Survival After Minimally Invasive vs Open Radical Hysterectomy for Early-Stage Cervical Cancer

Abstract

IMPORTANCE Minimally invasive techniques are increasingly common in cancer surgery. A recent randomized clinical trial has brought into question the safety of minimally invasive radical hysterectomy for cervical cancer.OBJECTIVE To quantify the risk of recurrence and death associated with minimally invasive vs open radical hysterectomy for early-stage cervical cancer reported in observational studies optimized to control for confounding. Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science (inception to March 26, 2020) performed in an academic medical setting. DATA SOURCESSTUDY SELECTION In this systematic review and meta-analysis, observational studies were abstracted that used survival analyses to compare outcomes after minimally invasive (laparoscopic or robot-assisted) and open radical hysterectomy in patients with early-stage (International Federation of Gynecology and Obstetrics 2009 stage IA1-IIA) cervical cancer. Study quality was assessed with the Newcastle-Ottawa Scale and included studies with scores of at least 7 points that controlled for confounding by tumor size or stage. DATA EXTRACTION AND SYNTHESISThe Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist was used to abstract data independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between surgical approach and oncologic outcomes.MAIN OUTCOMES AND MEASURES Risk of recurrence or death and risk of all-cause mortality.RESULTS Forty-nine studies were identified, of which 15 were included in the meta-analysis. Of 9499 patients who underwent radical hysterectomy, 49% (n = 4684) received minimally invasive surgery; of these, 57% (n = 2675) received robot-assisted laparoscopy. There were 530 recurrences and 451 deaths reported. The pooled hazard of recurrence or death was 71% higher among patients who underwent minimally invasive radical hysterectomy compared with those who underwent open surgery (hazard ratio [HR], 1.71; 95% CI, 1.36-2.15; P < .001), and the hazard of death was 56% higher (HR, 1.56; 95% CI, 1.16-2.11; P = .004). Heterogeneity of associations was low to moderate. No association was found between the prevalence of robot-assisted surgery and the magnitude of association between minimally invasive radical hysterectomy and hazard of recurrence or death (2.0% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, −3.4% to 7.7%]) or all-cause mortality (3.7% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, −4.5% to 12.6%]).CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis of observational studies found that among patients undergoing radical hysterectomy for early-stage cervical cancer, minimally invasive radical hysterectomy was associated with an elevated risk of recurrence and death compared with open surgery.

Financial viewpoint of minimally invasive radical hysterectomy for early cervical cancer: another disadvantage?

“…Decreased survival outcomes with minimally invasive radical hysterectomy, which were demonstrated in a recent meta-analysis of 15 studies, are particularly concerning. 6 As endorsed by the study team, it is paramount to be aware that open radical hysterectomy is the gold standard surgical treatment for women with early cervical cancer.…”

Sentinel lymph node mapping with indocyanine green in cervical cancer patients undergoing open radical hysterectomy: a single-institution series

“…Treatment of early-stage disease (clinical International Federation of Gynecology and Obstetrics (FIGO) stage IA1-IB1 and IIA1) is represented by radical hysterectomy and pelvic lymphadenectomy with sentinel lymph node (SLN) biopsy (Cibula 2018 ). After the publication of a randomized controlled trial, which demonstrated an inferior survival outcome if patients with early-stage cervical cancer were treated with minimally invasive, compared to open radical hysterectomy (Ramirez 2018 ), multiple retrospective studies showed a survival difference between the two approaches, with consequent recommendations amendment by international societies (Koh 2019 ; Nitecki 2020 ; Querleu 2020 ), particularly for tumors larger than 2 cm (Pedone Anchora 2020 ).…”

Time to accept a new old standard of care in cervical cancer

“…Finally, their efforts to assess how manipulator use and vaginal closure may modify the magnitude of the associations between minimally invasive hysterectomy and adverse survival outcomes is an important step in elucidating the factors that may mediate these effects. While some recent well-designed observational studies have not found an association between minimally invasive radical hysterectomy and recurrence or death, 17 18 the majority of such studies [6][7][8][9][10][11][12][13][14][15] have found evidence of harm. The SUCCOR study delivers another significant blow to a surgical paradigm that is increasingly difficult to justify in routine clinical practice.…”

“…[2][3][4][5] In addition to LACC, these guidelines have cited a growing literature of adequately powered, well-designed observational studies that, overall, have had concordant results. [6][7][8][9][10][11][12][13][14][15] In this issue of the International Journal of Gynecological Cancer, Chiva and colleagues 16 present additional evidence of the deleterious effect of minimally invasive radical hysterectomy, and suggest possible mechanisms underlying this association. The SUCCOR study is a large, retrospective, observational cohort study that evaluates associations between surgical approach and survival outcomes among women with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage 1B1 cervical cancer within 126 institutions in 29 European countries.…”