Minimally Invasive Radical Hysterectomy For Cervical Cancer: A Systematic Review And Meta-Analysis

Objectives: Recent studies have identified higher recurrence and lower survival with a minimally-invasive approach (MIS) versus abdominal approach to radical hysterectomy for early-stage cervical cancer. We aim to compare recurrence rate, progression-free survival, and overall survival for cervical cancer after MIS versus abdominal radical hysterectomy. Methods: We searched Medline, Embase, Central, and the Cochrane Library to identify studies from 1990 to 2020 that included women with stage 1 or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or progession-free survival (PFS) and overall survival with MIS versus abdominal hysterectomy (PROSPERO 2020 CRD42020173600). Results: 50 studies, including 22,593 women with cervical cancer, met inclusion criteria. 29% of studies had less than 30 months of follow-up and 14% had 60+ months of follow-up. Of the 37 studies reporting PFS, 29 reported no difference and 8 reported decreased PFS with MIS approach. Of the 37 studies reporting OS, 2 studies reported improved OS with MIS approach, 31 reported no difference, and 4 reported decreased overall survival with MIS approach. For progression-free survival, the odds were non-significantly worse for women undergoing MIS radical hysterectomy (OR 1.25, 95% CI 0.98-1.52, 14 studies) when all studies were included. When limited to studies with 30+ months follow-up, the odds of progression-free survival were worse with MIS radical hysterectomy (OR 1.39 for 30+ months, 95% CI 1.09-1.70, 12 studies; OR 1.49 for 48+ months, 95% CI 0.94-2.03, 4 studies). For overall survival, the odds were not significantly different for MIS vs. abdominal hysterectomy (OR 0.82, 95% CI 0.58-1.06, 14 studies). When limited to studies with longer follow-up, the odds of overall survival remained non-significantly different for MIS vs. abdominal (OR 0.90 for 30+ months, 95% CI 0.53-1.26, 11 studies; OR 0.94 for 48+ months, 95% CI 0.42-1.46, 4 studies; OR 1.70 for 60+ months, 95% CI 0.62-2.78, 2 studies). Conclusions: In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse progression-free survival compared to open radical hysterectomy for cervical cancer in studies with 30+ months of follow-up. The emergence of this finding with longer follow-up highlights the importance of high-quality studies to guide cancer and surgical treatment. Recent studies have identified higher recurrence and lower survival with a minimally-invasive approach (MIS) versus abdominal approach to radical hysterectomy for early-stage cervical cancer. We aim to compare recurrence rate, progression-free survival, and overall survival for cervical cancer after MIS versus abdominal radical hysterectomy. We searched Medline, Embase, Central, and the Cochrane Library to identify studies from 1990 to 2020 that included women with stage 1 or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or progession-free survival (PFS) and overall survival with MIS versus abdominal hysterectomy (PROSPERO 2020 CRD42020173600). 50 studies, including 22,593 women with cervical cancer, met inclusion criteria. 29% of studies had less than 30 months of follow-up and 14% had 60+ months of follow-up. Of the 37 studies reporting PFS, 29 reported no difference and 8 reported decreased PFS with MIS approach. Of the 37 studies reporting OS, 2 studies reported improved OS with MIS approach, 31 reported no difference, and 4 reported decreased overall survival with MIS approach. For progression-free survival, the odds were non-significantly worse for women undergoing MIS radical hysterectomy (OR 1.25, 95% CI 0.98-1.52, 14 studies) when all studies were included. When limited to studies with 30+ months follow-up, the odds of progression-free survival were worse with MIS radical hysterectomy (OR 1.39 for 30+ months, 95% CI 1.09-1.70, 12 studies; OR 1.49 for 48+ months, 95% CI 0.94-2.03, 4 studies). For overall survival, the odds were not significantly different for MIS vs. abdominal hysterectomy (OR 0.82, 95% CI 0.58-1.06, 14 studies). When limited to studies with longer follow-up, the odds of overall survival remained non-significantly different for MIS vs. abdominal (OR 0.90 for 30+ months, 95% CI 0.53-1.26, 11 studies; OR 0.94 for 48+ months, 95% CI 0.42-1.46, 4 studies; OR 1.70 for 60+ months, 95% CI 0.62-2.78, 2 studies). In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse progression-free survival compared to open radical hysterectomy for cervical cancer in studies with 30+ months of follow-up. The emergence of this finding with longer follow-up highlights the importance of high-quality studies to guide cancer and surgical treatment.