although ovarian cancer is usually diagnosed in postmenopausal women , 12% of ovarian cancer cases occur in women of child - bearing age . several reports have estimated that 3% to 17% of all eocas occur in woman younger than 40 years of age . ovarian germ cell tumors ( gcts ) account for 20% to 25% of all ovarian neoplasms ; however , only 3% are malignant . the peak incidence of gcts is in young women or adolescent girls , accounting for 58% of all ovarian tumors in women younger than 20 years of age ; one - third of these tumors are malignant . traditionally , treatment consisted of complete surgical staging in the form of total abdominal hysterectomy , bilateral salpingo - oopherectomy , omentectomy , and pelvic and para - aortic lymphadenectomy . a more conservative approach is now being used with preservation of the uterus and contralateral ovary in patients with early - stage cancer who want to remain fertile . although several authors have reported their experiences with laparoscopic fertility - sparing surgery , to our knowledge , there have been no reported cases of robotic - assisted fertility - sparing surgery . we present two cases of robotic - assisted fertility - sparing surgery in reproductive - aged women : one for eoca and the other for gct . both surgeries were performed at a university - affiliated teaching hospital by a board - certified gynecologist - oncologist proficient in robotic surgery and assisted by a surgical fellow specializing in minimally invasive gynecological surgery , as well as a resident . a 29-year - old woman ( gravida 0 para 0)5 feet 2 inches tall and weighing 120 lbs , with a body mass index of 21.95without any significant past medical or surgical history presented for evaluation of infertility , at which time a left ovarian cyst was found . in november 2008 , she underwent a laparoscopic left ovarian cystectomy , ablation of endometriosis , hysteroscopic polypectomy , and endometrial biopsy . findings were significant for pelvic endometriosis and a left ovary adhered to the sidewall with a dermoid - appearing cyst , as well as an endometrial polyp . during separation of the cyst , inadvertent rupture occurred . the pathology of the cyst revealed a well - differentiated endometrioid adenocarcinoma with foci of squamous metaplasia , and the endometrial pathology showed proliferative endometrium and polypoid fragments of endometrium with complex endometrial hyperplasia with marked atypia . subsequently , she was referred to our center for evaluation . a positron emission tomography  computed tomography scan revealed a focus of activity corresponding to the uterus and increased activity in the ovaries bilaterally , however , with low standard uptake value ( suv ) of 2 on the left and 2.1 on the right . after consultation with the patient and based on her desire for future fertility , in december 2008 she underwent fertility - sparing surgery in the form of an examination under anesthesia , exploratory laparoscopy , peritoneal washings , omentectomy , robotic - assisted laparoscopic left salpingo - oopherectomy , left extensive pelvic side wall dissection , ureterolysis , bilateral pelvic and para - aortic lymphadenectomy , multiple peritoneal biopsies , hysteroscopy , and dilation and curettage . specifically because the ovary was severely attached to the side wall , to be certain that no metastatic disease remained , extensive resection of the left pelvic side wall , pararectal area , and left uterosacral ligament was performed . operative findings revealed an 8-cm uterus and no obvious signs of peritoneal carcinomatosis or ascites . total operative time was 5 hours 43 minutes , and estimated blood loss was 100 ml . there were 17 peritoneal and diaphragmatic biopsy specimens , 18 pelvic lymph nodes , and 13 para - aortic nodes and omentum , all of which were found to be benign . endometrial curettings revealed complex hyperplasia with tubal metaplasia , no atypia , and follicular cysts and small foci of endometriosis of the left ovary . based on recommendations from our hospital multidisciplinary tumor conference , she received 3 cycles of carboplatin and paclitaxel . in addition , because of the diagnosis of atypical hyperplasia , she also received medroxyprogesterone acetate for the duration of her chemotherapy . she has conceived twice spontaneously since her surgery and had two successful pregnancies . at the time of this writing , she is currently without evidence of disease ( 46 months ) . a 31-year - old woman ( para 0)5 feet 4 inches tall and weighing 162 lbs , with a body mass index of 27.8with no significant past medical history presented to her gynecologist with left lower quadrant pain and a palpable mass on examination . transvaginal ultrasonography revealed a complex cystic and solid lesion in the left adnexa measuring 7.4  7.3  9.7 cm . ca-125 marker reading was 6.7 u / ml , ca-199 was 8.2 u / ml , carcinoembryonic antigen ( cea ) was 1.6 ng / ml , inhibin a was 24.7 pg / ml , and human chorionic gonadotropin was < 0.5 miu / ml . in february 2010 , she underwent a laparoscopic cystectomy for presumed benign dermoid cyst ; however , pathologic findings revealed an immature grade 1 teratoma . during the procedure , the cyst was inadvertently ruptured , and she was sent to our center for consultation . a positron emission tomography  computed tomography scan was performed and demonstrated no evidence of intraperitoneal or retroperitoneal metastatic disease . based on recommendations from our hospital multidisciplinary tumor conferences , she underwent robotic - assisted surgical staging in april 2010 . operative findings revealed an 8-cm uterus with disseminated suspicious peritoneal lesions in different parts of the pelvic cavity ranging from 1 mm to 2 cm . the mid and upper abdomen was normal except for a 2-mm lesion on the surface of the right diaphragm . peritoneal washings were obtained , and the robotic - assisted laparoscopic approach included resection of all peritoneal lesions and left salpingo - oopherectomy , with the infracolic omentectomy performed via conventional laparoscopy . a frozen section of one of the peritoneal lesions was positive for metastatic immature teratoma ; based on that finding and also the low probability of the lymph nodes being affected , no lymphadenectomy was performed . total operative time was 2 hours 52 minutes , and estimated blood loss was 200 ml . pathology findings revealed teratomatous disease in the left ovary and 4 biopsy sites ( rectum , cul - de - sac , pelvic side wall , and right broad ligament ) with focally immature - appearing cartilage . the omentum was negative , endometrial currettings showed proliferative endometrium , and peritoneal washings were negative for malignancy . because her stage was ic , recommendation from a multidisciplinary tumor conference was that she be treated with three cycles of adjuvant chemotherapy in the form of bleomycin , etoposide , and cisplatin . the patient conceived spontaneously and had a normal spontaneous vaginal delivery in march 2011 . at 19 months ' follow - up , she had no evidence of disease . using general endotracheal anesthesia , the patients were placed in the dorsal lithotomy position using allen stirrups with venodyne boots . in both cases , a standard intuitive robotic platform ( intuitive surgical , sunnyvale , ca ) was used . port placement included a 12-mm primary , 4 cm above the umbilicus , 2 robotic 8-mm midlateral , and 10-mm and 5-mm ports in the right and left upper abdomen for introduction of ancillary instruments . after the robotic apparatus was docked , robotic bipolar and electrosurgical scissors are inserted and used for desiccation and cutting the tissues . after thorough laparoscopic evaluation of the abdominal and pelvic cavity and after obtaining peritoneal washings , the robot was docked and the robotic portion of the surgery proceeded . the left ovary was mobilized from the pelvic sidewall , and a left pelvic wall dissection was performed . after identifying the ureter , the infundibulopelvic ligament was electrodesiccated and the left tube and ovary were confined to a laparoscopy bag and removed from the abdominal cavity . an extensive resection of the left pelvic sidewall to the pararectal area and the left uterosacral ligament was performed , and all areas were inspected for possible metastatic disease . in both cases , all peritoneal lesions were removed . multiple biopsies from different parts of the anterior , posterior , left , right , pelvic , and abdominal wall were performed . in the first case , lymphadenectomy was performed . for pelvic lymphadenectomy , after the pelvic side wall on each side was opened , the paravesical and pararectal spaces were developed and pelvic nodes were sampled from the external iliac vessels ( from the mid common iliac artery to the deep circumflex vein ) , obturator fossa , and hypogastric vessels . for the para - aortic lymphadenectomy , the posterior parietal peritoneum was incised over the right common iliac artery . the incision was extended all the way up to the gonadal vein on the right side and the renal vein on the left side . the ureters were identified , and the para - aortic nodes over the vena cava on the right side and on the left side from below and above the inferior mesenteric artery were sampled . the inferior mesenteric artery was electrodessictaed and cut to allow complete removal of all of the lymph nodes . using general endotracheal anesthesia , the patients were placed in the dorsal lithotomy position using allen stirrups with venodyne boots . in both cases , a standard intuitive robotic platform ( intuitive surgical , sunnyvale , ca ) was used . port placement included a 12-mm primary , 4 cm above the umbilicus , 2 robotic 8-mm midlateral , and 10-mm and 5-mm ports in the right and left upper abdomen for introduction of ancillary instruments . after the robotic apparatus was docked , robotic bipolar and electrosurgical scissors are inserted and used for desiccation and cutting the tissues . after thorough laparoscopic evaluation of the abdominal and pelvic cavity and after obtaining peritoneal washings , the robot was docked and the robotic portion of the surgery proceeded . the left ovary was mobilized from the pelvic sidewall , and a left pelvic wall dissection was performed . after identifying the ureter , the infundibulopelvic ligament was electrodesiccated and the left tube and ovary were confined to a laparoscopy bag and removed from the abdominal cavity . an extensive resection of the left pelvic sidewall to the pararectal area and the left uterosacral ligament was performed , and all areas were inspected for possible metastatic disease . in both cases , all peritoneal lesions were removed . multiple biopsies from different parts of the anterior , posterior , left , right , pelvic , and abdominal wall were performed . in the first case , after the pelvic side wall on each side was opened , the paravesical and pararectal spaces were developed and pelvic nodes were sampled from the external iliac vessels ( from the mid common iliac artery to the deep circumflex vein ) , obturator fossa , and hypogastric vessels . the incision was extended all the way up to the gonadal vein on the right side and the renal vein on the left side . the ureters were identified , and the para - aortic nodes over the vena cava on the right side and on the left side from below and above the inferior mesenteric artery were sampled . the inferior mesenteric artery was electrodessictaed and cut to allow complete removal of all of the lymph nodes . we present two successful cases of robotic - assisted laparoscopic fertility - sparing surgery for stage ic well - differentiated endometrioid adenocarcinoma and stage ic immature teratoma . both patients were successfully treated , conceived spontaneously , and currently have no evidence of disease . in both cases , surgical restaging was important , both to remove the affected ovary and to correctly stage the patients . this played a role in predicting future prognosis and in altering the decision for postoperative chemotherapy . published one of the earlier reports on fertility - sparing surgery for reproductive age women with epithelial ovarian cancer . they showed that this is an appropriate treatment option for early - stage patients with an acceptable oncological safety profile . since then , several authors have published their results . in 2002 , schilder et al . published a multi - institutional retrospective investigation on patients with stage ia and ic epithelial ovarian cancer who were treated with fertility - sparing surgery ( in the form of unilateral adnexectomy ) . fifty - two patients with stage i epithelial ovarian cancer treated from 1965 to 2000 at 8 participating institutions were identified . forty - two patients had stage ia disease , and 10 had stage ic cancers . cell type included 25 mucinous , 10 serous , 10 endometrioid , 5 clear cell , and 2 mixed histology ; 38 were grade 1 , 9 were grade 2 , and 5 were grade 3 . duration of follow - up ranged from 6 to 426 months ( median , 68months ) . twenty - four patients attempted to become pregnant , and 17 ( 71% ) conceived . these 17 patients had 26 term deliveries ( no congenital anomalies noted ) and 5 spontaneous abortions . they concluded that fertility - sparing surgery should be considered as a treatment option in women with stage i epithelial ovarian cancer who desire future child - bearing . satoh et al . , in 2010 , attempted to systematically determine selection criteria for fertility - sparing surgery in stage i epithelial cancer . a relapse of 8.5% was reported , with 27% of the relapsed patients presenting recurrence exclusively in the remaining ovary without any distant or peritoneal metastases . the authors concluded that with favorable histology ( mucinous , serous , endometrioid , or mixed histology ) and low grade ( 1 or 2 ) , patients can safely undergo fertility - sparing surgery , even without postoperative chemotherapy . however , in cases of stage ia disease with clear cell histology or stage ic with unilateral ovarian involvement and unfavorable histology , the authors emphasized the need for adjuvant platinum - based chemotherapy . on the basis of these and other studies , fertility - sparing surgery may be an option in patients with early - stage epithelial ovarian cancer ; however , it should not be an option for patients with higher than stage i , synchronous endometrial cancer , grade 3 disease , hereditary syndromes , and poor histology ( clear cell , anaplastic , and small cell ) . germ cell tumors arise from primordial germ cells and comprise dysgerminomatous and nondysgerminomatous tumors , including yolk sac tumors ( endodermal sinus tumors ) , immature teratomas , mixed germ cell tumors , pure embryonal carcinomas , and nongestational choriocarcinomas . they differ from epithelial ovarian cancers in that they predominantly involve one ovary and usually affect girls and women of reproductive age . they are usually also chemosensitive and have specific tumor markers , which can aid in their diagnosis and management . before more advanced chemotherapies were available , complete surgical removal and staging was the gold standard in treatment of gcts . more recently , however , the management of these tumors in reproductive age women typically includes fertility - sparing surgery ( preservation of the uterus and unaffected ovary ) whenever appropriate , with a thorough staging procedure , followed by adjuvant chemotherapy consisting of bleomycin , etoposide , and cisplatin ( except for stage ia or ib pure dysgerminoma and stage ia grade 1 immature teratoma ) . with the addition of postoperative chemotherapy , 90% to 95% of malignant gcts are curable . in a review of the literature , eskander et al . reported that of 515 patients with malignant gcts treated conservatively , there were 185 pregnancies and 148 live births . only 9 patients had disease recurrence with a death rate of 3% . in recent years , several authors have suggested that laparoscopic surgery is a feasible , safe , and adequate technique for surgical staging and debulking in ovarian cancer when compared with laparotomy . furthermore , various advantages have been attributed to minimally invasive surgery , such as decreased hospital stay , quicker recovery times , and faster return to daily living without compromising oncological outcomes reports in the literature on laparoscopic fertility - sparing surgery for ovarian cancer are scant . performed a prospective study involving 27 patients who had already been operated on elsewhere for a presumably benign ovarian cyst . pathology after the initial surgery revealed 12 low - malignant - potential neoplasms , 11 invasive epithelial ovarian carcinomas , 1 sex - cord stromal cell neoplasm , and 3 germ cell neoplasms . patients underwent subsequent laparoscopic fertility - sparing surgery in the form of exploration of the peritoneal cavity , peritoneal washings , multiple peritoneal biopsies , unilateral adnexectomy ( except in borderline tumors ) , omentectomy , unilateral or bilateral pelvic and para - aortic lymph node sampling ( except in borderline tumors , well - differentiated , mucinous , and granulosa cell tumors ) , endometrial biopsy , and appendectomy in mucinous tumors . seven patients ( 26% ) were upstaged and 6 received adjuvant platinum - based chemotherapy . all patients were alive at that time ; however , one patient with international federation of gynecology and obstetrics stage ic clear cell carcinoma had a recurrence 8 months after surgery . the authors concluded that laparoscopy is acceptable in surgical staging of patients with early - stage ovarian cancer undergoing conservative surgery with preservation of the uterus and contralateral ovary . performed a retrospective study on 19 patients with borderline ovarian tumors who underwent laparoscopy over a 3-year period , all of whom desired preservation of fertility . of the 19 patients , 10 attempted pregnancy and 6 conceived spontaneously and carried to term without the disease interfering with gestation or follow - up period after surgery . they concluded that laparoscopic fertility - sparing surgery for borderline ovarian tumors is a safe option in women who desire future fertility without interfering with fertility and pregnancy outcomes . more recently , hu et al . performed a retrospective study of young patients with epithelial ovarian cancer stage i , grade 1 in 8 institutions from january 1994 to december 2010 . ninety - four patients were treated with fertility - sparing surgery : 72 had laparotomies , 22 had laparoscopies , and 5 had laparoscopy that was converted to laparotomy intraoperatively . median follow - up time was 58.7 months , and mean follow - up time was 58.7 months . overall survival and disease - free survival rates declined in patients undergoing fertility - sparing surgery with increased histologic grade . in patients with early - stage disease , on the other hand , overall survival and disease - free survival were not affected by staging method . at the end of the follow - up , 7 of 12 patients had conceived . they concluded that fertility - sparing surgery could be considered for young patients with epithelial ovarian cancer stage i , grade 1 and that the surgical method may not significantly influence the prognosis . computer - enhanced telesurgery , known as robotic - assisted surgery , is the latest innovation in videoendoscopy , which profoundly revolutionized the concept of minimally invasive surgery in the past 3 decades . operative laparoscopy has several advantages over laparotomy , including faster postoperative recuperation , shorter hospitalization course , cosmetic benefits , improved visualization , decreased blood loss , and fewer postoperative complications . despite these advantages , there are several drawbacks to conventional videolaparoscopy , including 2-dimensional views , a slower learning curve , operator fatigue , counterintuitive hand movements , and tremor amplification . with the advent of computer - enhanced surgery , some of these limitations can be overcome , allowing for improved visualization , coordination , and dexterity . furthermore , robotic surgery can be viewed as an extension of conventional laparoscopy , making the procedure more reproducible , especially in lengthy , complicated cases such as para - arotic and pelvic lymphadenectomy , as well as in obese patients . furthermore , the surgeon is able to sit for the surgery , which is another advantage because this can decrease physician fatigue and long - term physical impairment . in 2002 , schilder et al . published a multi - institutional retrospective investigation on patients with stage ia and ic epithelial ovarian cancer who were treated with fertility - sparing surgery ( in the form of unilateral adnexectomy ) . fifty - two patients with stage i epithelial ovarian cancer treated from 1965 to 2000 at 8 participating institutions were identified . forty - two patients had stage ia disease , and 10 had stage ic cancers . cell type included 25 mucinous , 10 serous , 10 endometrioid , 5 clear cell , and 2 mixed histology ; 38 were grade 1 , 9 were grade 2 , and 5 were grade 3 . duration of follow - up ranged from 6 to 426 months ( median , 68months ) . twenty - four patients attempted to become pregnant , and 17 ( 71% ) conceived . these 17 patients had 26 term deliveries ( no congenital anomalies noted ) and 5 spontaneous abortions . they concluded that fertility - sparing surgery should be considered as a treatment option in women with stage i epithelial ovarian cancer who desire future child - bearing . satoh et al . , in 2010 , attempted to systematically determine selection criteria for fertility - sparing surgery in stage i epithelial cancer . a relapse of 8.5% was reported , with 27% of the relapsed patients presenting recurrence exclusively in the remaining ovary without any distant or peritoneal metastases . the authors concluded that with favorable histology ( mucinous , serous , endometrioid , or mixed histology ) and low grade ( 1 or 2 ) , patients can safely undergo fertility - sparing surgery , even without postoperative chemotherapy . however , in cases of stage ia disease with clear cell histology or stage ic with unilateral ovarian involvement and unfavorable histology , the authors emphasized the need for adjuvant platinum - based chemotherapy . on the basis of these and other studies , fertility - sparing surgery may be an option in patients with early - stage epithelial ovarian cancer ; however , it should not be an option for patients with higher than stage i , synchronous endometrial cancer , grade 3 disease , hereditary syndromes , and poor histology ( clear cell , anaplastic , and small cell ) . germ cell tumors arise from primordial germ cells and comprise dysgerminomatous and nondysgerminomatous tumors , including yolk sac tumors ( endodermal sinus tumors ) , immature teratomas , mixed germ cell tumors , pure embryonal carcinomas , and nongestational choriocarcinomas . they differ from epithelial ovarian cancers in that they predominantly involve one ovary and usually affect girls and women of reproductive age . they are usually also chemosensitive and have specific tumor markers , which can aid in their diagnosis and management . before more advanced chemotherapies were available , complete surgical removal and staging was the gold standard in treatment of gcts . more recently , however , the management of these tumors in reproductive age women typically includes fertility - sparing surgery ( preservation of the uterus and unaffected ovary ) whenever appropriate , with a thorough staging procedure , followed by adjuvant chemotherapy consisting of bleomycin , etoposide , and cisplatin ( except for stage ia or ib pure dysgerminoma and stage ia grade 1 immature teratoma ) . with the addition of postoperative chemotherapy , 90% to 95% of malignant gcts are curable . in a review of the literature , eskander et al . reported that of 515 patients with malignant gcts treated conservatively , there were 185 pregnancies and 148 live births . in recent years , several authors have suggested that laparoscopic surgery is a feasible , safe , and adequate technique for surgical staging and debulking in ovarian cancer when compared with laparotomy . furthermore , various advantages have been attributed to minimally invasive surgery , such as decreased hospital stay , quicker recovery times , and faster return to daily living without compromising oncological outcomes reports in the literature on laparoscopic fertility - sparing surgery for ovarian cancer are scant . performed a prospective study involving 27 patients who had already been operated on elsewhere for a presumably benign ovarian cyst . pathology after the initial surgery revealed 12 low - malignant - potential neoplasms , 11 invasive epithelial ovarian carcinomas , 1 sex - cord stromal cell neoplasm , and 3 germ cell neoplasms . patients underwent subsequent laparoscopic fertility - sparing surgery in the form of exploration of the peritoneal cavity , peritoneal washings , multiple peritoneal biopsies , unilateral adnexectomy ( except in borderline tumors ) , omentectomy , unilateral or bilateral pelvic and para - aortic lymph node sampling ( except in borderline tumors , well - differentiated , mucinous , and granulosa cell tumors ) , endometrial biopsy , and appendectomy in mucinous tumors . seven patients ( 26% ) were upstaged and 6 received adjuvant platinum - based chemotherapy . all patients were alive at that time ; however , one patient with international federation of gynecology and obstetrics stage ic clear cell carcinoma had a recurrence 8 months after surgery . the authors concluded that laparoscopy is acceptable in surgical staging of patients with early - stage ovarian cancer undergoing conservative surgery with preservation of the uterus and contralateral ovary . performed a retrospective study on 19 patients with borderline ovarian tumors who underwent laparoscopy over a 3-year period , all of whom desired preservation of fertility . of the 19 patients , 10 attempted pregnancy and 6 conceived spontaneously and carried to term without the disease interfering with gestation or follow - up period after surgery . they concluded that laparoscopic fertility - sparing surgery for borderline ovarian tumors is a safe option in women who desire future fertility without interfering with fertility and pregnancy outcomes . more recently , hu et al . performed a retrospective study of young patients with epithelial ovarian cancer stage i , grade 1 in 8 institutions from january 1994 to december 2010 . ninety - four patients were treated with fertility - sparing surgery : 72 had laparotomies , 22 had laparoscopies , and 5 had laparoscopy that was converted to laparotomy intraoperatively . median follow - up time was 58.7 months , and mean follow - up time was 58.7 months . overall survival and disease - free survival rates declined in patients undergoing fertility - sparing surgery with increased histologic grade . in patients with early - stage disease , on the other hand , overall survival and disease - free survival were not affected by staging method . at the end of the follow - up , they concluded that fertility - sparing surgery could be considered for young patients with epithelial ovarian cancer stage i , grade 1 and that the surgical method may not significantly influence the prognosis . computer - enhanced telesurgery , known as robotic - assisted surgery , is the latest innovation in videoendoscopy , which profoundly revolutionized the concept of minimally invasive surgery in the past 3 decades . operative laparoscopy has several advantages over laparotomy , including faster postoperative recuperation , shorter hospitalization course , cosmetic benefits , improved visualization , decreased blood loss , and fewer postoperative complications . despite these advantages , there are several drawbacks to conventional videolaparoscopy , including 2-dimensional views , a slower learning curve , operator fatigue , counterintuitive hand movements , and tremor amplification . with the advent of computer - enhanced surgery , some of these limitations can be overcome , allowing for improved visualization , coordination , and dexterity . furthermore , robotic surgery can be viewed as an extension of conventional laparoscopy , making the procedure more reproducible , especially in lengthy , complicated cases such as para - arotic and pelvic lymphadenectomy , as well as in obese patients . furthermore , the surgeon is able to sit for the surgery , which is another advantage because this can decrease physician fatigue and long - term physical impairment . robotic - assisted surgery provides a 3-dimensional view , magnified stereovision , 7 degrees of freedom , tremor filtering , and improvement of the surgeons ' ergonomic position during the surgery . to our knowledge , there have been no published reports on robotic - assisted laparoscopy for fertility - sparing surgery in ovarian cancer . the two patients in this report were treated with conservative surgery via robotic - assisted laparoscopy , and both resulted in favorable outcomes . from this , it appears that robotic - assisted laparoscopic fertility - sparing surgery is both a feasible and acceptable option for low - grade and low - stage ovarian cancer in patients desiring future fertility .