August 16, 2021

Survival after minimally invasive vs open radical hysterectomy for early stage cervical cancer - Meta analysis

Cervical cancer is one of the most common women cancers in developing countries like India. As we know that women with early-stage cervical cancer who undergo radical hysterectomy show an excellent 5- year disease free survival rates. Over the last few years, there is wider acceptance of minimally invasive hysterectomy over open abdominal approach. This provides a perfect platform for systematic review and meta-analyses comparing the risk of recurrence and death between patients who underwent minimally invasive vs open radical hysterectomy for early stage cervical cancer.

Brief overview of this meta-analysis

Roni Nitecki at al. reviewed and analysed various observational studies from multiple data sources that used survival analyses to compare outcomes after minimally invasive and open radical hysterectomy in patients with early-stage cervical cancer. All relevant studies related to this topic were searched in various search engines like ovid medline, ovid embase, pubmed, scopus and web of science (from inception to march 2020)

Studies fulfilling following criteria were included in analysis

  1. Enrolled adult (18 years) with stage IA1 to II A as per FIGO 2009 (irrespective of histologic type)
  2. Studies which compared overall survival or disease-free survival or disease-free progression.
  3. Studies which used a survival analyses method
  4. Reported median follow up of at least 24 months
  5. Had New castle Ottawa scale score of 7 points or higher and was interpreted as being of good quality.

 Studies fulfilling these above criteria were thoroughly analyzed which was approximately 1428 in number, to which inclusion and exclusion criteria were applied and 863 studies were excluded and 49 articles were retrieved. Finally, 15 articles were selected after excluding confounding factors, poor quality studies and duplicated populations.

Pros and cons of the meta-analysis


  1. Present meta-analysis is a large analysis conducted so far and included studies that were not included in prior meta analyses
  2. Study addressed to minimize confounding factors by demographic factors and tumor characters like stage and size.


  1. Low to moderate heterogeneity was found in estimates of hazard of recurrence and mortality associated with minimally invasive surgery.
  2. Many studies included laparoscopic and robotic as minimally invasive surgeries which greatly depends on various factors like surgeons learning curve, selection of cases, operative techniques which were not analyzed in studies.


Data from 9499 patients who underwent radical hysterectomy were included in the meta-analyses. Of these 49% of patients received minimally invasive surgery. Of these patients who received minimally invasive surgery, 57% received robot-assisted laparoscopy. The total recorded recurrences in all the studies included is 530 and death in 450. It was observed that pooled hazard of recurrence or death was 71% higher among patients who underwent minimally invasive radical hysterectomy compared with those who underwent open surgery. 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 or all-cause mortality.

Finally, the systematic review and meta-analyses concluded that among patients undergoing radical hysterectomy for early-stage cervical cancer, minimally invasive radical hysterectomy was associated with an elevated risk of recurrence of and death compared with open surgery.

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