# Robot-assisted versus conventional laparoscopic hysterectomy in endometrial cancer: an observational study in a French tertiary teaching hospital at the beginning of the learning curve

Emma Bajeux, Stephanie Hamonic, Solène Brunet-Houdard, Krystel Nyangoh

Timoh, L. Dion, Alexia Guecheff, Vincent Lavoué

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Emma Bajeux, Stephanie Hamonic, Solène Brunet-Houdard, Krystel Nyangoh Timoh, L. Dion, et al. Robot-assisted versus conventional laparoscopic hysterectomy in endometrial cancer: an observational study in a French tertiary teaching hospital at the beginning of the learning curve. Journal of Gynecology Obstetrics and Human Reproduction, 2025, 54 (4), pp.102917. 10.1016/j.jogoh.2025.102917. hal-04928748

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Original Article

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# Robot-assisted versus conventional laparoscopic hysterectomy in endometrial cancer: An observational study in a French tertiary teaching hospital at the beginning of the learning curve

Emma Bajeux<sup>a</sup>, Stéphanie Hamonic<sup>b</sup>, Solène Brunet-Houdard<sup>c</sup>, Krystel Nyangoh Timoh<sup>d,e</sup>,
Ludivine Dion<sup>d,f</sup>, Alexia Guecheff<sup>d</sup>, Vincent Lavoue<sup>d,f,*</sup>

ARTICLE INFO

Keywords:

Endometrial cancer – Robot-assisted hysterectomy – laparoscopic hysterectomy

Hospital length of stay – Complications

ABSTRACT

**Introduction:** The role of Robotic Assisted Laparoscopy (RAL) versus conventional laparoscopy (CL) in the surgical treatment of endometrial cancer remains a matter of debate. We aimed to compare RAL and CL in terms of clinical outcomes (hospital stay characteristics and 3-month complications) in patients undergoing hysterectomy for endometrial cancer.

**Materials and Methods:** We conducted a single-center, retrospective study in a tertiary teaching hospital comparing two groups of women who underwent hysterectomy for endometrial carcinoma by RAL performed by a surgeon during the beginning of learning curve, or CL.

**Results:** Of the 110 patients included, 56 were in the RAL group and 54 in the CL group. The patients in the RAL group were significantly older (71.6±8.7 vs 67.8±9.7, p=0.031) and had a higher BMI (33.1±7.0 vs 29.8±6.1, p=0.030) than those in the CL group. Operating room occupancy time was higher with RAL (4.6 hours±1.3 vs 3.5±1.3, p<0.001). Although less spinal analgesia was used in the RAL group (35% vs 74%, p<0.001), the patients in this group consumed less postoperative paracetamol (9.4g±5.3 vs 13.0±9.9, p=0.032) meaning faster recovery. Conversely, there was a higher rate of unplanned consultations during the 3-month follow-up in the RAL vs CL group (18.5% vs 3.6%, p=0.012).

**Discussion:** RAL was associated with less postoperative pain even at the beginning of learning curve. Surgeons were more likely to perform RAL than CL for older and/or obese patients, suggesting they intuitively consider RAL of added benefit for these patients.

Introduction

Surgical management of endometrial cancer requires hysterectomy (HST) with bilateral salpingo-oophorectomy, often accompanied by sentinel lymph node biopsy or lymphadenectomy and potentially omentectomy, depending on the clinical stage, histological type, and FIGO classification of the tumor. The recommended surgical approach is

minimally invasive surgery including conventional laparoscopy (CL) and robotic-assisted laparoscopy (RAL) [1].

Despite the widespread adoption of minimally invasive techniques, the role of RAL versus CL in the surgical treatment of endometrial cancer remains a matter of debate. Recent studies indicate that RAL and CL exhibit comparable long-term survival outcomes [2,3]. Nonetheless, there is no consensus about the benefits of RAL in reducing the rates of

Abbreviations: RAL, Robotic assisted laparoscopy; CL, Conventional laparoscopy; HST, hysterectomy.

* Correspondence author at Service de gynécologie et d'obstétrique, Hôpital Sud, 16 boulevard de Bulgarie F-35200 RENNES Cedex, France.

E-mail addresses: Emma.bajeux@chu-rennes.fr (E. Bajeux), Stephanie.hamonic@chu-rennes.fr (S. Hamonic), Solene.brunet-houdard@chu-brest.fr (S. Brunet-Houdard), Krystel.nyangoh-timoh@chu-rennes.fr (K. Nyangoh Timoh), Ludivine.dion@chu-rennes.fr (L. Dion), alexia.guecheff@gmail.com (A. Guecheff), Vincent.lavoue@chu-rennes.fr (V. Lavoue).

https://doi.org/10.1016/j.jogoh.2025.102917

Received 14 November 2024; Received in revised form 25 January 2025; Accepted 27 January 2025

Available online 30 January 2025

2468-7847/© 2025 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

<footnote><sup>a</sup> Univ Rennes, CHU Rennes, CIC 1414, Service d'Epidémiologie et de Santé publique, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, F-35033 RENNES Cedex, France</footnote>

<footnote><sup>b</sup> CHU Rennes, Service d'Epidémiologie et de Santé publique, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, F-35033 RENNES Cedex, France</footnote>

<footnote><sup>c</sup> CHU Brest, Direction de la Recherche Clinique et de l'Innovation, 2 avenue Foch, F-29609 BREST Cedex, France</footnote>

<footnote><sup>d</sup> Univ Rennes, CHU Rennes, CIC 1414, Service de gynécologie et d'obstétrique, Hôpital Sud, 16 boulevard de Bulgarie F-35200 RENNES Cedex, France</footnote>

<footnote><sup>e</sup> INSERM U1099, LTSI, Equipe MEDICIS, Rennes, France</footnote>

<footnote><sup>f</sup> INSERM U1085, IRSET, équipe 8 URGENT, Rennes France</footnote>
<figure><img src="image_4.png" /><figcaption>Fig. 1. Inclusion flow-chart.</figcaption></figure>

conversion to open surgery [4–6]. Furthermore, data about operative
times and the risk of intra- and postoperative complications are incon-
clusive from one study to another [5–8]. Despite this, numerous retro-
spective cohort studies have suggested potential benefits of robotic
surgery for obese and elderly patients, including fewer complications
and shorter hospital stays compared to CL [9,10]. Additionally, RAL has
been associated with shorter hospital stays in several studies [4,6,11,
12]. In the United States and Scandinavia, approximately 75–80% of
HST procedures for endometrial cancer are performed using RAL [13,
14]. However, the preference for RAL over CL in these regions contrasts
sharply with its limited use in France, where only 13% of such proced-
ures utilized robotics in 2016. This discrepancy largely stems from the
high cost of robotic platforms.

This study aimed to comprehensively compare RAL performed by
surgeons at the beginning of the learning curve and CL in terms of
clinical outcomes, length of hospital stay, and the incidence of compli-
cations within 3 months in patients undergoing HST for low-risk endo-
metrial cancer.

Methods

Study design and population

We conducted a single-center, retrospective study in Rennes tertiary teaching hospital (CHU), France, including women who underwent minimally invasive HST for endometrial cancer.

The study population consisted of two groups: the CL group including patients who underwent CL between January 1, 2016 and December 31, 2017 (i.e., before the acquisition of the surgical robot by the hospital); and the RAL group including patients who underwent RAL between January 1, 2018 and June 30, 2020 (i.e., after acquisition of the robotic system). We did not include patients who underwent CL after acquisition of the robot as, beyond the availability of the robot, surgeons may have selected one of the two approaches based on individual

patient characteristics and this could have compromised the comparability of the groups. The two retrospective cohorts were thus staggered in time on the assumption that, apart from the acquisition of the robot, changes in practice for similar management during this period were negligible.

Although the study was conducted at the beginning of the learning
curve, only women whose surgeon had performed at least five robot-
assisted surgical procedures in gynecology, regardless of the indica-
tion, were included in the RAL group.

Non-opposition was sought for the women included in the study and
the study was approved by the local ethics committee.

Surgical procedures

Surgery was performed under general anesthesia. All RAL proced-
ures were carried out with the robotic system Da Vinci Si Intuitive®,
USA. Patients were positioned in the supine position with both arms
along the body. Pneumoperitoneum was established using the trans-
umbilical open laparoscopy technique. Four trocars were inserted for
the robot: a 12 mm trocar at the umbilical level for the optics, and three
8 mm trocars on the right and left flanks, placed at a minimum distance
of 8 cm from each other. A fifth trocar was added for surgical assistance
in the operative field. The robotic cart was docked from the patient's
right side.

For CL, a total of four trocars were used: a 12 mm trocar at the
umbilical site for the camera and three 5 mm trocars in the right and left
flanks and in the suprapubic region.

In both cohort, a 12 mm Hg pressure value of pneumoperitoneum
was used in the two cohorts.

All the patients underwent HYS with bilateral salpingo-
oophorectomy, with or without sentinel lymph node biopsy or lym-
phadenectomy. In the two post-operative weeks, preventive anti-
coagulant drugs were administered in both cohorts.
<table><caption>**Table 1**

Patient preoperative characteristics (n=110).</caption><thead><tr><th></th><th>Conventional laparoscopy n=56</th><th>Robot-assisted laparoscopy n=54</th><th>Total n=110</th><th>p</th></tr></thead><tbody><tr><td>Age (years) (mean ± SD)</td><td>67.8 ± 9.7</td><td>71.6 ± 8.7</td><td>69.7 ± 9.4</td><td>0.031 *</td></tr><tr><td>Employed</td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>21</td><td>14</td><td>35</td><td></td></tr><tr><td>Yes</td><td>9 (25.7%)</td><td>4 (10.0%)</td><td>13 (17.3%)</td><td>0.073</td></tr><tr><td>Parity</td><td></td><td></td><td></td><td>0.501</td></tr><tr><td>Missing</td><td>2</td><td>0</td><td>2</td><td></td></tr><tr><td>None</td><td>8 (14.8%)</td><td>6 (11.1%)</td><td>14 (13.0%)</td><td></td></tr><tr><td>1-2</td><td>25 (46.3%)</td><td>21 (38.9%)</td><td>46 (42.6%)</td><td></td></tr><tr><td>≥3</td><td>21 (38.9%)</td><td>27 (50.0%)</td><td>48 (44.4%)</td><td></td></tr><tr><td>Previous laparoscopy surgery</td><td>11 (19.6%)</td><td>14 (25.9%)</td><td>25 (22.7%)</td><td>0.432</td></tr><tr><td>Previous laparotomy surgery</td><td>18 (32.1%)</td><td>15 (27.8%)</td><td>33 (30.0%)</td><td>0.617</td></tr><tr><td>High blood pressure<sup>b</sup></td><td>24 (42.9%)</td><td>23 (42.6%)</td><td>47 (42.7%)</td><td>0.978</td></tr><tr><td>Dyslipidemia</td><td>9 (16.1%)</td><td>12 (22.2%)</td><td>21 (19.1%)</td><td>0.412</td></tr><tr><td>Diabetes</td><td>8 (14.3%)</td><td>10 (18.5%)</td><td>18 (16.4%)</td><td>0.549</td></tr><tr><td>Body Mass Index (kg/m<sup>2</sup>) (mean ± SD)</td><td>29.8 ± 6.1</td><td>33.1 ± 7.0</td><td>31.8 ± 6.8</td><td>0.030 *</td></tr><tr><td>Missing</td><td>24</td><td>3</td><td>27</td><td></td></tr><tr><td>Normal and overweight &lt;30</td><td>19 (59.4%)</td><td>19 (37.3%)</td><td>38 (45.7%)</td><td></td></tr><tr><td>Obese ≥30</td><td>13 (40.6%)</td><td>32 (62.7%)</td><td>45 (54.2%)</td><td>0.049 *</td></tr><tr><td>ASA score</td><td></td><td></td><td></td><td>0.567</td></tr><tr><td>Missing</td><td>3</td><td>1</td><td>4</td><td></td></tr><tr><td>1</td><td>12 (22.6%)</td><td>9 (17.0%)</td><td>21 (19.8%)</td><td></td></tr><tr><td>2</td><td>25 (47.2%)</td><td>31 (58.5%)</td><td>56 (52.8%)</td><td></td></tr><tr><td>3</td><td>15 (28.3%)</td><td>13 (24.5%)</td><td>28 (26.4%)</td><td></td></tr><tr><td>4</td><td>1 (1.9%)</td><td>0 (0.0%)</td><td>1 (0.9%)</td><td>0.993</td></tr><tr><td>FIGO tumoral stage</td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>0</td><td>1</td><td>1</td><td></td></tr><tr><td>Stage I</td><td>25 (44.6%)</td><td>24 (45.3%)</td><td>49 (45.0%)</td><td></td></tr><tr><td>Stage II</td><td>21 (37.5%)</td><td>20 (37.7%)</td><td>41 (37.6%)</td><td></td></tr><tr><td>Stage III</td><td>10 (17.9%)</td><td>9 (17.0%)</td><td>19 (17.4%)</td><td></td></tr></tbody></table>

<sup>c</sup> We only considered women taking treatment for high blood pressure

* p<0.05

ASA: American Society of Anesthesiologists; SD: Standard Deviation

Percentages were calculated excluding missing data.

## Data collection

The following data were retrospectively collected from the patients' medical charts for both groups: socio-demographic data (age, employment status), clinical data (number of pregnancies and children, surgical history, hypertension, dyslipidemia, diabetes, body mass index (BMI), the American Society of Anesthesiologists (ASA) class, the International Federation of Gynecology and Obstetrics (FIGO) tumoral stage, and biological data (hemoglobin) before surgery. The surgical procedure data collected included: operative time, operative room occupancy, type of lymphadenectomy, conversion to laparotomy and reasons, intra-abdominal drainage, and type of anesthesia), as well as any intra- and

postoperative complications occurring during the hospital stay (vascular, urological, digestive wounds, surgical revision...), and the consumption of analgesics. We also collected data about the characteristics of the patients' hospital stays (length of stay, admission in intensive care unit) as well as imaging tests and consultation or rehospitalization in Rennes hospital within 3 months after surgery.

## Outcomes

All the patients were scheduled for a systematic post-operative follow-up consultation at 4 weeks. Any other consultation or emergency visit to the Rennes CHU during the 3-month follow-up period was considered as unscheduled.

Operative time was defined as the time from incision to skin closure and included docking time, console time, and opening and closing times. Operating room occupancy time was defined as the time that elapsed from the patient's entry into the operating room and the arrival of the next patient (or closure of the room, where applicable).

## Statistical analysis

The demographic, clinical and biological characteristics of the patients, as well as the characteristics of the surgical procedure, the hospital stays, and the occurrence of any complication were described and compared between the RAL and CL groups by the usual statistical tests (Student's t test or Wilcoxon rank-sum test, depending on the conditions of application, for quantitative variables, Chi-square test or Fisher's exact test for qualitative variables). The qualitative variables were presented as numbers and percentages and the quantitative variables by their mean, standard deviation, median and inter-quartile range.

Percentages were calculated excluding missing data. All reported p-values are based on two-tailed tests of significance. All the analyses were performed using SAS® version 9.4 statistical software (SAS Institute, Cary, NC, USA).

## Results

### Clinical and hospital stay outcomes

Of the 212 patients who underwent HYS for endometrial cancer in the Rennes CHU during the study period, 102 patients were finally excluded. Of the remaining 110, the analysis population, 56 were in the CL group, and 54 in the RAL group (Fig. 1).

The patients' preoperative demographic and clinical characteristics are shown in Table 1. The patients in the RAL group were significantly older, had fewer children and a higher BMI than the patients in the CL group. The two groups did not differ for other comorbidities or for cancer stage.

Operating times as well as the operating room occupancy time were significantly higher in the RAL group. Additional spinal anesthesia was less frequent in the RAL group and the dose of paracetamol consumed during the hospital stay was lower than in CL group (Table 3).

The docking time was 12.9±7.9 min in the RAL group.

Only three of the procedures were converted to laparotomy: two in the RAL group and one in the CL group. Intraoperative complications occurred in five patients: two in the CL group (both were urinary tract wounds), and three in the RAL group (one urinary tract wound, one vascular wound, and one vaginal wound due to vaginal uterus extraction) without any significant difference between the groups (Table 2).

Postoperative complications occurred in nine patients during the initial hospital stay: six in the RAL group (eventration (n=2), acute pyelonephritis (n=1), hematoma (n=1), abscess (n=1), and ileus (n=1)); and three in the CL group (abscess (n=1), vaginal cuff dehiscence (n=1), and acute pyelonephritis (n=1)) without any significant difference between the groups. Five of the nine patients experiencing complications required surgical revision: for eventration or hematoma
<table><caption>**Table 2**

**Surgical procedure.**</caption><thead><tr><th></th><th>Conventional laparoscopy n=56</th><th>Robot-assisted laparoscopy n=54</th><th>Total n=110</th><th>p</th></tr></thead><tbody><tr><td>Operative time (hours)<sup>a</sup></td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>0</td><td>5</td><td>5</td><td></td></tr><tr><td>Mean ± SD</td><td>2.3 ± 1.1</td><td>3.0 ± 1.2</td><td>2.7 ± 1.2</td><td>0.0014<sup>**</sup></td></tr><tr><td>Median (IQR)</td><td>2.2 (1.5-3.0)</td><td>2.8 (2.1-4.1)</td><td>2.4 (1.8-3.4)</td><td></td></tr><tr><td>Operating room occupancy time (hours)</td><td></td><td></td><td></td><td></td></tr><tr><td>Mean ± SD</td><td>3.5 ± 1.3</td><td>4.6 ± 1.3</td><td>4.0 ± 1.4</td><td>&lt;0.001<sup>***</sup></td></tr><tr><td>Median (IQR)</td><td>3.4 (2.5-4.3)</td><td>4.7 (3.5-5.8)</td><td>3.8 (3.1-5.0)</td><td></td></tr><tr><td>Time from when patient exited operating room to next patient (min)</td><td></td><td></td><td></td><td></td></tr><tr><td>Mean ± SD</td><td>22.5 ± 12.1</td><td>39.5 ± 27.8</td><td>29.1 ± 21.2</td><td>&lt;0.001<sup>***</sup></td></tr><tr><td>Median (IQR)</td><td>20.0 (14.0-28.0)</td><td>32.0 (21.0-43.0)</td><td>22.0 (17.0-33.0)</td><td></td></tr><tr><td>Sentinel node research</td><td>14 (25.0%)</td><td>20 (37.0%)</td><td>34 (30.9%)</td><td>0.172</td></tr><tr><td>Pelvic lymphadenectomy</td><td>32 (57.1%)</td><td>23 (42.6%)</td><td>55 (50.0%)</td><td>0.127</td></tr><tr><td>Para-aortic lymphadenectomy</td><td>10 (17.9%)</td><td>13 (24.1%)</td><td>23 (20.9%)</td><td>0.423</td></tr><tr><td>Drain placement after surgery</td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>0</td><td>1</td><td>1</td><td></td></tr><tr><td>Yes</td><td>29 (51.8%)</td><td>31 (58.5%)</td><td>60 (55.0%)</td><td>0.482</td></tr><tr><td>Spinal analgesia</td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>5</td><td>0</td><td>5</td><td></td></tr><tr><td>Yes</td><td>38 (74.5%)</td><td>19 (35.2%)</td><td>57 (54.3%)</td><td>&lt;0.001<sup>***</sup></td></tr><tr><td>Conversion to laparotomy</td><td>1 (1.8%)</td><td>2 (3.7%)</td><td>3 (2.7%)</td><td>0.615</td></tr><tr><td>Intraoperative complications</td><td>2 (3.6%)</td><td>3 (5.6%)</td><td>5 (4.5%)</td><td>0.676</td></tr></tbody></table>

<sup>a</sup> Operating time from incision to skin closure

* p<0.05,

** p<0.01,

*** p<0.001

Percentages were calculated excluding missing data.

in the RAL group, and abscess and disunion of the vagina in the CL group. One patient with obesity in the RAL group who underwent surgical revision was transferred to the intensive care unit for septic shock after evisceration. The complications that occurred within the 3-month follow-up (after hospitalization) are reported in Table 3.

## Discussion

The present study showed that RAL was associated with significantly less postoperative pain than CL in women undergoing surgery for endometrial cancer. Furthermore, we observed that surgeons, even at the beginning of learning curve, were more likely to select RAL rather than CL for older and/or obese patients suggesting they intuitively consider RAL of added benefit for these patients.

Nevertheless, some drawbacks of the RAL approach were observed. Firstly, as other studies have already reported, the operative time was longer for RAL than for CL [8,15], as was the overall operating room occupancy time. Previous published data are controversial about operative times with some reporting higher or lower operative lengths for RAL compared with CL [11,16–18]. The longer times we observed in our study can be at least partially explained by the fact that the study was conducted with surgical teams at the start of the learning curve. The commonly used performance threshold for the learning curve for RAL is between 20 and 50 cases and so the operating times we recorded were probably longer than they are today [19][20]. The same reason may explain why our study, as well as previous studies, did not find any difference in the length of hospital stay [16,21]. Secondly, our study found a higher rate of postoperative complications and unscheduled consultations at 3 months with RAL whereas previous studies suggest the opposite [16,22] or no significant difference [23]. This could also be due to lack of sufficient experience with using the robotic system: there is an absence of force feedback with the robot which may result in poorer suturing of the vaginal cuff which could, in turn, be responsible for more postoperative bleeding. It would seem that this drawback of the robotic system can be overcome with experience: two reviews showed no significant differences in the rate of conversion to laparotomy and intraoperative complications between RAL and CL [15,18], and another recent review found a lower intraoperative complication rate with RAL [24]. Furthermore, we found a significantly higher proportion of obese

women in the RAL group which could also account for the higher postoperative complication rate and unscheduled consultations. Another weakness could be the variation of surgical management of endometrial cancer such as the implementation of Enhanced Recovery After Surgery (ERAS) protocol or evolution of recommendations about endometrial cancer management. Nevertheless, during the two periods of inclusion, the department of gynecologic surgery did not implement ERAS protocol and we showed that the two cohorts showed no significant difference concerning lymph node evaluation strategy. Because of retrospective nature of present study, other point of weakness is the lack of some data in our medical report such as exact time of feeding or ambulation in the post operative period. Lastly, our study suffers from the usual limits of other retrospective studies in which the type of surgery is not randomly allocated, such as loss of data or limits of comparability between the two groups. In the same way, all surgeons in the first period were experienced surgeons well-trained in laparoscopic surgery, but one experienced surgeon in conventional laparoscopic group was not in the RAL group because this experienced surgeon did not use robot.

In several countries, the deployment of robotic platforms has led to an increase in the number of minimally invasive endometrial cancer surgeries performed [7], and its effectiveness and cost-effectiveness versus laparotomy has already been widely demonstrated in the literature [7,17,25]. To date, the question of the place of RAL in endometrial cancer remains unanswered, and needs to be evaluated in large prospective randomized trials comparing the different surgical approaches in patients with an indication of HST for endometrial cancer performed by highly experienced surgeons (such as the ongoing trial NCT06348719). Furthermore, studies should be conducted on subgroups of patients who could particularly benefit from robotic surgery, in particular older and/or obese patients as suggested in several recent studies [10,26].

## Conclusion

RAL performed by surgeons at the beginning of the learning curve requires longer operative times compared with CL. However, surgeons tend to choose RAL over CL for obese patients, suggesting that RAL may be more effective or, at the very least, facilitate the surgical procedure in
<table><caption>**Table 3**
Hospital stays and postoperative complications.</caption><thead><tr><th></th><th>Conventional laparoscopy n=56</th><th>Robot-assisted laparoscopy n=54</th><th>Total n=110</th><th>p</th></tr></thead><tbody><tr><td><strong>Postoperative hospital outcomes</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Time in recovery room (hours)</td><td></td><td></td><td></td><td></td></tr><tr><td>Mean ± SD</td><td>6.6 ± 4.7</td><td>5.7 ± 3.6</td><td>6.2 ± 4.2</td><td>0.297</td></tr><tr><td>Median (IQR)</td><td>5.1 (3.5-7.3)</td><td>4.7 (3.4-5.9)</td><td>4.8<br>(3.5-6.5)</td><td></td></tr><tr><td>Blood loss (%)<sup>a</sup></td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>37</td><td>34</td><td>71</td><td></td></tr><tr><td>Mean ± SD</td><td>11.3 ± 7.7</td><td>6.7 ± 10.7</td><td>8.9 ± 9.5</td><td></td></tr><tr><td>Median (IQR)</td><td>10.0<br>(-18.1-5.1)</td><td>8.4<br>(-13.0-0.8)</td><td>9.2<br>(-14.5-3.0)</td><td>0.182</td></tr><tr><td>Analgesics</td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>1</td><td>1</td><td>2</td><td></td></tr><tr><td>Paracetamol only</td><td>10 (18.2%)</td><td>9 (17.0%)</td><td>19 (17.6%)</td><td></td></tr><tr><td>Paracetamol + steroidal anti-inflammatory agents</td><td>1 (1.8%)</td><td>1 (1.9%)</td><td>2 (1.9%)</td><td></td></tr><tr><td>Paracetamol + analgesics grade II<sup>c</sup></td><td>44 (80.0%)</td><td>43 (81.1%)</td><td>87 (80.6%)</td><td></td></tr><tr><td>Paracetamol dose taken during the first post operative day (g)</td><td></td><td></td><td></td><td></td></tr><tr><td>Missing</td><td>1</td><td>1</td><td>2</td><td></td></tr><tr><td>Mean ± SD</td><td>13.0 ± 9.9</td><td>9.4 ± 5.3</td><td>11.2 ± 8.1</td><td>0.032</td></tr><tr><td>Median (IQR)</td><td>12.0 (7.0-16.0)</td><td>8.0<br>(6.0-10.0)</td><td>9.0<br>(6.0-14.0)</td><td>*</td></tr><tr><td>Postoperative complications during hospital stay</td><td>3 (5.4%)</td><td>6 (11.1%)</td><td>9 (8.2%)</td><td>0.316</td></tr><tr><td>ICU admission</td><td>0.0 (0.0%)</td><td>1 (16.7%)</td><td>1 (11.1%)</td><td>-</td></tr><tr><td>Need for surgical revision</td><td>2 (66.7%)</td><td>3 (50.0%)</td><td>5 (55.6%)</td><td>-</td></tr><tr><td><strong>Hospital stay duration (days)</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Mean ± SD</td><td>6.5 ± 5.8</td><td>5.4 ± 3.2</td><td>6.0 ± 4.7</td><td>0.159</td></tr><tr><td>Median (IQR)</td><td>5.0 (4.0-8.0)</td><td>4.0 (3.0-7.0)</td><td>5.0<br>(3.0-7.0)</td><td></td></tr><tr><td><strong>3-month follow-up outcomes</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Unplanned gynecologic consultation</td><td>2 (3.6%)</td><td>10 (18.5%)</td><td>12 (10.9)</td><td>0.012</td></tr><tr><td>Vaginal bleeding without any diagnosis</td><td>0</td><td>5</td><td>5</td><td>*</td></tr><tr><td>Vaginal hematoma</td><td>1</td><td>2</td><td>3</td><td></td></tr><tr><td>Pain</td><td>0</td><td>2</td><td>2</td><td></td></tr><tr><td>Abscess</td><td>1</td><td>0</td><td>1</td><td></td></tr><tr><td>Occlusion</td><td>0</td><td>1</td><td>1</td><td></td></tr><tr><td>Rehospitalization</td><td>1 (1.8%)</td><td>3 (5.6%)</td><td>4 (3.6%)</td><td>0.355</td></tr></tbody></table>

this subgroup of patients. The imbalanced distribution of obese and non-obese women between the RAL and CL groups in our study probably contributed to the higher rate of postoperative complications and emergency outpatient consultations observed in the RAL group. Future research should focus on comparing RAL and CL within homogeneous patient subgroups, especially among obese women, to provide clearer insights into the relative efficacy and safety of RAL compared with CL.

## Funding

This work was supported by Intuitive® Surgical SAS, USA.

## Declaration of competing interest

This study was funded by Intuitive® Surgical SAS, USA. Intuitive® did not have any involvement in the collection, analysis and interpretation of data, in the writing of the report and in the decision to submit the article for publication (See Funding section).

## Acknowledgments

The authors would like to thank Elisa Fustec for her help in data collection.

## References

[1] Concin N, Creutzberg CL, Vergote I, Cibula D, Mirza MR, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Virchows Arch. févr 2021;478(2):153-90.

[2] Eoh KJ, Kim TJ, Park JY, Kim HS, Paek J, Kim YT. Robot-assisted versus conventional laparoscopic surgery for endometrial cancer: long-term comparison of outcomes. Front Oncol. 15 sept 2023;13:1219371.

[3] Fu H, Zhang J, Zhao S, He N. Survival outcomes of robotic-assisted laparoscopy versus conventional laparoscopy and laparotomy for endometrial cancer: A systematic review and meta-analysis. Gynecologic Oncology. juil 2023;174:55-67.

[4] Zanagnolo V, Garbi A, Achilarre MT, Minig L. Robot-assisted surgery in gynecologic cancers. J Minim Invasive Gynecol 2017;24(3):379-96.

[5] Renaud MC, Sebastianelli A, Grégoire J, Plante M. Five-year experience in the surgical treatment of endometrial cancer: comparing laparotomy with robotic and minimally invasive hysterectomy. J Obstet. Gynaecol. Canada. janv 2022;44(1): 21-7.

[6] Borgfeldt C, Kalapotharakos G, Asciutto KC, Löfgren M, Högberg T. A population-based registry study evaluating surgery in newly diagnosed uterine cancer. Acta Obstet Gynecol Scand. août 2016;95(8):901-11.

[7] Jørgensen SL, Mogensen O, Wu C, Lund K, Iachina M, Korsholm M, et al. Nationwide introduction of minimally invasive robotic surgery for early-stage endometrial cancer and its association with severe complications. JAMA Surg. 1 juin 2019;154(6):530.

[8] Narducci F, Bogart E, Hebert T, Gauthier T, Collinet P, Classe JM, et al. Severe perioperative morbidity after robot-assisted versus conventional laparoscopy in gynecologic oncology: results of the randomized ROBOGYN-1004 trial. Gynecol Oncol. août 2020;158(2):382-9.

[9] Bourgin C, Lambaudie E, Houvenaeghel G, Foucher F, Levèque J, Lavoué V. Impact of age on surgical staging and approaches (laparotomy, laparoscopy and robotic surgery) in endometrial cancer management. European Journal of Surgical Oncology (EJSO) 2017;43(4):703-9. avr.

[10] Cusimano MC, Simpson AN, Dossa F, Liani V, Kaur Y, Acuna SA, et al. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications. Am J Obstet Gynecol 2019;221(5):410-428.e19. nov.

[11] Vuorinen RLK, Mäenpää MM, Nieminen K, Tomás EI, Luukkaala TH, Auvinen A, et al. Costs of robotic-assisted versus traditional laparoscopy in endometrial cancer. Int J Gynecol Cancer. oct 2017;27(8):1788-93.

[12] Laursen KR, Hyldgård VB, Jensen PT, Søgaard R. Health care cost consequences of using robot technology for hysterectomy: a register-based study of consecutive patients during 2006-2013. J Robotic Surg. juin 2018;12(2):283-94.

[13] Åkesson Å, Adok C, Dahm-Kähler P. Recurrence and survival in endometrioid endometrial cancer - a population-based cohort study. Gynecologic Oncology. janv 2023;168:127-34.

[14] Lavoue V, Collinet P, Fernandez H. Robotic surgery in gynecology: has France lost its leadership in minimally invasive surgery? Journal of Gynecology Obstetrics and Human Reproduction. avr 2020;49(4):101708.

[15] Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, et al. Robot-assisted surgery in gynaecology. Cochrane Database Syst Rev. 15 avr 2019;4(4):CD011422.

[16] Ind T, Laios A, Hacking M, Nobbenhuis M. A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: A systematic review and meta-analysis. Int J Med Robot. déc 2017;13(4):e1851.

<footnote><sup>a</sup> blood loss were calculated as the relative difference between pre- and day-1 post-operative hemoglobin measurement (%)</footnote>

<footnote><sup>b</sup> according Clavien-Dindo classification</footnote>

<footnote><sup>c</sup> including chlorhydrate de nefopam and tramadol</footnote>

<footnote>* p<0.05,</footnote>

<footnote>** p<0.01, ***p<0.001</footnote>

<footnote>ICU: Intensive Care Unit</footnote>

<footnote>Percentages were calculated excluding missing data.</footnote>
[17] Ran L, Jin J, Xu Y, Bu Y, Song F. Comparison of robotic surgery with laparoscopy and laparotomy for treatment of endometrial cancer: a meta-analysis. PLoS One 2014;9(9):e108361.

[18] Mäenpää MM, Nieminen K, Tomás EI, Laurila M, Luukkaala TH, Mäenpää JU. Robotic-assisted vs traditional laparoscopic surgery for endometrial cancer: a randomized controlled trial. Am J Obstet Gynecol 2016;215(5):588.e1-7. nov.

[19] Gest R, Nyangoh Timoh K, Chmielewski MC, Sardain H, Foucher F, Coiffic J, et al. Robotic surgery program in gynecology: lessons from the first 100 procedures]. Gynecol Obstet Fertil Senol. déc 2019;47(12):825-30.

[20] Lee YJ, eun Lee D, Oh HR, Ha HI, Lim MC. Learning curve analysis of multiport robot-assisted hysterectomy. Arch Gynecol Obstet. 29 juin 2022;306(5):1555-61.

[21] Lundin ES, Wodlin NB, Nilsson L, Kjölhede P. A prospective randomized assessment of quality of life between open and robotic hysterectomy in early endometrial cancer. Int J Gynecol Cancer. 28 mars 2019. ijgc-2019-000285.

[22] Eoh KJ, Kim TJ, Park JY, Kim HS, Paek J, Kim YT. Robot-assisted versus conventional laparoscopic surgery for endometrial cancer: long-term comparison of outcomes. Front Oncol. 15 sept 2023;13:1219371.

[23] Narducci F, Bogart E, Hebert T, Gauthier T, Collinet P, Classe JM, et al. Severe perioperative morbidity after robot-assisted versus conventional laparoscopy in gynecologic oncology: results of the randomized ROBOGYN-1004 trial. Gynecologic Oncology. aoft.2020;158(2):382-9.

[24] Gungorduk K, Kahramanoglu O, Ozdemir IA, Kahramanoglu I. Robotic platforms for endometrial cancer treatment: review of the literature. Minerva Med [Internet] 2021;112(1). févr[cité 2 févr 2024]Disponible sur, https://www.minervamedica.it/index2.php?show=R10Y2021N01A0047.

[25] Clair KH, Tewari KS. Robotic surgery for gynecologic cancers: indications, techniques and controversies. J Obstet Gynaecol Res. juin 2020;46(6):828-43.

[26] Kosa SD, Ferguson SE, Panzarella T, Lau S, Abitbol J, Samouélian V, et al. A prospective comparison of costs between robotics, laparoscopy, and laparotomy in endometrial cancer among women with class III obesity or higher. J Surg Oncol. mars 2022;125(4):747-53.