Robotic versus laparoscopic and open surgery in obese endometrial cancer patients: A systematic review and meta-analysis

Obesity is a risk factor for endometrial cancer and complicates its surgical. Robotic-assisted laparoscopy, have been proposed to overcome these challenges, but their relative advantages over conventional laparoscopy and laparotomy in obese patients remain uncertain. To compare perioperative outcomes of robotic-assisted, laparoscopic, and open surgical approaches in the management of obese patients with endometrial cancer. A systematic review and meta-analysis was conducted according to PRISMA guidelines (PROSPERO registration: CRD420251109990). PubMed, Embase, Scopus, and Cochrane Library were searched for studies published between January 2000 and June 2025. Risk of bias was assessed with ROBINS-IV2 Cochrane tool. Eligible studies included obese patients (BMI ≥ 30 kg/m²) undergoing hysterectomy for endometrial cancer, directly comparing robotics with laparoscopic or open approaches. Primary outcomes were operative time, estimated blood loss, hospital stay, and conversion to laparotomy; secondary outcomes included intraoperative and postoperative complications. Data were synthesized using random-effects meta-analysis models. Twenty-one studies involving 4,865 obese patients were included. Robotic surgery was associated with a shorter hospital stay compared to laparoscopy (1.9 vs. 3.8 days) and laparotomy (1.9 vs. 4.3 days), and with lower blood loss compared to laparotomy (97 vs. 337 mL). Operative time was longer with robotics (183 min) compared to laparoscopy (147 min) and laparotomy (129 min). Complications were lower with minimally invasive approaches: robotic (14%) and laparoscopic (15%) versus laparotomy (30%). Postoperative complications were lowest with robotics (13%) compared to laparoscopy (14%) and laparotomy (29%). Conversion rates were similar between robotic (3%) and laparoscopic (4%) procedures. A considerable risk of serious bias was observed, primarily due to potential confounding. Robotic surgery is associated with shorter hospital stays compared to laparoscopy, and both minimally invasive approaches have been linked to reduced perioperative complications compared with laparotomy. In the absence of randomized studies, further research is needed to validate these findings.