Rafał Stojko | President, Polish Society of Gynaecologists and Obstetricians (PTGiP); Head of the Department of Gynaecology, Medical University of Silesia, Katowice, Poland
Citation: EMJ. 2026; https://doi.org/10.33590/emj/N832920A
The theme of this year’s European Society for Gynaecological Endoscopy (ESGE) Congress is “Precision, Progress, and Partnership.” Where do you think gynaecological surgery has made the greatest progress, and where are we still falling short?
The greatest progress has been the move to minimally invasive surgery as the standard approach. Procedures that once meant a large incision, a week in hospital, and a long recovery are now often performed laparoscopically, hysteroscopically, or vaginally, with same-day or next-day discharge. Better imaging, energy devices, and structured training have made complex surgery safer, including deep endometriosis excision, nerve-sparing techniques, and fertility-preserving oncology. Office hysteroscopy has also changed daily practice by moving many diagnoses and treatments out of the operating theatre.
We still fall short in three areas. The first is equal access: a woman’s chance of having minimally invasive surgery still depends too much on where she lives and who operates on her.
The second is evidence. We adopt new technology faster than we test it properly. The LACC trial, which showed worse outcomes with minimally invasive radical hysterectomy for early cervical cancer, reminded us that ‘less invasive’ does not always mean ‘better’.
The third is measuring outcomes that matter to patients. We are good at measuring blood loss and operating time, but much weaker at tracking pain, sexual function, fertility, and quality of life years after surgery. Precision, progress, and partnership should mean closing these gaps, not only adding new tools.
You have spoken about the growing role of robotic surgery in gynaecology. Which procedures do you think genuinely benefit from robotics, and where does conventional laparoscopy remain the better option?
Robotics helps most when surgery is technically demanding, involving deep pelvic dissection, extensive suturing, or difficult patient factors. Examples include severe deep endometriosis, particularly with bowel, ureter, or nerve involvement; sacrocolpopexy; and complex myomectomy requiring multilayer suturing. It can also be useful for oncology staging and lymphadenectomy, particularly in patients with obesity, and for surgery in women with a very high BMI.
The 3D view, wristed instruments, tremor filtering, and better ergonomics make a real difference in these cases. Robotics may also allow more surgeons to offer a minimally invasive approach to patients who would otherwise have had open surgery.
Conventional laparoscopy remains the better choice for most routine procedures, such as uncomplicated hysterectomy, adnexal surgery, ectopic pregnancy, and diagnostic laparoscopy. Comparative studies have generally shown no clear clinical advantage for robotics in these operations, while costs and theatre time are higher. A skilled laparoscopic surgeon is still worth more than an expensive console.
The real question is not ‘robot or laparoscopy’, but rather ‘which patient, which procedure, and which surgeon?’. We also have to make sure younger surgeons develop solid conventional laparoscopic skills.
In endometriosis surgery, one of the most difficult decisions is how far to operate in women who still want to conceive. How do you balance complete excision of disease against the risk of compromising ovarian reserve and future fertility?
I start from the patient’s goals, not from the disease. For a woman who wants to conceive, the aim is not the most radical operation possible, but the best chance of a healthy pregnancy, with symptoms under control.
Careful assessment comes first. Before deciding, I want expert imaging, an anti-Müllerian hormone measurement, an evaluation of the partner, and a discussion with the IVF team.
When ovarian surgery is needed, the approach must be gentle. We know that removing an endometrioma can lower ovarian reserve, especially with bilateral or repeat surgery. I use meticulous technique, avoid excessive bipolar coagulation, and sometimes choose a staged or combined approach. In some women, particularly when ovarian reserve is already low, it is better to go straight to IVF or preserve oocytes before surgery.
Surgery should have clear indications. These include pain that does not respond to treatment, organ involvement such as hydronephrosis or bowel stenosis, or deep disease that is likely to prevent conception. In those cases, complete excision by an experienced team can genuinely improve both quality of life and fertility.
Avoiding repeat operations is also essential. The first operation should be the best one, performed in an expert centre. Each repeat procedure costs ovarian tissue and causes adhesions. Above all, this is a shared decision: the patient needs honest information about the trade-offs.
Where do current endometriosis guidelines stop being helpful and clinical judgement has to take over?
Guidelines such as the European Society of Human Reproduction and Embryology (ESHRE)’s are very valuable. They have shifted us away from relying on diagnostic laparoscopy, supported non-invasive diagnosis and medical treatment, and established fertility-sparing principles. However, they are built on average patients and often limited evidence.
They are much less helpful when women have several problems at once, such as pain, infertility, adenomyosis, and previous surgery. They also cannot fully resolve the choice between surgery first or IVF first for an individual woman, or how radical surgery for deep disease should be. For example, they cannot tell us whether to use shaving, disc excision, or segmental bowel resection.
Other challenging situations include women who do not respond to medical treatment, cannot tolerate it, adolescents, or women approaching menopause. There can also be a large gap between the amount of visible disease and the pain a patient experiences.
In these situations, guidelines provide the framework, and clinical judgement has to do the rest. That judgement works best in a multidisciplinary team that includes surgeons, reproductive specialists, radiologists, pain specialists, and, when needed, colorectal surgeons and urologists. That is why I strongly support specialised endometriosis centres.
You are beginning your term as President of the Polish Society of Gynaecologists and Obstetricians (PTGiP) at the same time as leading this international Congress. What changes in women’s healthcare in Poland would you most like to see by the end of your presidency?
By the end of my presidency, I would like to see specialised referral networks for endometriosis, urogynaecology, and gynaecological oncology, with clear pathways so that complex patients reach experienced teams. I would also like to see a shorter time to endometriosis diagnosis. It still takes many years, and better awareness among general practitioners, teachers, and young women could help change that.
Better cancer prevention is another priority, especially wider HPV vaccination and a move to modern HPV-based cervical screening with higher uptake. Cervical cancer can largely be eliminated, and Poland should aim for that.
I would like minimally invasive surgery to become the norm across the country, supported by structured, certified training, such as the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) programme, and simulation. Equally, we need respectful, evidence-based perinatal care that rebuilds women’s trust, alongside open and evidence-based discussion of reproductive health.
Finally, I want stronger international partnerships, so that Polish gynaecology helps set European standards, rather than simply following them.
Looking 10 years ahead, what do you think will change most dramatically in the operating theatre, and is there anything we routinely do today that you think the next generation of gynaecologists will find outdated?
The biggest change will be digital and data-driven surgery. I expect AI-assisted recognition of anatomy, such as the ureters, vessels, and nerves, alongside real-time guidance from preoperative imaging and automated feedback on surgical performance. Robotic systems will become smaller, cheaper, and more modular, and much more surgery will take place in outpatient or office settings.
Surgical training will rely heavily on simulation and objective assessment of skills, so a surgeon’s competence will be measured, not assumed.
Some things we routinely do today will probably look outdated to the next generation. These include diagnostic laparoscopy performed only to confirm endometriosis, once imaging and biomarkers improve, and learning complex surgery mainly on patients rather than through simulation. Judging surgical quality mainly by operating time and complications, instead of long-term patient-reported outcomes, may also seem outdated.
Some of our current overtreatment, such as unnecessarily radical procedures, will probably look outdated, while some of our undertreatment will look just as outdated. I hope the next generation will also see it as outdated that a woman’s surgical outcome could depend so much on her postcode.
