Comparing postoperative complications and outcomes between minimally assisted vs open abdominal hysterectomy for women with cervical cancer

Background: Cervical cancer remains a leading cause of mortality, being the fourth most common cancer affecting women worldwide. While radical hysterectomy remains the mainstay approach to treat early-stage cervical cancers, the surgical approach remains a point of clinical correlation. Traditionally, abdominal radical hysterectomy (ARH) was the preferred standard. However, the rise of Minimally Invasive Hysterectomy (MIH) offered the promise of reduced morbidity and faster recovery. This trajectory was significantly challenged by the 2018 LACC trial, which reported higher recurrence and lower survival rates for MIH, leading to a global shift back to open surgery. Despite this, a significant literature gap remains regarding the safety of MIH in specific patient subgroups and the impact of improved surgical techniques developed post-LACC.
Aim: Does the minimally invasive approach offer significant surgical advantages without compromising oncological safety when compared to the open abdominal approach?
Methods: This systematic review analyses 16 studies: (1 RCT and 15 retrospective studies) comprising 24096 patients: 8371 in the ARH group and 15725 in the MIH group. Advanced literature searches were conducted using PubMed, Embase, and Cochrane Library in accordance with PRISMA guidelines. Risk of bias was assessed using ROB2 and ROBINS-I, and quality of evidence using GRADE framework. Primary outcomes included intraoperative and postoperative complications, ureteric injury, and fistula formation. Secondary outcomes included Overall Survival (OS), Disease-Free Survival (DFS), Estimated Blood Loss (EBL), and operating time.
Results: The review demonstrates that postoperative complications were significantly higher in the ARH group (8.29%) compared to the MIH group (3.86%), representing a relative risk reduction of 53% (RR 0.47) for minimally invasive surgery. Intraoperative complications, ureteric injury, and ureterovaginal fistula rates were comparable between both cohorts. While MIH was associated with a longer mean operating time (230.5 vs. 214.6 minutes), it yielded a significantly lower estimated blood loss (186.6 mL vs. 362.3 mL). Regarding oncological outcomes, while ARH showed slightly higher Overall Survival (OS) and Disease-Free Survival (DFS) rates, these differences did not reach statistical significance, suggesting potential oncological equivalence in modern cohorts.
Conclusion: This thesis concludes that MIH offers clearly superior short-term surgical outcomes, significantly reducing postoperative morbidity and blood loss. However, the long-term oncological role of MIH remains a subject of controversy due to the heterogeneity of current data and hence, is to be interpreted with caution. To bridge the existing literature gap, it is recommended that future clinical practice focuses on patient selection, prioritizing tumour sizes <2cm and the standardization of surgical techniques, such as the avoidance of uterine manipulators. Further the initiation of robust, multicentre RCTs that stratify outcomes by surgical volume and specific minimally invasive modalities (robotic vs. laparoscopic) is needed to close the literature gap. Until such data is available, MIH should remain a safe and effective alternative to ARH only when performed by highly proficient surgical teams within a framework of rigorous oncological surveillance.