Our study searched SCIENCE DIRECT, COCHRANE LIBRARY, MEDSCAPE, WILLEY ONLINE LIBRARY, PUBMED, and TAYLOR FRANCIS using the following keywords: “Uterine Fibroids” “HIFU”, “Da Vinci Robotic”, “Laparoscopic”, “efficiency”, and “benefits”. Data were collected in the endnote standard software and Microsoft excel. Of the 512 articles that were identified, 29 were included in the systematic qualitative review, of which 24 were quantitively eligible and hence included in the meta-analysis. These English-language articles published during 1995 to 2021 in Taiwan, Hong Kong, China, Korea, USA, Canada, France, Italy, Greece, Israel, UK, Germany and South Africa include 6482 women who diagnosed with uterine fibroids.

Study titles, abstracts, and full text were screened and studies selected as an observational and experimental studies including retrospective studies, cross-sectional study, prospective studies, non-randomized control study, and randomized control studies included in our study. Study population was patients with uterine fibroids who underwent treatments with HIFU, robotic, and laparoscopic surgery.

Not original study, other intervention or other outcomes were excluded.

Observational studies are evaluated by the Newcastle-Ottawa Quality Assessment (NOQA) and experimental-randomized control studies are evaluated by the Critical Appraisal Skills Programme (CASP) (Supplementary Tables 1,2). Quality assessment was indicated by a “star systems” as excellent-very good 10–9, good 8–7, satisfactory 6–5, and unsatisfactory 4–0 were given. The CASP was evaluated using 11 questions that were either “yes”, “no” or “can’t say”.

The primary outcome, clinical outcomes were triaged according to patient compared with patient age, body mass index, operative time (OT), estimated blood loss, uterine fibroid diameter, and length of hospital stay.

Secondary outcomes were treatment efficiencies as measured by the Uterine Fibroid Symptom Health-Related Quality of Life (UFS-QOL) and Symptom Severity Score (SSS).

The final outcome was pregnancy outcome as defined by birth outcomes delineated by live births and between normal spontaneous delivery (NSD) and caesarean section.

The meta-analysis performed using Review manager (RevMan) Version 5.4. (the Cochrane Collaboration, 2020, London, UK) and analyzes performed by pooling the weighted mean difference (WMD) with 95% Confidence interval (CI) for studies given as (mean + standard deviation [SD]).

For combined variables, pooled results were evaluated using random or fixed effect models, and risk ratio (RR) was expressed for dichotomous variables. Heterogeneity was assessed using the I${}^2$ statistic. A random effects model was performed if the significance value of I${}^2$ was greater than 50% and significantly different. Publication bias using the funnel plots were available for comparing the standard error of the mean difference (Supplementary Figs. 1–5).

Clinical outcomes were compared according to patient age, body mass index, operative time (OT), estimated blood loss, uterine fibroid diameter, and length of hospital stay. First, a pooled comparison of age and body mass index between HIFU, robotic, and robotic laparoscopic surgery is shown in Table 2.

The patient age of five was HIFU treatment studies [19, 21, 23, 28, 30] ranging from 40.7 $\pm$ 5.9 to 46.9 $\pm$ 3 years and five robotic surgery studies [32, 33, 34, 35, 36] ranging from 34 $\pm$ 3.8 to 38.26 $\pm$ 6.3 years old are of significantly different heterogeneity (I${}^2$ = 85%, p 0.0001), (WMD 7.58 [5.59, 9.57] with statistically significance (p 0.00001) (Fig. 2A).

On the other hand, the patient ages of five laparoscopic surgery studies [37, 38, 43, 47, 48] ranging from 32.9 $\pm$ 4.8 to 38 $\pm$ 6.1 years old and five studies robotic surgery studies [32, 33, 34, 35, 36] ranging from 34 $\pm$ 3.8 to 38.26 $\pm$ 6.3 years old showed significantly different heterogeneity (I${}^2$ = 70%, p = 0.010), (WMD 0.06 [–1.91, 2.03], but this was not statistically significant (p = 0.96) (Fig. 2B).

Patient’s average body mass index from three studies of HIFU [19, 24, 28] ranging from 22.4 $\pm$ 2.6 to 23.5 $\pm$ 2.6 kg/m${}^2$ and three studies of robotic surgery [33, 34, 35] ranging from 25.1 $\pm$ 4.8 to 27.97 $\pm$ 4.8 kg/m${}^2$ showed significantly different heterogeneity (I${}^2$ = 81%, p = 0.005), (WMD –3.26 [–5.30, –1.22] and statistical significance (p = 0.002) (Fig. 2C).

Second, operative times for HIFU, robotic surgery, and laparoscopic surgery were compared. The sizes of fibroids in relation to operative times for robotic surgery and laparoscopic surgery was also compared. A summary of pooled effects is presented in Table 3.

Three studies [19, 24, 25] of HIFU ranging from 86.13 $\pm$ 36.37 min to 120.2 $\pm$ 63 min and three of robotic surgery [31, 34, 35] ranging from 166 $\pm$ 48.5 min to 278 $\pm$ 67 min showed significantly different heterogeneity (I${}^2$ = 97%, p 0.00001), (WMD –111.88 [–189.68, – 34.08]) with statistical significance (p = 0.005) (Fig. 3A).

Three studies [19, 24, 25] of HIFU ranging from 86.13 $\pm$ 36.37 min to 120.2 $\pm$ 63 min and three studies [37, 38, 40] of laparoscopic surgery ranging from 79 $\pm$ 30 min to 106.4 $\pm$ 38.5 min showed significantly different heterogeneity (I${}^2$ = 96%, p 0.00001), (WMD 5.51 [–27.82, 38.83]) but it is statistically insignificant (p = 0.75) (Fig. 3B).

Comparing between three studies [37, 38, 40] of laparoscopic ranging from 79 $\pm$ 30 min to 106.4 $\pm$ 38.5 min and three studies of robotic surgery [31, 34, 35] ranging from 166 $\pm$ 48.5 min to 278.6 $\pm$ 67 min showed significantly different heterogeneity (I${}^2$ = 96%, p 0.00001), (WMD –117.64 [–187.15, –48.12] with statistical significance (p = 0.0009) (Fig. 3C).

With regard to fibroid size versus operative time in laparoscopic surgery, there were three studies [37, 40, 47] of laparoscopic surgery with fibroid sizes ranging from 6.2 $\pm$ 0.7 cm to 13.6 $\pm$ 3.1 cm and surgery time ranging from 79 $\pm$ 30 min to 106.4 $\pm$ 38.5 min which showed significantly different heterogeneity (I${}^2$ = 85%, p = 0.002), (WMD –85.71 [–98,83, –72.58] with statistical significance (p 0.00001) (Fig. 3D).

In addition, there were three studies [31, 34, 35] of robotic surgery with fibroids sizes ranging from 6.9 $\pm$ 1.77 cm to 9.1 $\pm$ 2 cm and surgery times ranging from 166 $\pm$ 48.5 min to 278.6 $\pm$ 67 min showed significantly different heterogeneity (I${}^2$ = 96%, p 0.00001), (WMD –202.54 [–262.00, –143.07] with statistically significance (p 0.00001) (Fig. 3E).

Finally, comparisons of blood loss and fibrosis rates between robotic and laparoscopic surgeries, hospital length of stay and bleeding between robotic and laparoscopic surgeries are shown in Table 4.

Blood loss compared between three studies [31, 34, 35] of robotic surgery ranging from 214 $\pm$ 161 min to 235.7 $\pm$ 283.3 min and three studies of laparoscopic surgery [37, 38, 40] ranging from 154 $\pm$ 75 min to 200 $\pm$ 107 min showed not significantly different heterogeneity (I${}^2$ = 0%, p = 0.85), (WMD 61.23 [14.98, 107.48]) and statistically significant (p = 0.009) (Fig. 4A).

There were two studies [37, 40] of laparoscopic surgery was compared between blood loss ranging from 154 $\pm$ 75 mL to 278.2 $\pm$ 164.6 mL and fibroids size ranging from 6.5 $\pm$ 2.9 cm to 13.6 $\pm$ 3.1 cm showed significant difference heterogeneity (I${}^2$ = 91%, p = 0.0007), (WMD 202.29 [87.77, 316.80]) with statistically significant (p = 0.0005) (Fig. 4B).

There were three studies [38, 40, 48] of laparoscopic surgery compared between length of hospital stay at 1.2 $\pm$ 0.9 days to 5.4 $\pm$ 0.2 days and blood loss ranging from 200 $\pm$ 107 mL to 346.3 $\pm$ 299.6 mL showed significant differences (I${}^2$ = 90%, p 0.0001), (WMD –269.71 [–361.33, –178.09] with statistical significance (p 0.00001) (Fig. 4C).

There were two studies [31, 34] of robotic surgery compared between blood loss ranging from 214 $\pm$ 161 mL to 235.7 $\pm$ 283.3 mL and 7.3 $\pm$ 3.5 cm to 9.1 $\pm$ 2 cm showed no differences in heterogeneity (I${}^2$ = 0%, p = 0.66), (WMD 210.52 [165.87, 255.17]) with statistical significance (p 0.00001) (Fig. 4D).

Three studies [31, 34, 35] of robotic surgery was compared between hospital stay from at 1.2 $\pm$ 0.5 days to 4.5 $\pm$ 0.8 days and blood loss ranging from 214 $\pm$ 161 mL to 235.7 $\pm$ 283.3 mL showed insignificant differences heterogeneity (I${}^2$ = 0%, p = 0.67), (WMD –226.15 [–266.69, –185.60] was statistically significant (p 0.00001) (Fig. 4E).

The Efficiency outcomes of HIFU treatment were evaluated by UFS-QOL (Uterine Fibroid Symptom Health-Related Quality of Life) and SSS (Symptom Severity Scale) and are shown in Table 5.

UFS-QOL was analyzed between the fibroid group and the adenomyosis group. Two studies for uterine fibroids [19, 28] and three studies for adenomyosis [19, 25, 27] were compared. For the fibroids group, baseline 79.3 $\pm$ 25.1 to 63.9 $\pm$ 29.9 and post-HIFU at 3 months ranging from 70.6 $\pm$ 26.1 to 45.3 + 26.9 showed significantly different heterogeneity (I${}^2$ = 83%, p = 0.02), (WMD 14.08 [4.42, 23.75]) with statistical significance (p = 0.0004) (Fig. 5A).

For the adenomyosis group, ranging from baseline 74.5 $\pm$ 26.7 to 24.53 $\pm$ 8.22 and post-HIFU at 3 months ranging from 79.64 $\pm$ 17.91 to 56.31 + 8.35 showed significant difference heterogeneity (I${}^2$ = 97%, p 0.00001), (WMD –15.95 [–28.06, –3.84]) with statistically significant (p = 0.010) (Fig. 5B).

SSS score for fibroids group, four studies [23, 25, 28, 29] compared ranging from baseline 54.5 + 6.3 to 34.4 $\pm$ 14.7 and at 3 months from 36.6 $\pm$ 7.9 to 24.74 + 16.28 showed significantly different heterogeneity (I${}^2$ = 95%, p 0.00001), (WMD 16.22 [8.33, 24.11]) with statistical significance (p 0.0001) (Fig. 5C).

Pregnancy outcomes for both HIFU and laparoscopy were compared according to delivery outcomes between normal spontaneous delivery (NSD) and cesarean section (C-section). Table 6 summarizes the comparison of live births between NSD and C-section for HIFU and laparoscopic surgery.

For delivery outcomes compared between HIFU and laparoscopy, there were three studies [19, 26, 45] of HIFU from 4 out of 8 live births 4 (8) to 165 out of 219 live births 165 (219) and three studies [37, 45, 46] of laparoscopic from 7 out of 23 live births 7 (23) to 158 out of 224 158 (224) was showed not significant heterogeneity (p = 0.20), (I${}^2$ = 0%, p = 0.44), (RR 1.06 [0.97, 1.17]) and not statistical significance (Fig. 6A).

For NSD, there were three studies [19, 26, 45] of HIFU, 3 out of 8 pregnancies 3 (8) and 91 out of 219 pregnancies 91 (219) and three studies [37, 45, 46] of laparoscopy were 1 out of 23 pregnancies 1 (23) and 63 out of 224 pregnancy 63 (224) were compared and showed significant lower risk heterogeneity (I${}^2$ = 66%, p = 0.05), (RR 1.38 [0.65, 2.95]) with not statistical significance (p = 0.40) (Fig. 6B).

For C-section delivery, three studies [19, 26, 45] of HIFU from 1 out of 8 pregnancies 1 (8) to 74 out of 219 pregnancies 74 (219) and there three studies [37, 45, 46] of laparoscopic from 6 out of 23 pregnancy 6 (23) to 95 out of 224 pregnancies 95 (224) were compared and showed insignificant lower heterogeneity (I${}^2$ = 43%, p = 0.18), (RR 0.86 [0.71, 1.04]) neither not statistically significant (p = 0.13) (Fig. 6C).

Comparing between NSD and C-section, three studies [19, 26, 45] of HIFU, from 3 out of 8 pregnancy 3 (8) to 15 out of 80 pregnancies 15 (80) and from 1 out of 8 pregnancies 1 (8) to 74 out of 219 pregnancies 74 (219) showed significant high heterogeneity (I${}^2$ = 94%, p 0.00001) (RR 0.82 [0.22, 3.05] with statistical insignificant (p = 0.76) (Fig. 6D).

In the comparison between NSD and C-section, there were three studies [37, 45, 46] of laparoscopic surgery from 1 out of 23 pregnancies 1 (23) to 63 out of 224 pregnancies 63 (224) and from 6 out of 23 pregnancies 6 (23) to 95 out of 224 pregnancies 95 (224) was showed insignificant lower heterogeneity (I${}^2$ = 50%, p = 0.14), (RR 0.59 [0.46, 0.75] was statistically significant (p 0.0001) (Fig. 6E).