Beyond feasibility: an oncology-first framework for defining the role of robot-assisted surgery in ovarian cancer-patient selection, surgical adequacy, and conversion pathways.

Abstract

Robot-assisted surgery has expanded in gynecologic oncology, but its role in ovarian cancer remains uncertain because oncologic success depends on completion of the required cancer operation rather than on the access route. This critical narrative review evaluates selective use of a robotic approach in apparent early-stage disease, interval cytoreduction after neoadjuvant chemotherapy, exceptional primary cytoreduction, and selected platinum-sensitive recurrence in candidates for secondary cytoreduction. Robotics-specific evidence is distinguished from conventional laparoscopic and mixed minimally invasive surgery (MIS) evidence, which is treated as indirect when a robotics-specific estimate cannot be isolated. Available robotics-specific evidence is predominantly retrospective or feasibility-based, and no randomized robotics-specific trial has established oncologic equivalence to laparotomy. Selected cohorts support technical feasibility and favorable short-term perioperative outcomes more consistently than long-term route equivalence, while patient-reported recovery remains insufficiently characterized. In apparent early-stage disease, intact specimen retrieval, systematic abdominopelvic assessment, and staging completeness are central. In interval and recurrent cytoreduction, complete gross resection is the principal surgical adequacy endpoint, whereas recovery, time to subsequent systemic therapy, patient-reported outcomes, and resource use are complementary endpoints. We propose a three-stage conceptual framework comprising preoperative route assessment, systematic intraoperative reassessment, and predefined conversion criteria. On current evidence, robot-assisted surgery is best regarded as a conditional route for carefully selected patients in experienced centers rather than as a default alternative to laparotomy.