radical hysterectomy is considered the standard treatment for patients with early - stage cervical cancer . in the past two decades , the gynaecologic oncologic surgeons performed minimally invasive techniques in order to decrease morbidity while maintaining surgical and oncological outcomes . many studies showed the safety and feasibility of laparoscopic radical hysterectomy for the treatment of early - stage cervical cancer [ 2 , 3 ] . the laparoscopic approach provides comparable long - term outcomes to open radical hysterectomy by adding benefits of minimally invasive surgery in terms of blood loss , analgesic requirement , and hospital stay . despite all these clear advantages , laparoscopic radical hysterectomy was not widely adopted in surgical practice , probably due to some drawbacks of this technique : long learning curve , two - dimensional view , poor ergonomics surgeon position , and limited instruments movements . these conditions negatively influenced the surgical performance , resulting in more tremor , fatigue , and subsequent less accuracy . , sunnyvale , calif , usa ) emerged in the contest of minimally invasive surgery to overcome shortcomings of conventional laparoscopy . robotic system provides three - dimensional view , more ergonomic surgeon position and articulated wrist - like instruments , increasing surgical precision , and dexterity [ 4 , 5 ] . the robotic application grew rapidly in gynaecological oncology field , especially for technically challenging procedures by laparoscopy , such as radical hysterectomy [ 69 ] . in the present paper we sought to review the available descriptive and comparative evidences concerning surgical and oncological outcomes of robot - assisted radical hysterectomy for early cervical cancer . longer operative time and learning curve are among the reasons why the minimally invasive staging has not yet been adopted worldwide in gynaecological oncology practice . for robotic system the first is the time needed to assemble instruments and attach patient to the robot : advancing the column to the operating table , fastening the robotic arms to the inserted trocars , and introducing the laparoscope . console time is defined as the surgical time needed to perform the entire operation at the console . retrospective studies on robotic radical hysterectomy that have considered operative time as surgical outcome reported similar results . sert and eraker described 25 patients with early stage cervical cancer who underwent robot - assisted radical hysterectomy and pelvic lymph node dissection , showing a total mean time of 219  min , with a mean console time of 170  min . the multi - institutional study by lowe et al . on 10 type ii and 32 type iii robotic radical hysterectomy found a median operating time , from skin incision and skin closure , of 215 minutes . all comparative studies between open ( orh ) , laparoscopic ( tlrh ) , and robotic radical hysterectomy ( rrh ) considered the operative time using different definitions . compared the outcomes of 51 patients who underwent robotically assisted hysterectomy with 41 treated by open type iii radical hysterectomy . the operative time , defined as first skin incision to skin closure , was significantly shorter for rrh than orh ( 210.9  45.5  min versus 247.8  48.8  min ) . prospectively analyzed that 30 patients underwent tlrh for cervical cancer and 13 patients underwent rrh with no statistical differences regarding mean operative time ( 323  min versus 318  min ) . the prospective study by magrina et al . compared 27 patients who underwent robotic radical or modified radical hysterectomy with laparoscopic and laparotomic approach . they found a similar operative time from skin incision to skin closure , between robotic ( 189.6  min ) and laparotomic radical hysterectomy , but it was significantly shorter than laparoscopic approach . in particular , this result was retrieved in the subgroup of patients who underwent the modified radical hysterectomy but not the radical one . the mean console time was 150.4 minutes , and it was longer for the radical ( 182.1  min ) than the modified radical hysterectomy ( 126.1  min ) . moreover , lambaudie et al . confirmed a significant difference in operative time between three approaches , showing a longer time for the laparoscopic procedure . on the contrary , estape et al . compared 32 radical hysterectomy by robotic approach with 17 by laparoscopy and 14 by open surgery , showing no significant difference for the operative time , defined from the insertion of the foley catheter and the closing of the last trocar site . the lack of standardization in  operating time cited it can be affirmed that robotic and open technique seem to have a similar mean operating time , which is significantly shorter than conventional laparoscopy . this issue suggests that robotic technique may simplify and accelerate some demanding steps of laparoscopic radical hysterectomy . overall , surgical experience and personal learning curve may influence the length of operative time .   while a learning curve has been extensively described for laparoscopic surgery , little is known about the use of robotic platform in gynaecological oncology . to date no comparative studies evaluated the learning curve for robotic and laparoscopic radical hysterectomy . there are several parameters to be estimated which are able to influence this outcome for robotic system . firstly , it must be considered the time required to prepare and activate the robot , the time to complete the operation , and finally the number of cases necessary to stabilize surgeon operative time . is reported a docking time until 68 minutes , defined from patients entry in the operating room to onset of surgery . several studies demonstrated a significant decrease of robotic docking time as the surgeon and assistant gained experience , the reported mean docking time was 10 min at the beginning and 2 - 3 minutes at the end of the learning curve [ 1317 ] . in conclusion , docking time seems to have an influence in overall operative time only in training phase , because expertise is quickly gained for robotic setup . the operative learning curve seems to be shorter for robotic than for conventional laparoscopy [ 18 , 19 ] . performed 20 robotic radical hysterectomies showing a median operative time of 6.5 hours with a reducing time of surgery from 8 hours to 3.5 hours after 20 procedures . boggess et al . in a subanalysis of rrh found a decrease of 50 minutes between the first ( 243.4  min ) and the ultimate 12 patients ( 193.2  min ) . furthermore , lenihan et al . indicated that after 50 cases the surgeons developed a standard technique , stabilizing operative time and improving outcomes for benign gynaecological robotic surgery . in conclusion , technical advantages of robotic system may allow to perform advanced surgical procedures , such as radical hysterectomy , with a faster learning curve than conventional laparoscopy . unfortunately , to date no consensus and standardisation are reached for the number of cases required to obtain or maintain robotic practice by one institution . training programs and credentialing guidelines about robotic special skills and proficiency are ongoing . there is general agreement about the significant decrease of intraoperative bleeding in minimally invasive surgery . the literature reported similar values of blood loss comparing robotic with laparoscopic radical hysterectomy , with important differences with respect to open surgery . table 1 summarizes the estimate blood loss for robotic , laparoscopic , and laparotomy techniques for radical hysterectomy . in patients who underwent robotic or laparoscopy radical hysterectomy , blood transfusion rates for symptomatic postoperative anaemia after robotic radical hysterectomy vary from 5 to 35% [ 12 , 14 , 15 , 20 , 21 ] . minimally invasive surgery provides a lower intraoperative complications rate than open approach , due to a more accurate tissue manipulation and a better anatomic visualization . robotic surgery may further reduce intraoperative morbidity and improve surgical precision as a consequence of several technical advantages over conventional laparoscopy . urinary injuries , which may happen during ureterolysis and bladder isolation steps , are frequent reported complications for radical hysterectomy . sert and eraker described , among 25 robotic radical hysterectomies , three cases of bladder perforation , which were successfully repaired robotically . the multi - institutional experience by lowe et al . reported one bladder injury adjacent to the trigone and one ureteral injury . a recent review comparing robotic versus total laparoscopic radical hysterectomy for early cervical cancer found a similar percentage of overall major intraoperative complications rate , about 6% , with a lower rate of vascular and bladder injuries for rrh . reported one cystotomy in the robotic group in a patient with three caesarean sections , and two cystotomies in the laparoscopic group . on the contrary , nezhat et al . did not note significant differences between robotic and laparoscopic approach with respect to intraoperative complications : in both groups two incidental cystotomies were described . ko et al . compared 32 cases of orh to 16 cases rrh : no intraoperative complications occurred in the rrh group , while they reported in the orh group one case of ureteral transection requiring surgical repair .   regarding neural damage , maggioni et al . persson et al . found six genitofemoral nerve injuries and one partial obturator nerve palsy at one year of followup in robot - assisted radical hysterectomy with pelvic lymphadenectomy . recently a higher nerve injuries rate was found for rrh than lrh , probably due to thermal cauterisation . concerning conversion to laparotomy in rrh , it has been reported only one case with a conversion rate of 2.8% among all 42 patients . there is a general agreement about the substantial advantages of minimally invasive surgery with respect to open technique also in terms of postoperative complications . comparing robotic or laparoscopic approach to open for radical hysterectomy revealed a lower rate of serious complications for minimally invasive surgery [ 7 , 12 , 17 ] otherwise , comparing laparoscopic and robotic approaches , it is still unclear which one is associated with the lower postoperative morbidity . a recent review of the literature described a significant difference in number of major postoperative complications between rrh ( 9.6% ) and tlrh ( 5.5% ) . in the rrh group were included 11 cases of vaginal dehiscence , 10 cases of vaginal cuff abscess , and 5 cases of port site hernia . demonstrated that the incidence of postoperative complications was less in the robotic group ( 18.8% ) than either the laparoscopic group ( 23.5% ) or the laparotomy group ( 28.6% ) . in the first group , two other studies did not observe any significant differences in postoperative outcomes [ 13 , 14 ] . described similar early ( < 6 weeks ) major postoperative complications in rrh ( 7% ) , ltrh ( 6% ) , and orh ( 9% ) groups . overall postoperative complications rate described by lowe et al . was 12% , including deep venous thrombosis ( 2.4% ) , pyelonephritis ( 2.4% ) , prolonged bladder catheterization of 21 days ( 2.4% ) , and infection ( 4.8% ) . there are evidences of an increased relative risk of vaginal cuff complications for minimally invasive hysterectomy techniques when compared to vaginal or abdominal ones [ 24 , 25 ] . the literature concerning this topic is controversial , also for the lack of a standardized method of classification and registration of postoperative injuries . a recent review showed a higher rate of vaginal dehiscence in the rrh group than in the laparoscopic one . it may be associated with an extensive use of monopolar and bipolar electrosurgery , which may increase thermal damage and devascularisation of the cuff site . other studies are in disagreement with the prior review and described a similar incidence of vaginal cuff separation comparing laparoscopy and robotic [ 24 , 26 ] . persson et al . reported also a leaking of lymphatic fluid through vagina and/or vaginal cuff dehiscence in 10 out of 80 women ( 12% ) who underwent robotic radical hysterectomy with pelvic lymphadenectomy . the frequency of this complication was significantly different between three surgeons who performed robotic radical hysterectomy . table 2 summarizes the number of intra- and postoperative complications in different studies concerning robotic radical hysterectomy . due to the acceptable overall complication rate , robotic technique is considered a safe and feasible alternative to open approach for patients requiring radical hysterectomy . moreover , robot - assisted surgery demonstrated some advantages over traditional laparoscopy , causing less vascular and urethral injuries . a recent study by magrina et al . described the nerve - sparing technique in robot - assisted radical hysterectomy . technical aspects of nerve - sparing operation can be easily included in the robotic surgery , without compromising surgical radicality . indeed , nerve - sparing approach improves visualization of the pelvic autonomic nerves facilitating their preservation , reducing bladder and rectal dysfunctions . the shorter length of hospital stay is one of the most important advantages of minimally invasive surgery . all comparative studies concerning robotic radical hysterectomy reported a mean length of hospital stay of 1 - 2 days , similar to the laparoscopic group , but significantly shorter than open group [ 1012 , 14 , 15 , 21 ] . accordingly , robotic surgery provides other advantages , such as lower perioperative complications and reintervention rates , less postoperative pain , and analgesic consumption . all these issues positively influence hospital stay , quality of life , and time to return to full activities , providing a benefit from a medical and socioeconomic point of view . there are no studies about cost - benefit analysis to evaluate whether the robot imposes financial gain or damages to the healthcare system . this subject is controversial ; in fact , being a new technology , the expense of the robotic system is still high . high surgical costs may be balanced by a shorter operative time and hospital stay . moreover , the lower complications rate for complex and high morbidity interventions may increase the cost effectiveness of robotic technique . the primary endpoint to be considered when comparing minimally invasive techniques and conventional laparotomy for gynaecological oncology is the equivalence in terms of surgical staging completeness and survival . oncological outcomes after radical hysterectomy for early cervical cancer are the number of lymph node retrieved and the recurrence rate . there are controversial results concerning the number of lymph nodes collected by different surgical approaches . several comparative studies found no significant differences in the number of lymph nodes retrieved between robotic , laparoscopic , and open techniques [ 14 , 21 , 23 ] . a case control study which compared robotic to open type iii radical hysterectomy found a nodes retrieval in favour of robotic approach . on the contrary , maggioni et al . showed a reduced number of lymph node in rrh group compared to the orh one . more recently , estape et al . in a case - matched comparative analysis between laparoscopic , robotic , and abdominal radical hysterectomy with lymphadenectomy reported a significantly higher number of nodes for robotic approach and an equivalent rate of positive surgical margins . the increased lymph node yield may be explained by the agility of the robotic instruments that would allow a more comprehensive and accurate node dissection . although most of the current published series have a short followup and a retrospective design , recurrence rate seems to be equivalent between rrh and tlrh in patients with early cervical cancer [ 2 , 12 ] . reported no recurrences in tlrh and rrh groups at 12 months and in tlrh group at 29 months . in the prospective study by magrina et al all patients of the three groups are alive and free from disease at mean followup of 31.1 months . finally , cantrell et al . assessed the progression - free and overall survival for 71 women who attempted rrh for cervical cancer . their experience demonstrated that rrh appears to have equivalent oncological outcomes compared with laparotomic surgery in the first three years of followup . they showed a 94% of progression - free and overall survival in the robotic cohort at 36 months . in conclusion , early data seem to confirm similar oncological outcomes for robotic radical hysterectomy with respect to other surgical modalities in terms of lymph node retrieval and recurrence rate . a prospective randomised trial is currently being performed to test the equivalence for minimally invasive radical hysterectomy ( laparoscopy or robotics ) over laparotomy in terms of disease - free survival . current evidences demonstrated the safety and feasibility of robot - assisted radical hysterectomy for early cervical cancer . robotic approach provides clear benefits of minimally invasive surgery , such as a reduced blood loss , a lower morbidity , and a faster recovery than open surgery . although surgical outcomes are similar or slightly improved when compared to laparoscopy , there are multiple potential advantages . in fact , robotic technology may increase surgical precision and reduce operative time and training for technically challenging steps , encouraging the widespread of minimally invasive approach . we have a preliminary experience in robotic - assisted laparoscopy in surgical treatment of benign pathology and of endometrial cancer . early cervical cancers were usually treated in our centre by radical hysterectomy via conventional laparoscopy , with good results in terms of operative time , functional and oncological outcomes . according to the literature evidence reviewed , robotic radical hysterectomy seems to be a surgical procedure which may benefit from da vinci use . prospective randomized controlled trials will give more definite results , especially concerning surgical outcomes comparing robotic and laparoscopy techniques . although early data support the equivalence of minimally invasive approach with respect to other modalities in terms of staging completeness , progression - free , and overall survival , further studies with longer followup are needed to confirm survival outcomes and to analyse morbidity after surgery and adjuvant therapies .
robot - assisted procedures are being increasingly incorporated in gynaecologic oncology . 
 several studies have confirmed the feasibility and safety of robotic radical hysterectomy for selected patients with early - stage cervical cancer . 
 it has been demonstrated that robotic radical hysterectomy offers an advantage over other surgical approaches with regard to operative time , blood loss , and hospital stay . 
 also initial evidences concerning oncological outcomes seem to confirm the equivalence to traditional open technique . despite the fact that costs of robotic system are still high , they could be partially offset by several health - related and social benefits : less pain , faster dismissal , and return to full activity than other surgical approaches . 
 the development of robotic technology may facilitate the spread of minimally invasive surgery in gynaecological oncology , overcoming some drawbacks of laparoscopic technique for challenging intervention such as radical hysterectomy . 
 further studies are needed to evaluate overall and disease - free survival of this technique and associated morbidity after adjuvant therapies .