Minimally invasive surgery without a uterine manipulator versus open radical hysterectomy for early-stage cervical cancer: A retrospective propensity-score-matched single-center cohort study

Abstract

Objective: To evaluate the surgical outcomes and oncological safety of minimally invasive radical hysterectomy (MIS-RH) without uterine manipulator versus open radical hysterectomy (O-RH) for early-stage cervical cancer (CC).Methods: This retrospective propensity score-matched cohort study analyzed 1,798 patients (539 MIS-RH vs. 1,259 O-RH) treated at a tertiary referral center (from 2019 to 2023). All MIS procedures avoided uterine manipulators, utilizing innovative exposure techniques (fundal suture suspension, “Zheng's 4C” suspension method, and banding method) and protective vaginal transection method. Endpoints included perioperative outcomes, disease-free survival (DFS) and overall survival (OS).Results: After 1:1 matching (n=539 per group), MIS-RH demonstrated superior perioperative outcomes: reduced blood loss (100mL vs. 300mL, P<0.05), lower transfusion rates (0.56% vs. 6.31%, P<0.05), and faster recovery (exhaust time: 48h vs 60h, P<0.05; hospital stay: 6d vs. 7d, P<0.05). While operative time was longer (260min vs. 235min, P<0.05), perioperative complication rates were comparable (intraoperation: 3.34% vs. 3.71%, P>0.05; postoperation: 32.10% vs. 27.64%, P>0.05). 5-year DFS (93.3% vs. 90.3%, P=0.623) and OS (96.3% vs. 97.6%, P=0.253) between groups showed no significant differences. Subgroup analyses by tumor size (≤2cm, >2cm) and LVSI status confirmed equivalent oncological outcomes (P>0.05).Conclusion: MIS-RH without uterine manipulator, which adheres to no-tumor principles, not only provides non-inferior survival outcomes regardless of tumor size or LVSI status but also facilitates enhanced recovery compared to O-RH, positioning it as a potential standard alternative for cervical cancer. However, the procedure demands advanced minimally invasive surgical skills from the surgeon. Prospective and multicenter trials are warranted to validate these findings.