Robotic Surgery Conservative Approaches for Uterine Adenomyosis: A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for submitting this manuscript. The topic is clinically relevant, particularly for patients seeking symptom control and fertility preservation while avoiding hysterectomy. That said, the manuscript has major methodological, reporting and interpretive weaknesses that substantially limit its reliability and clinical value. Several conclusions are stronger than justified by the small, heterogeneous, mostly low-quality evidence base. Below I provide detailed comments:

1) Novelty and contribution to the field

Major concern: novelty is overstated

You state (explicitly or implicitly) that this is the first systematic review addressing robotic conservative surgery for adenomyosis. This is not convincingly supported because prior reviews exist on robotic adenomyomectomy/robotic approaches in gynecologic surgery, and your own reference list includes literature that overlaps conceptually with your scope. If your intent is an update focused strictly on uterus-sparing robotic surgery for adenomyosis, state that clearly and explain what is new (e.g., additional years searched, newer robotic platforms/techniques, newer outcomes).

2) Methods: systematic review standards are not met

2.1 Search strategy and reproducibility

A systematic review must be reproducible. Currently, the search description is not sufficiently transparent for replication.

Required improvements

• Provide full search strategies for each database (exact strings, limits/filters, date of last search).

• Clearly describe any supplementary searching (reference lists, citation searching). If you did not do these, state so explicitly.

• Clarify whether language restrictions were applied in practice (your manuscript text is inconsistent on this point).

2.2 Study selection and data extraction

Your manuscript should clearly report:

• whether screening was performed independently by two reviewers,

• how disagreements were resolved,

• whether extraction was duplicated,

• whether a standardized extraction form was used.

Required improvements

• Add explicit reviewer workflow details (screening, extraction, RoB assessment).

• Provide a complete list of exclusion reasons at full-text stage (not just broad categories), consistent with PRISMA expectations.

2.3 Eligibility: ensure included studies truly match the clinical question

Your stated scope is robotic, uterus-preserving surgery for adenomyosis. At least one included study appears to involve mixed “gynecological procedures” with limited or non-extractable adenomyosis-specific outcomes. If adenomyosis outcomes are not extractable, inclusion risks biasing the review and inflating the perceived evidence base.

Required improvements

• Confirm adenomyosis diagnosis and uterus-sparing intent for every included study.

• Exclude mixed-indication studies unless adenomyosis subgroup data are clearly extractable and explicitly reported.

2.4 Risk-of-bias assessment is a critical flaw

The risk-of-bias method is misapplied and/or misreported. You state use of ROBINS-I, but the domains you present do not correspond to ROBINS-I. In addition, most included studies appear to be uncontrolled case series where ROBINS-I is generally not appropriate.

Required improvements

• Re-do RoB using tools appropriate to study design:

  • Use a case series checklist/tool for uncontrolled case series (e.g., JBI case series checklist if you planned it).

  • Use ROBINS-I only for appropriate nonrandomized comparative studies and present the correct ROBINS-I domain structure.

  • Use RoB-2 only if randomized trials exist (if none, state this explicitly).

• Provide domain-level judgments with rationale, not just global labels.

• Ensure RoB results are integrated into interpretation (if all studies are serious/critical risk of bias, conclusions must be very cautious).

2.5 Data synthesis plan and implementation

You state no formal meta-analysis. That is acceptable given heterogeneity and sparse data, but narrative synthesis must still be structured.

Required improvements

• Use a structured narrative synthesis approach:

  • stratify by focal vs diffuse adenomyosis (if reported),

  • stratify by surgical technique (adenomyomectomy vs wedge resection vs other uterus-sparing procedures),

  • stratify by follow-up duration (short vs mid vs long),

  • stratify by adjuvant medical therapy vs surgery alone.

• Provide clear denominators and timepoints for every outcome.

3) Results: extraction completeness and internal consistency problems

3.1 Inconsistencies between text and tables

There is at least one clear discrepancy where postoperative complication counts are attributed to one study in the narrative but appear under a different study in the tables. This undermines confidence in the extraction.

Required improvements

• Perform a full cross-check audit:

  • every numeric statement in text must match tables,

  • tables must match the original articles,

  • define exactly what constitutes an outcome event (e.g., fever definition, ileus definition, abscess definition).

3.2 Missing outcomes are treated as favorable (interpretive error)

Several key outcomes are “not reported” in included studies, yet the manuscript language implies low complication rates and good outcomes. Absence of reporting is not evidence of absence.

Required improvements

• When outcomes are not reported, state explicitly “not reported” and avoid positive inference.

• Consider excluding studies that fail to report minimum critical outcomes if they cannot inform your main questions.

3.3 Outcome set is incomplete relative to your aims

Adenomyosis management is not only pain/CA-125. Clinically meaningful outcomes include abnormal bleeding, quality of life, recurrence, reintervention, fertility and obstetric endpoints.

Required improvements

• Extract abnormal bleeding using defined measures (PBAC score, patient-reported bleeding improvement, validated scales, or clearly defined surrogate endpoints).

• Extract quality-of-life outcomes if reported.

• For fertility outcomes, report:

  • denominator (how many were trying to conceive),

  • ART use,

  • clinical pregnancy, live birth, miscarriage,

  • pregnancy complications when available.

• For recurrence, define recurrence criteria and follow-up windows.

4) Discussion and conclusions: over-claiming beyond the evidence

4.1 Safety and effectiveness claims are too strong

Given the study designs (mostly small observational series) and high risk-of-bias, it is not appropriate to imply that robotic conservative surgery is “safe” or “effective” in a generalizable way. At best, the evidence supports feasibility in selected settings.

Required improvements

• Rewrite conclusions to reflect uncertainty:

  • feasibility is described,

  • comparative benefit vs laparoscopy/laparotomy is not established,

  • long-term outcomes, recurrence, fertility and obstetric safety are insufficiently reported,

  • evidence quality is low and biased.

4.2 Confounding is not adequately addressed

At least one included study combines surgery with or without medical treatment (e.g., GnRH or other therapies). Symptom reduction and CA-125 improvement cannot be attributed to the robotic platform or surgery alone without stratification.

Required improvements

• Explicitly separate outcomes for:

  • surgery alone vs surgery + adjuvant therapy,

  • and avoid causal interpretation when co-interventions exist.

4.3 Mechanistic interpretation (e.g., inflammation via CA-125) is speculative

CA-125 is not specific and can be influenced by multiple factors (including endometriosis, inflammation, menstrual phase). Mechanistic language should be minimized unless supported directly by the data.

5) Reference practices and citation ethics - irrelevant self-citation

I noted multiple references that appear to be the authors’ prior work but are not directly relevant to robotic uterus-sparing adenomyosis surgery, for example:

• Robotic pelvic exenteration for gynecologic malignancies (radical oncologic surgery; different indication and population).

• Hemostatic approach after laparoscopic endometrioma excision and ovarian reserve (endometrioma/endometriosis focus; not adenomyosis-specific and not robotic conservative adenomyosis surgery).

• Vaginal delivery after myomectomy (fibroid surgery; relevance to adenomyosis is indirect and must be justified if used only as background obstetric safety context).

5. Protocol adherence and transparency.

The review is registered in PROSPERO with explicit eligibility criteria and planned methods, yet the manuscript does not include a clear “protocol deviations” statement and several elements appear inconsistent with the registration. Specifically, the protocol restricts eligible languages to English, Italian, French, and Spanish, whereas the manuscript states that no language restrictions were applied. The protocol also specifies inclusion of case series above a minimum sample size (case series ≥ 5), but the manuscript states that no small-sample restrictions were applied and includes a case series with n = 4. In addition, the protocol excludes studies without extractable adenomyosis-specific outcomes, yet at least one included study is described broadly as “gynecological procedures” and is presented with largely non-extractable adenomyosis outcomes in the tables (NR), raising concern that it may not meet the protocol eligibility requirements. Finally, the protocol plans a design-appropriate risk-of-bias approach (RoB-2/ROBINS-I plus a case-series appraisal tool), but the risk-of-bias reporting in the manuscript does not follow ROBINS-I domain structure and it is not evident that a case-series appraisal tool was applied.

Comments on the Quality of English Language

There are numerous grammar/wording issues and occasional imprecise phrasing that reduce clarity, especially in Methods and Discussion.

Author Response

Point to point response:

1) Novelty and contribution to the field

Major concern: novelty is overstated

You state (explicitly or implicitly) that this is the first systematic review addressing robotic conservative surgery for adenomyosis. This is not convincingly supported because prior reviews exist on robotic adenomyomectomy/robotic approaches in gynecologic surgery, and your own reference list includes literature that overlaps conceptually with your scope. If your intent is an update focused strictly on uterus-sparing robotic surgery for adenomyosis, state that clearly and explain what is new (e.g., additional years searched, newer robotic platforms/techniques, newer outcomes).

 

Response:
Thanks to the reviewer for this meaningful note regarding the novelty of our work. We concur that there have been some reviews regarding adenomyosis surgery or robotic gynecologic procedures written. However, up until now, there are no systematic reviews on robotic uterus-sparing surgery for adenomyosis. Some of the reviews available refer to conservative surgery for adenomyosis, in general, and some discuss robotic approaches in gynecologic surgery, without a specific focus on robotic adenomyomectomy. We appreciate that the context in which we were writing before might have exaggerated the novelty of the manuscript. Also, to prevent any misconstrual and to more appropriately mirror the literature, we have removed the statement suggesting that it is the first such systematic review. The manuscript therefore has been revised. We hope to offer a new synthesis of the existing evidence specifically addressing robotic-assisted conservative surgery for adenomyosis, emphasizing surgical techniques, perioperative outcomes, and symptom improvement as described in the literature. In the Discussion section, we have also made the corresponding modification.

 

2) Methods: systematic review standards are not met

2.1 Search strategy and reproducibility

A systematic review must be reproducible. Currently, the search description is not sufficiently transparent for replication.

Required improvements

• Provide full search strategies for each database (exact strings, limits/filters, date of last search).
• Clearly describe any supplementary searching (reference lists, citation searching). If you did not do these, state so explicitly.
• Clarify whether language restrictions were applied in practice (your manuscript text is inconsistent on this point).

RESPONSE:
We appreciate this reviewer's comment on the search strategy's transparency and reproducibility. In the aim of providing full reproducibility of the systematic review, we have outlined complete search strategies for each database in Appendix A (Table A1). This appendix now presents the exact search strings used for PubMed, Scopus, EMBASE, CENTRAL, and ClinicalTrials.gov which empowers readers to search for data transparently and to simulate the search process. We have further stated in the Methods section that the search was carried out from database inception until 21 December 2025 (i.e. the date of the last search conducted). As for supplementary search methods, we have identified that the reference lists of the chosen articles were manually screened to find some additional relevant papers. And, it has been made clear that no language or date restrictions were imposed on the search. We also widened the Discussion section to better incorporate the methodological limitations of the review, which are highlighted in the previous studies already presented in the manuscript. These modifications were made to enhance methodological transparency and reproducibility within the review.

 

2.2 Study selection and data extraction

Your manuscript should clearly report:

• whether screening was performed independently by two reviewers,
• how disagreements were resolved,
• whether extraction was duplicated,
• whether a standardized extraction form was used.

Required improvements

• Add explicit reviewer workflow details (screening, extraction, RoB assessment).
• Provide a complete list of exclusion reasons at full-text stage (not just broad categories), consistent with PRISMA expectations.

RESPONSE
We thank the reviewer for this helpful comment and for highlighting the importance of clearly reporting the study selection and data extraction process. Following this suggestion, we have revised and improved the Methods section (2.2 Study Selection and 2.3 Data Extraction) to clarify the reviewer workflow. Specifically, we now explicitly state that study screening was performed independently by two reviewers, and that any disagreements were resolved through discussion with a third senior reviewer. We also clarified that data extraction was conducted independently by two reviewers using a standardized data extraction form, and that discrepancies were resolved by consensus with the senior reviewer. In addition, the description of the risk of bias assessment procedure was clarified to indicate that it was also performed independently by two reviewers using the ROBINS-I tool, with arbitration by a third reviewer when necessary. Finally, in accordance with PRISMA recommendations, we have improved the reporting of the study selection process and clarified the reasons for exclusion at the full-text stage in the PRISMA flow diagram. We thank the reviewer for this suggestion, which helped us improve the methodological clarity of the manuscript.

 

2.3 Eligibility: ensure included studies truly match the clinical question

Your stated scope is robotic, uterus-preserving surgery for adenomyosis. At least one included study appears to involve mixed “gynecological procedures” with limited or non-extractable adenomyosis-specific outcomes. If adenomyosis outcomes are not extractable, inclusion risks biasing the review and inflating the perceived evidence base.

Required improvements

• Confirm adenomyosis diagnosis and uterus-sparing intent for every included study.
• Exclude mixed-indication studies unless adenomyosis subgroup data are clearly extractable and explicitly reported.

RESPONSE: We appreciate the reviewer for this important comment, and for focusing on the need to ensure all included studies were fully aligned with the clinical question that the review addressed. After this recommendation, we reviewed the eligibility criteria and provided details about the study selection process in the result section. We specifically expanded the text to state that only studies reporting robotic-assisted uterus-preserving surgical procedures that were performed for adenomyosis were eligible for inclusion. We further stipulated that the full-text evaluation phase was characterized by a focus on verifying adenomyosis diagnosis, as well as on confirming uterus-sparing intent of the surgical intervention. If the studies described more general gynecological surgery experiences, inclusion would only be applied when the adenomyosis-related surgery (and outcomes, in this case) were clearly identifiable in the population of interest. To increase transparency and ease of reading, we further expanded the language of the Methods section outlining how eligibility could be assessed and how possibly mixed-indication studies were assessed during the selection process. As such, we owe all credit to the reviewer for this meaningful suggestion, which influenced our development and methodological clarification in our manuscript.

 

2.4 Risk-of-bias assessment is a critical flaw

The risk-of-bias method is misapplied and/or misreported. You state use of ROBINS-I, but the domains you present do not correspond to ROBINS-I. In addition, most included studies appear to be uncontrolled case series where ROBINS-I is generally not appropriate.

Required improvements

• Re-do RoB using tools appropriate to study design:
• Use a case series checklist/tool for uncontrolled case series (e.g., JBI case series checklist if you planned it).
• Use ROBINS-I only for appropriate nonrandomized comparative studies and present the correct ROBINS-I domain structure.
• Use RoB-2 only if randomized trials exist (if none, state this explicitly).
• Provide domain-level judgments with rationale, not just global labels.
• Ensure RoB results are integrated into interpretation (if all studies are serious/critical risk of bias, conclusions must be very cautious).

 

RESPONSE: We thank the reviewer for this careful and important observation. We sincerely apologize for this issue. During submission, an incorrect draft version of the risk-of-bias table was uploaded, and, thanks to the reviewer’s comment, we were able to identify this mistake and replace it with the correct version. The revised manuscript now includes the appropriate risk-of-bias assessment according to study design. In particular, we have removed the incorrect ROBINS-I presentation for studies where it was not appropriate, and the risk-of-bias assessment has now been corrected and reported in its proper form. We also revised the presentation of the results so that the assessment is now consistent with the included study designs and with the methodological approach described in the manuscript. In addition, we have ensured that the interpretation of the findings is appropriately cautious in light of the methodological limitations and the low quality of the available evidence. We are grateful to the reviewer for pointing out this problem, which allowed us to identify the mistakenly uploaded version and correct the manuscript accordingly.

 

 

2.5 Data synthesis plan and implementation

You state no formal meta-analysis. That is acceptable given heterogeneity and sparse data, but narrative synthesis must still be structured.

Required improvements

• Use a structured narrative synthesis approach:
• stratify by focal vs diffuse adenomyosis (if reported),
• stratify by surgical technique (adenomyomectomy vs wedge resection vs other uterus-sparing procedures),
• stratify by follow-up duration (short vs mid vs long),
• stratify by adjuvant medical therapy vs surgery alone.
• Provide clear denominators and timepoints for every outcome

 

RESPONSE: We appreciate this helpful suggestion by the reviewer regarding the structure of the narrative synthesis. Based on this comment, we have amended the manuscript to clarify the methods employed for synthesizing the included studies. In particular, we have noted in the Methods section that, given the limited number of available studies and the heterogeneity of the reported data, a structured narrative synthesis was conducted considering surgical technique, follow-up duration, and reported clinical outcomes. Furthermore, we have clarified in the Results section that detailed stratification according to adenomyosis phenotype (e.g., focal vs diffuse disease) or the use of adjuvant medical therapy was not consistently reported across the included studies, which limited the possibility of performing more detailed subgroup analyses. We thank the reviewer for this helpful comment, which allowed us to improve the clarity of the data synthesis methodology in our manuscript.

 

3) Results: extraction completeness and internal consistency problems

3.1 Inconsistencies between text and tables

There is at least one clear discrepancy where postoperative complication counts are attributed to one study in the narrative but appear under a different study in the tables. This undermines confidence in the extraction.

Required improvements

• Perform a full cross-check audit:
• every numeric statement in text must match tables,
• tables must match the original articles,
• define exactly what constitutes an outcome event (e.g., fever definition, ileus definition, abscess definition).

RESPONSE
We extend our utmost appreciation to the reviewer for this incredibly thorough treatment of our manuscript. First, we regret the transcription errors found in our Results and tables. Our gratitude goes out to the reviewer that has closely read our text for us to detect and rectify these inconsistencies. We thank everyone for taking the time and attention to this element of the manuscript. After the reviewer’s comments, we conducted a thorough cross-referencing of all extracted numeric data with the original articles, and we adjusted for some small transcription errors that were made as a result of preparing the tables and narrative text. Specifically, the following corrections were made:

 

Results section and Table 2 – Complications. The postoperative complications were incorrectly attributed to Chung et al., and the correct study is Chong et al. (2016). The right number of patients with complications is 5 cases (15%), not 15 cases. The text and Table 2 have been adjusted accordingly.

 

Table 3 – Clinical outcome values. Hijazi et al.: the preoperative VAS value has been corrected from 8.1 to 8.68 ± 1.12. Chong et al.: the postoperative CA-125 value at 12 months was corrected from 13.0 ± 13.0 to 13.9 ± 13.0. Chung et al.: the preoperative VAS value corrected from 9.0 ± 1.4 to 9.0 ± 1.41.

 

Ranges published in The Abstract and Results. Preoperative VAS corrected from 8.1–9.0 to 7.5–9.0, corresponding to the value obtained in Shim et al. Corrected range of blood loss adjusted from 25–296 mL to 25–300 mL, consistent with the median suggested by Shim et al. Operative time period adjusted to reflect exact data of the original studies.

 

Table 1 – Characteristics of study. Follow-up information concerning Barton et al. has been amended to reflect detailed perioperative data described in the original article. Zhao et al. age information was revisited and clarified as and when available.

 

We so very much apologize for these slight errors in transcription and thank the reviewer for identifying them. They have enhanced both the fidelity and internal consistency of the manuscript.

 

3.2 Missing outcomes are treated as favorable (interpretive error)

Several key outcomes are “not reported” in included studies, yet the manuscript language implies low complication rates and good outcomes. Absence of reporting is not evidence of absence.

Required improvements

• When outcomes are not reported, state explicitly “not reported” and avoid positive inference.
• Consider excluding studies that fail to report minimum critical outcomes if they cannot inform your main questions.

RESPONSE:
We appreciate this important methodological note to the reviewer. We agree that the absence of reported events should not be assumed to be evidence of the lack of occurrence thereof. Taking note of this comment, we have modified the wording of the Results and Discussion sections to avoid the undesired inference of any positive positives if not reported in the original studies were to be made. Specifically, we explained that we had not consistently reported many outcomes (complications and reproductive outcomes) across the studies considered, and hence the absence of reported events should not be seen as a reflection of low complication rates. As described in the manuscript, there were several (complications and reproductive outcomes) that were not consistently reported across the included studies, and our conclusions should not be taken as generalizable. Because only a few studies on robotic conservative surgery for adenomyosis were available, we retained their data for studies where certain outcomes were not reported, although acknowledged in the interpretation of the results that the limitation may apply. We would like to thank the reviewer for such an incredibly useful remark that has allowed us to bring about a more robust methodological treatment of the methods and to interpret our conclusion more closely.

 

3.3 Outcome set is incomplete relative to your aims

Adenomyosis management is not only pain/CA-125. Clinically meaningful outcomes include abnormal bleeding, quality of life, recurrence, reintervention, fertility and obstetric endpoints.

Required improvements

• Extract abnormal bleeding using defined measures (PBAC score, patient-reported bleeding improvement, validated scales, or clearly defined surrogate endpoints).
• Extract quality-of-life outcomes if reported.
• For fertility outcomes, report:
• denominator (how many were trying to conceive),
• ART use,
• clinical pregnancy, live birth, miscarriage,
• pregnancy complications when available.
• For recurrence, define recurrence criteria and follow-up windows.

 

RESPONSE: We appreciate the reviewer for this important comment regarding the completeness of the outcome set. Following this suggestion, we carefully re-examined the included studies to verify whether additional clinically relevant outcomes, such as abnormal uterine bleeding, quality-of-life measures, detailed fertility outcomes, and recurrence criteria, were reported. However, these outcomes were inconsistently reported or not available in most of the included studies. In particular, standardized measures for abnormal bleeding (such as PBAC scores), validated quality-of-life instruments, and detailed fertility outcomes (including denominators of patients attempting conception, ART use, live birth, and miscarriage rates) were rarely reported in the available literature. We have therefore clarified this limitation in the Results, explicitly stating that several clinically meaningful outcomes could not be systematically analyzed due to incomplete reporting in the original studies. We thank the reviewer for this valuable suggestion, which helped us improve the transparency of the outcome reporting in our review.

 

4) Discussion and conclusions: over-claiming beyond the evidence

4.1 Safety and effectiveness claims are too strong

Given the study designs (mostly small observational series) and high risk-of-bias, it is not appropriate to imply that robotic conservative surgery is “safe” or “effective” in a generalizable way. At best, the evidence supports feasibility in selected settings.

Required improvements

• Rewrite conclusions to reflect uncertainty:
• feasibility is described,
• comparative benefit vs laparoscopy/laparotomy is not established,
• long-term outcomes, recurrence, fertility and obstetric safety are insufficiently reported,
• evidence quality is low and biased.

4.2 Confounding is not adequately addressed

At least one included study combines surgery with or without medical treatment (e.g., GnRH or other therapies). Symptom reduction and CA-125 improvement cannot be attributed to the robotic platform or surgery alone without stratification.

Required improvements

• Explicitly separate outcomes for:
• surgery alone vs surgery + adjuvant therapy,
• and avoid causal interpretation when co-interventions exist.

4.3 Mechanistic interpretation (e.g., inflammation via CA-125) is speculative

CA-125 is not specific and can be influenced by multiple factors (including endometriosis, inflammation, menstrual phase). Mechanistic language should be minimized unless supported directly by the data.

5) Reference practices and citation ethics - irrelevant self-citation

I noted multiple references that appear to be the authors’ prior work but are not directly relevant to robotic uterus-sparing adenomyosis surgery, for example:

• Robotic pelvic exenteration for gynecologic malignancies (radical oncologic surgery; different indication and population).
• Hemostatic approach after laparoscopic endometrioma excision and ovarian reserve (endometrioma/endometriosis focus; not adenomyosis-specific and not robotic conservative adenomyosis surgery).
• Vaginal delivery after myomectomy (fibroid surgery; relevance to adenomyosis is indirect and must be justified if used only as background obstetric safety context).

RESPONSE:
We appreciate these thoughtful comments from the reviewer on the analysis of the findings and the citation systems in the manuscript.

Discussion and conclusions

In line with feedback from the reviewer, we also updated the Discussion and Conclusions to not over-interpret existing evidence. The wording was adapted to more closely match the nature of the current literature, which is mostly small observational series with a high degree of risk of bias. The present manuscript therefore highlights that the majority of the evidence to date has concentrated on how technically effective robotic-assisted conservative surgery is in selected patients, and there is no definitive conclusion to draw concerning safety, effectiveness, or comparability of the surgery with other surgical approaches.

We also noted that the evidence we were provided with limited the reporting of long-term outcome, recurrence, fertility outcomes and obstetric safety, thus limiting the generalisability of our findings.

Potential confounding

We addressed the possible role of confounding factors as the reviewer recommended. More specifically, the Discussion now details that some of the included studies combined surgical treatment with adjuvant medical therapies (e.g., GnRH agonists, oral contraceptives, progestins, or intrauterine devices) which may facilitate symptom improvement and biomarker changes, also limiting the attribution of these outcomes to surgery alone.

References

Lastly, we systematically re-read the reference list and deleted references not applicable to robotic conservative surgery for adenomyosis, keeping only those citations that pertain directly to the procedure described in the manuscript.

We appreciate the reviewer for presenting those constructive suggestions, which enabled us to tighten, develop and improve the manuscript's balance, clarity and scientific integrity.

 

5. Protocol adherence and transparency.

The review is registered in PROSPERO with explicit eligibility criteria and planned methods, yet the manuscript does not include a clear “protocol deviations” statement and several elements appear inconsistent with the registration. Specifically, the protocol restricts eligible languages to English, Italian, French, and Spanish, whereas the manuscript states that no language restrictions were applied. The protocol also specifies inclusion of case series above a minimum sample size (case series ≥ 5), but the manuscript states that no small-sample restrictions were applied and includes a case series with n = 4. In addition, the protocol excludes studies without extractable adenomyosis-specific outcomes, yet at least one included study is described broadly as “gynecological procedures” and is presented with largely non-extractable adenomyosis outcomes in the tables (NR), raising concern that it may not meet the protocol eligibility requirements. Finally, the protocol plans a design-appropriate risk-of-bias approach (RoB-2/ROBINS-I plus a case-series appraisal tool), but the risk-of-bias reporting in the manuscript does not follow ROBINS-I domain structure and it is not evident that a case-series appraisal tool was applied.

RESPONSE:
We appreciate the reviewer for making this vital comment on adherence to the registered PROSPERO protocol, followed by transparency when deviations from the protocol were encountered. In response to this notice, we stated the relevant features directly in the manuscript. Specifically, immediately following the PROSPERO registration number, we included the following statement to note these methodological choices with specificity:

“Given the small number of available studies, we included also small case series (n < 5) to avoid potential loss of relevant evidence, and no language limitations were applied.”

We introduced this clarification in a bid to transparently explain both the inclusion of one small case series, as well as the broader language approach adopted during the search process, given the very small amount of literature particularly about robotic uterus-sparing surgery for adenomyosis. This reviewer's informative comment was helpful as we made the methodological reporting of the manuscript more transparent.

Reviewer 2 Report

Comments and Suggestions for Authors

Overall, the manuscript addresses a relevant and emerging topic—the role of robotic surgery in uterus-preserving management of adenomyosis. The topic is clinically meaningful given the increasing use of robotic platforms in gynecologic surgery and the complexity of adenomyomectomy. However, several methodological, reporting, and language issues need to be addressed before the manuscript can be considered for publication.

 

Major Comments

1. Search strategy
The search strategy appears insufficiently described. It is unclear whether all relevant synonyms and MeSH terms for robotic surgery and adenomyosis were consistently used across databases. The authors should clarify the full strategy and ensure it is comprehensive.

2. Study design heterogeneity
Most included studies are small retrospective series, with only one prospective study. This should be emphasized more clearly in the manuscript, as it significantly limits the strength of the conclusions.

3. Lack of quantitative synthesis
The authors state that meta-analysis was not possible due to heterogeneity, but this decision is not sufficiently justified. Even a descriptive pooled analysis of common outcomes such as operative time or blood loss could be considered.

4. Limited fertility outcomes
Fertility outcomes are poorly reported in the included studies. Given that uterus preservation is a key indication for conservative surgery, this limitation should be discussed in greater depth.

Discuss https://pubmed.ncbi.nlm.nih.gov/41045388/

5. Interpretation of results
All included studies show serious or critical risk of bias. Therefore, the conclusions should be more cautious and avoid suggesting strong evidence supporting robotic surgery.

Minor Comments

• The manuscript requires substantial English language editing.

• Some sentences are unclear or grammatically incorrect.

• Results should be reported more consistently (e.g., ranges, units).

• Tables contain several missing values that should be clarified.

Comments on the Quality of English Language

• The manuscript requires substantial English language editing.

Author Response

We acknowledge the reviewer's thorough reading of our manuscript and for all the constructive comments submitted. We thank you very much for the time and knowledge you have given to review our work. The recommendations greatly increase the clarity, methodological quality, and manuscript quality. Herein we present a full point-by-point reply to each comment.

Major Comments

1. Search strategy

We thank the reviewer for making it clear how to describe the search strategy. After this comment, we provided guidelines for the search methodology in the manuscript and the complete search strategy for each database in Appendix A (Table A1). We now also add the precise search strings for PubMed, Scopus, EMBASE, CENTRAL, and ClinicalTrials.gov to this appendix, which would achieve full reproducibility for the search procedure. We also indicated that the last search date (21 December 2025) was included and added that reference lists (of selected articles) would be selected manually and reviewed to find other pertinent studies.

2. Study design heterogeneity

We concur with the reviewer that the predominance of small retrospective studies is an important limitation of the existing evidence. In response to this suggestion, most included studies were characterized as small observational or retrospective series with only one prospective study available, and we clarified this more clearly in the manuscript. This is more specifically addressed in the Results and Discussion, conclusions were changed to reflect the low quality of existing evidence.

3. No quantitative synthesis

Thank you for this comment of possible quantitative synthesis. A meta-analysis, as noted in the revised manuscript, or a quantitative group meta-analysis in a pooled fashion was not deemed necessary due to considerable heterogeneity across studies, such as variations in surgical methodologies, patient populations, duration of follow-up, definition of outcomes including endpoints, and frequent usage of combined surgical and treatment approaches. Besides, various outcomes were not consistently described or presented in a few studies only. For such reasons, we chose to use a structured narrative synthesis, now further illustrated in the Methods section.

4. Limited fertility outcomes

We wholeheartedly concur that fertility outcomes are clinically relevant if uterus-preserving surgery is discussed. In accordance with the reviewers’ suggestion, we re-study the included studies and extended the discussion of fertility outcomes. However, we discovered poor, inconsistent reporting of fertility data in the studies available, with scant information on denominators of patients who attempted conception, use of assisted reproductive technologies, or specific pregnancy outcomes. Now this limitation will be much more clearly addressed in the manuscript. The reviewer's proposed study (PMID: 41045388) has also been considered and discussed within the current literature.

5. Interpretation of results

Thank you for that important observation. In addition, we have modified the Discussion and Conclusions so that we do not overly generalise or overfit the evidence. The manuscript now explicitly states that the included studies indicate serious or critical risk of bias and that the literature largely corroborates that the technical feasibility of robotic conservative surgery in some patients is better supported than safety or efficacy. The weaknesses on the study design, sample size, and incomplete outcome reporting were now better described.

Minor Comments

English language editing

The entire manuscript has been rewritten into English for easy reader’s understanding, good structure, and clear syntax.

Clarity of sentences

Some sentences have been changed and improved to make them clear and grammatically correct.

Consistency of results reporting

Based on reviewer guidelines we checked manuscript to ensure that ranges, units, and numbers are repeated in the abstract, the tables, and results section.

Tables and missing values

We reviewed all tables and cleaned up any missing data. If data were not included in the original studies, this has now been changed to "NR (not reported)" as we do not want misrepresentation.

We thank the reviewer once again for providing constructive comments and suggestions that have helped to further enhance the clarity, transparency, and scientific rigor of the manuscript dramatically.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for submitting the revised manuscript and for providing a detailed point-by-point response. I appreciate the effort invested in addressing reviewer feedback, particularly the additions aimed at improving search transparency and clarifying aspects of the screening and data extraction workflow. These revisions have improved readability and methodological reporting in parts of the paper.

Author Response

Dear Reviewer,

 We appreciate your review of our revised manuscript and thank you for your thoughtful and encouraging response. Thank you very much for your time and consideration of our work. We are pleased that the revisions—especially those related to the transparency of the search process and the explanation of the screening and data extraction procedures—have improved the manuscript. Your insightful feedback has significantly improved the clarity and methodological robustness of the study. If any additional modifications or clarifications are necessary, we remain at your disposal. Thank you again for your support and thoughtful guidance. Kind regards,

 

Dr. Marco La Verde.

Reviewer 2 Report

Comments and Suggestions for Authors

Revised version. The authors addressed all the recorwers comments

Author Response

Dear Reviewer.

Thank you very much for your kind and constructive feedback on our revised manuscript. Thank you so much for reviewing our work and for your positive remarks regarding the improvements made. We are especially grateful for your recognition of the revisions aimed at enhancing the transparency of the search strategy and clarifying the screening and data extraction processes. Your comments have been invaluable in strengthening the clarity and methodological rigor of the manuscript. We remain committed to further improving the work and are happy to address any additional suggestions you may have. Thank you again for your thoughtful evaluation and support.

 

Dr. Marco La Verde