We very much appreciate the comments by Drs Mendise, Roulette, and von Gruenigan. Prospective surgical trials are difficult to accomplish and often meet critical appraisal for surgical skill bias. We agree that very few (if any) surgeons are equally proficient in laparoscopic and robotic-assisted procedures. However, some of the enrolling physicians in our investigation have been performing robotic-assisted gynecologic procedures for more than a decade and, in fact, were pioneers in the application of robotic technology in gynecologic surgery. An alternative study design would compare experienced robotic surgeons with experienced laparoscopic surgeons. The senior author in our study published an investigation using this methodology with myomectomies and the robotic-assisted procedures required significantly longer operating times.

The evidence comparing robotic-assisted and traditional laparoscopy for benign gynecological disease (myomectomy, hysterectomy, sacrocolpopexy, and tubal reanastamosis), some of which are randomized clinical trials, has consistently shown robotic access to be associated with significantly longer operative times. A number of studies have demonstrated that increased operating room time translates to increased cost. In the modern era of cost-effective surgery, this should be considered. Hence, we reiterate our recommendation that more well-designed investigations are warranted so that we may optimize the indications for robotic technology, not only in benign gynecology but also in other surgical fields.