RAS. RESULTS: Of the 97 centers contacted, 66% (n = 64) participated. RAS is used for the treatment of endometriosis in 60.8% (n = 31) of the centers with access to a SR, which corresponds to 48.4% of all participating centers. In Austria, 81.8% (n = 9) of centers have SR access, respectively, 88.9% (n = 8) use RAS for endometriosis; in Switzerland, 91.6% (n = 11) and 36.4% (n = 4); and in Germany, 74.4% (n = 29) and 62.1% (n = 18). The reported advantages of RAS include precision (80%, n = 40), instrument mobility (74%, n = 37), and visualization (72%, n = 36). Compared to CLS, RAS is preferred in multidisciplinary cases (84.6%, n = 22), and overweight patients (61.5%, n = 16) and deep endometriosis (61.5%, n = 16). Specific anatomical indications for RAS vs. CLS include FU (57.7%, n = 15), C (53.9%, n = 14), and FB (50%, n = 13) (#Enzian classification). Patient outcomes of RAS compared to CLS are rated as advantageous in 69.2% (n = 18). The main barriers for RAS for centers without an SR include costs (100%, n = 12) and lack of scientific evidence (33.3%, n = 4). 69.2% (n = 18) have dedicated robotic teams, 42.3% (n = 11) have a second console, 69.2% (n = 18) have a simulator, and 34.6% (n = 9) have training programs. A total of 65.4% (n = 17) believes that RAS will replace CLS in selected cases, and 73.1% (n = 19) would prefer RAS if costs were equal. CONCLUSION: This study demonstrates that RAS is already being used in approximately half of the participating endometriosis centers. While the proportion of RAS procedures compared to CLS is increasing, it still remains comparatively low. Country-specific differences in the use of RAS are evident and are most likely linked to healthcare system structures. Participating centers report both technical and general surgical advantages, as well as specific benefits in cases of deep endometriosis. The main barriers include costs and a lack of scientific evidence. Further research is needed to evaluate the long-term role of RAS in the management of endometriosis.

Clinic of Gynecology Obstetrics and Gynecological Oncology University Hospital for Gynecology Pius Hospital Oldenburg Medical Campus University of Oldenburg Oldenburg Germany

Department of Gynecology and Obstetrics Hospital Schaffhausen Schaffhausen Switzerland

Department of Gynecology and Obstetrics Saarland University Hospital Homburg Germany

Department of Gynecology University Hospital of Zurich Zurich Switzerland

Department of Obstetrics Gynecology and Gynecological Oncology Bethesda Hospital Duisburg Germany

Endometriosis Clinic Dres Keckstein Villach Austria

Stiftung Endometriose Forschung Westerstede Germany

See more in PubMed

Zondervan KT, Becker CM, Missmer SA (2020) Endometriosis. N Engl J Med 382(13):1244–1256 PubMed

Nisolle M, Donnez J (2019) Reprint of: peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril. 112(4 Suppl):e125–e136 PubMed

Shafrir AL, Farland LV, Shah DK, Harris HR, Kvaskoff M, Zondervan K et al (2018) Risk for and consequences of endometriosis: a critical epidemiologic review. Best Pract Res Clin Obstet Gynaecol 51:1–15 PubMed

Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I et al (2012) The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod 27(5):1292–1299 PubMed

Strowitzki T, Marr J, Gerlinger C, Faustmann T, Seitz C (2010) Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial. Hum Reprod 25(3):633–641 PubMed

Becker CM, Johnson NP, As-Sanie S, Arjona Ferreira JC, Abrao MS, Wilk K et al (2024) Two-year efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain: SPIRIT open-label extension study. Hum Reprod 39(3):526–537 PubMed PMC

Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L et al (2022) ESHRE guideline: endometriosis. Hum Reprod Open. 2022(2):h0ac009

International Working Group of Aagl EE, Wes TC, Johnson NP, Petrozza J, Abrao MS et al (2021) An international terminology for endometriosis. J Minim Invasive Gynecol 28(11):1849–1859

Condous G, Gerges B, Thomassin-Naggara I, Becker C, Tomassetti C, Krentel H et al (2024) Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: an International Consensus Statement. Ultrasound Obstet Gynecol 64(1):129–144 PubMed

Working group of Esge E, Wes, Keckstein J, Becker CM, Canis M, Feki A, et al. (2020) Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open 2020(1):hoaa002

Burla L, Kalaitzopoulos DR, Samartzis N, Khazali S, Bokor A, Renner SP et al (2024) Recommendations for the implementation and conduct of multidisciplinary team meetings for those providing endometriosis and adenomyosis care: a Delphi consensus of the European Endometriosis League (EEL). Facts Views Vis Obgyn 16(3):337–350 PubMed PMC

Lenfant L, Canlorbe G, Belghiti J, Kreaden US, Hebert AE, Nikpayam M et al (2023) Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis. J Robot Surg 17(6):2647–2662 PubMed PMC

Rivero-Moreno Y, Echevarria S, Vidal-Valderrama C, Pianetti L, Cordova-Guilarte J, Navarro-Gonzalez J et al (2023) Robotic surgery: a comprehensive review of the literature and current trends. Cureus 15(7):e42370 PubMed PMC

Restaino S, Mereu L, Finelli A, Spina MR, Marini G, Catena U et al (2020) Robotic surgery vs laparoscopic surgery in patients with diagnosis of endometriosis: a systematic review and meta-analysis. J Robot Surg 14(5):687–694 PubMed

Nezhat CR, Stevens A, Balassiano E, Soliemannjad R (2015) Robotic-assisted laparoscopy vs conventional laparoscopy for the treatment of advanced stage endometriosis. J Minim Invasive Gynecol 22(1):40–44 PubMed

Collinet P, Leguevaque P, Neme RM, Cela V, Barton-Smith P, Hébert T et al (2014) Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study. Surg Endosc 28(8):2474–2479 PubMed

Song Z, Li S, Luo M, Li H, Zhong H, Wei S (2023) Assessing the role of robotic surgery versus laparoscopic surgery in patients with a diagnosis of endometriosis: a meta-analysis. Medicine (Baltimore) 102(50):e33104 PubMed

Csirzó Á, Kovács DP, Szabó A, Fehérvári P, Jankó Á, Hegyi P et al (2024) Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: a systematic review and meta-analysis. Surg Endosc 38(2):529–539 PubMed

Saget E, Peschot C, Bonin L, Belghiti J, Boulland E, Ghesquiere L et al (2022) Robot-assisted laparoscopy for deep infiltrating endometriosis: a retrospective French multicentric study (2008–2019) using the Society of European Robotic Gynecological Surgery endometriosis database. Arch Gynecol Obstet 305(4):1105–1113 PubMed

Pavone M, Baroni A, Campolo F, Goglia M, Raimondo D, Carcagni A et al (2024) Robotic assisted versus laparoscopic surgery for deep endometriosis: a meta-analysis of current evidence. J Robot Surg 18(1):212 PubMed PMC

Andres MP, Souza C, Villaescusa M, Vieira M, Abrao MS (2022) The current role of robotic surgery in endometriosis management. Expert Rev Endocrinol Metab 17(1):63–73 PubMed

Morelli L, Perutelli A, Palmeri M, Guadagni S, Mariniello MD, Di Franco G et al (2016) Robot-assisted surgery for the radical treatment of deep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and functional outcomes. Int J Colorectal Dis 31(3):643–652 PubMed

Mikhail E, Pavlovic ZJ, Al Jumaily M, Kheil MH, Moawad GN, Soares T (2022) Robot-assisted surgery for endometriosis current and future perspectives. Surg Technol Int 40:197–202 PubMed

Nezhat C, Lewis M, Kotikela S, Veeraswamy A, Saadat L, Hajhosseini B et al (2010) Robotic versus standard laparoscopy for the treatment of endometriosis. Fertil Steril 94(7):2758–2760 PubMed

Kanno K, Yanai S, Masuda S, Ochi Y, Sawada M, Sakate S et al (2024) Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis. Arch Gynecol Obstet 310(3):1677–1685 PubMed

Soto E, Luu TH, Liu X, Magrina JF, Wasson MN, Einarsson JI et al (2017) Laparoscopy vs. robotic surgery for endometriosis (LAROSE): a multicenter, randomized, controlled trial. Fertil Steril 107(4):996-1002.e3 PubMed

Hebert T (2024) Robotic assisted laparoscopy for deep infiltrating endometriosis. Best Pract Res Clin Obstet Gynaecol 92:102422 PubMed

Ferrari FA, Youssef Y, Naem A, Ferrari F, Odicino F, Krentel H et al (2024) Robotic surgery for deep-infiltrating endometriosis: Is it time to take a step forward? Front Med (Lausanne) 11:1387036 PubMed

Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW et al (2021) The #Enzian classification: a comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 100(7):1165–1175 PubMed

Bachner F, Bobek J, Habimana K, Ladurner J, Lepuschütz L, Ostermann H, et al. (2019) Das österreichische Gesundheitssystem

Halwachs-Baumann G. (Mediziner2024) Gesundheitsökonomie für

Hanssens S, Nisolle M, Leguevaque P, Neme RM, Cela V, Barton-Smith P et al (2014) Robotic-assisted laparoscopy for deep infiltrating endometriosis: the register of the society of european robotic gynaecological surgery. Gynecol Obstet Fertil 42(11):744–748 PubMed

Yoshida K, Kondo E, Nimura R, Maki S, Kaneda M, Nii M et al (2021) Laparoscopic versus robotic hysterectomy in obese patients with early-stage endometrial cancer: a single-centre analysis. Anticancer Res 41(8):4163–4167 PubMed

Alshowaikh K, Karpinska-Leydier K, Amirthalingam J, Paidi G, Iroshani Jayarathna AI, Salibindla D et al (2021) Surgical and patient outcomes of robotic versus conventional laparoscopic hysterectomy: a systematic review. Cureus 13(8):e16828 PubMed PMC

El-Achi V, Weishaupt J, Carter J, Saidi S (2021) Robotic versus laparoscopic hysterectomy in morbidly obese women for endometrial cancer. J Robot Surg 15(3):483–487 PubMed

Brunes M, Johannesson U, Habel H, Soderberg MW, Ek M (2021) Effects of obesity on peri- and postoperative outcomes in patients undergoing robotic versus conventional hysterectomy. J Minim Invasive Gynecol 28(2):228–236 PubMed

Mendes V, Bruyere F, Escoffre JM, Binet A, Lardy H, Marret H et al (2020) Experience implication in subjective surgical ergonomics comparison between laparoscopic and robot-assisted surgeries. J Robot Surg 14(1):115–121 PubMed

Patel N, Chaudhari K, Jyotsna G, Joshi JS (2023) Surgical frontiers: a comparative review of robotics versus laparoscopy in gynecological interventions. Cureus 15(11):e49752 PubMed PMC

Kramer B, Neis F, Reisenauer C, Walter C, Brucker S, Wallwiener D et al (2023) Save our surgeons (SOS): an explorative comparison of surgeons’ muscular and cardiovascular demands, posture, perceived workload and discomfort during robotic vs. laparoscopic surgery. Arch Gynecol Obstet. 307(3):849–862 PubMed

Kanno K, Andou M, Sawada M, Hoshiba T (2025) Ureteroneocystostomy for ureteral endometriosis using the da Vinci SP. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2025.03.024 PubMed

Xu G, Lovell DY, Guan X (2024) Robot-assisted vaginal natural orifice transluminal endoscopic surgery (RvNOTES) with total hysterectomy for management of stage IV endometriosis with/without complete cul-de-sac obliteration: 23-case pilot feasibility study. J Minim Invasive Gynecol 31(6):496–503 PubMed

Berlanda N, Frattaruolo MP, Aimi G, Farella M, Barbara G, Buggio L et al (2017) “Money for nothing”. The role of robotic-assisted laparoscopy for the treatment of endometriosis. Reprod Biomed Online. 35(4):435–444 PubMed

Crestani A, Le Gac M, de Labrouhe E, Touboul C, Bendifallah S, Ferrier C et al (2024) Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy. J Robot Surg 18(1):87 PubMed

Ong HI, Shulman N, Nugraha P, Wrenn S, Nally D, Peirce C et al (2024) Role of robot-assisted laparoscopy in deep infiltrating endometriosis with bowel involvement: a systematic review and application of the IDEAL framework. Int J Colorectal Dis 39(1):98 PubMed PMC

Binder J, Brautigam R, Jonas D, Bentas W (2004) Robotic surgery in urology: Fact or fantasy? BJU Int 94(8):1183–1187 PubMed

Carbonara U, Srinath M, Crocerossa F, Ferro M, Cantiello F, Lucarelli G et al (2021) Robot-assisted radical prostatectomy versus standard laparoscopic radical prostatectomy: an evidence-based analysis of comparative outcomes. World J Urol 39(10):3721–3732 PubMed

Maynou L, Mehtsun WT, Serra-Sastre V, Papanicolas I (2021) Patterns of adoption of robotic radical prostatectomy in the United States and England. Health Serv Res. 56(Suppl 3):1441–1461 PubMed PMC

Verrelli L, Merlot B, Chanavaz-Lacheray I, Braund S, D'Ancona G, Kade S, et al. (2023) Robotic surgery for severe endometriosis: a preliminary comparative study of cost estimation. J Minim Invasive Gynecol

Olsen RG, Hartwell D, Dalsgaard T, Madsen ME, Bjerrum F, Konge L et al (2024) First experience with the Hugo™ robot-assisted surgery system for endometriosis: a descriptive study. Acta Obstet Gynecol Scand 103(2):368–377 PubMed

Byrn JC, Hrabe JE, Charlton ME (2014) An initial experience with 85 consecutive robotic-assisted rectal dissections: improved operating times and lower costs with experience. Surg Endosc 28(11):3101–3107 PubMed PMC

De Nagy J, Youssef Y, Moawad G (2023) Strategies and factors to maximize cost-effectiveness of robotic surgery in benign gynecological disease. Best Pract Res Clin Obstet Gynaecol 90:102380 PubMed

Terho AM, Makela-Kaikkonen J, Ohtonen P, Uimari O, Puhto T, Rautio T et al (2022) Robotic versus laparoscopic surgery for severe deep endometriosis: protocol for a randomised controlled trial (ROBEndo trial). BMJ Open 12(7):e063572 PubMed PMC