Short-term and Long-term Outcomes in Patients with Early-stage Cervical Cancer, Comparing Clinical and Adjuvant Therapy between Laparoscopic and Open Radical Hysterectomy: A Systematic Review and Meta-analysis

Abstract

BACKGROUND: Cervical cancer represents one of the most common gynecological malignancies worldwide and the standard treatment has been radical abdominal hysterectomy (RAH). Recent surgical developments can be done through minimally invasive surgery (MIS) using laparoscopic radical hysterectomy (LRH), but the data regarding LRH are still conflicting. AIM: Therefore, we undertook a systematic review and meta-analysis comparing the short-term and long-term outcomes of laparoscopic versus RAH in women with early-stage cervical cancer. METHODS: A systematic search was performed within PubMed, Cochrane, Science Direct, and Google Scholar databases to research the outcome of LRH versus RAH in early-stage cervical cancer. Two reviewers independently reviewed titles, abstracts, and full article text to identify studies meeting inclusion and exclusion criteria. If there any discrepancies, it will be resolved by discussion. The Newcastle–Ottawa scale (NOS) was used to assess the risk of bias of non-randomized studies in this analysis. We used Review Manager 5.4 to calculate the result of 95% CI for the outcomes, odds ratio (OR), and mean differences (MD). The endpoints of interest are short-term, during operation, early post-operation, and long-term outcomes. RESULT: The initial search identified 3.030 citations after a comprehensive review of the final 35 observational studies included, involving 6.919 early-stage cervical cancer patients. Pooled analysis showed that LRH had better intraoperative outcomes, estimated blood loss (EBL) significantly lower LRH (MD = 145.88 [95% CI: 132.84–158.92; p < 0.0001; I2 = 94%]), lesser intraoperative urinary tract injury (OR = 0.91), and vascular injury (OR = 0.76) but was not significant, number of pelvic lymph nodes resected tended to be higher in RAH with MD = 3.63 (95% CI: 3.10–4.15; p < 0.0001; I2  = 95%), shorter bowel recovery time post-operative (MD = 0.05 [95% CI: 0.34–0.66; p < 0.001]). Uniquely, the duration of surgery was not significantly different but still shorter in LRH with MD = 0.73. Long-term outcome was not significantly different for LRH from survival (OR = 1.17) and recurrence (OR = 0.83). LRH had shorter length of stay post-operative (MD = 13.23 [95% CI: 12.98–13.47; p < 0.001; I2 = 100%]) and tend to use significantly fewer adjunctive chemotherapy treatments (OR = 1.84 [95% CI: 1.38–2.45; p < 0.001; I2 = 73%]), the same was seen in radiotherapy treatment (OR = 1.27 [95% CI: 1.03–1.58; p = 0.03; I2 = 68%]). DISCUSSION: The result demonstrated that for the long-term outcome, there was no significant difference between the two techniques. In general, LRH is considered to be associated with better recovery, smaller scar, and faster back to normal life than ARH. Some comparative studies have reported that survival outcome and perioperative complications after LRH are comparable to those after ARH. However, some study found that MIS was associated with a higher risk of death than open surgery for patients with tumor size ≥2 cm (HR 1.66, 95% CI: 1.19–2.30) and had significantly worse progression-free survival than those in the open surgery group with tumor size >2 cm and ≤4 cm (p = 0.044). This may be because of the use of uterine manipulator or because the difference approaches in handling the vaginal margin. Thus, avoiding tumor spillage and diminishing tumor handling during MIS may be beneficial. A Korean study demonstrated that LRH was associated with a lower total cost of care within 6-month postoperatively than RAH. It appeared that using laparoscopic approach was the least expensive approach from a societal perspective followed by robotic and then abdominal hysterectomy. CONCLUSION: This systematic review and meta-analysis of observational studies found that among patients who underwent radical hysterectomy for early-stage cervical cancer, LRH had a better outcome in intraoperative, faster post-operative recovery time, and less need for adjunctive therapy.