This systematic review and meta-analysis evaluated the efficacy and safety of robot-assisted surgery for primary brainstem hemorrhage (PBSH).

Using the PICO framework, we compared robot-assisted surgery with conventional medical therapy regarding postoperative rebleeding, mortality, favourable functional outcomes, complications, and hematoma evacuation. A systematic search of PubMed, Web of Science, Embase, and the Cochrane Library was performed through July 2025, supplemented by manual citation screening. All five included studies were retrospective cohort studies.

Qualitative synthesis indicated that robotic approaches achieved more precise hematoma clearance, better neurological recovery, and fewer complications compared with conservative therapy. Meta-analyses demonstrated reduced postoperative rebleeding and mortality with robot-assisted interventions. However, analyses of favourable functional outcomes and length of hospital stay demonstrated substantial heterogeneity, limiting pooled estimates. Notably, many survivors after robotic evacuation had substantial disability.

Overall, current evidence suggests that robot-assisted neurosurgery offers promising clinical benefits over conventional management in selected PBSH patients, particularly in reducing mortality. The ethical implications of life-prolonging intervention that results in substantial disability warrant discussion. Further multicentre, high-quality prospective trials are warranted to confirm these findings and refine patient selection criteria.