Robot-assisted versus conventional endoscopic submucosal dissection: a systematic review and meta-analysis

Background: Robot-assisted endoscopic submucosal dissection (RA-ESD) has been developed to address the ergonomic and technical limitations of conventional ESD (C-ESD). However, the current evidence base remains limited and is predominantly derived from preclinical studies. Objectives: To systematically evaluate the comparative efficacy and safety of RA-ESD versus C-ESD. Design: Systematic review and meta-analysis. Data sources and methods: A comprehensive literature search was conducted in major electronic databases in accordance with the PRISMA 2020 Statement. Comparative studies assessing RA-ESD versus C-ESD were included. Continuous outcomes were pooled using mean differences (MDs), and dichotomous outcomes were analyzed using odds ratios (ORs), both with 95% confidence intervals (CIs). Random-effects models were applied for all primary analyses. Results: Twelve studies ( n = 581) were included, of which the majority were preclinical. In exploratory pooled analyses, RA-ESD was associated with shorter submucosal dissection time (min) (MD −6.62, 95% CI −9.38 to −3.86) and overall procedure time (min) (MD −6.00, 95% CI −9.13 to −2.86). Dissection speed (mm 2 /min) was higher with RA-ESD (MD 35.80, 95% CI 8.98 to 62.62), although heterogeneity was substantial. The blind dissection rate (%) was lower in the RA-ESD group (MD −22.64, 95% CI −31.49 to −13.78). RA-ESD was associated with a higher en bloc resection rate (OR 6.44, 95% CI 1.05 to 39.39) and a lower risk of muscular injury (OR 0.18, 95% CI 0.06 to 0.53). No significant difference in perforation was observed. Conclusion: RA-ESD demonstrates promising technical advantages over C-ESD, including improved procedural efficiency and reduced technical difficulty, without an apparent increase in major adverse events. However, given that the current evidence is predominantly preclinical and characterized by substantial heterogeneity, these findings should be interpreted as preliminary and hypothesis-generating. Further well-designed clinical studies are required to confirm the real-world effectiveness, safety, and long-term outcomes of RA-ESD. Trial registration: PROSPERO registration number: CRD420261336534.