<![CDATA[Introduction: Minimally invasive surgery (MIS), encompassing laparoscopic and robotic-assisted techniques, was rapidly adopted for early-stage cervical cancer due to perceived benefits of reduced morbidity and faster recovery. However, the landmark 2018 LACC trial raised significant concerns by demonstrating inferior survival outcomes for MIS compared to open radical hysterectomy (ORH), prompting a global reevaluation of surgical practices (Nitecki et al., 2020a). This synthesizes the extensive subsequent evidence to clarify the association between MIS and survival in cervical cancer. Methods: We conducted a comprehensive systematic review following PRISMA guidelines. Eighty studies (systematic reviews, meta-analyses, and key primary studies) comparing MIS to open surgery for cervical cancer were identified and synthesized. Screening criteria included studies reporting survival outcomes (Overall Survival/OS, Disease-Free Survival/DFS) with quantitative data. Data extraction covered study design, patient characteristics, surgical approaches, survival outcomes, subgroup analyses (tumor size, stage, histology), and center-related factors. Results: The synthesized evidence reveals significant heterogeneity. Overall, pooled analyses indicate MIS is associated with inferior DFS (HR range: 1.08-2.02) and, to a lesser extent, OS (HR range: 1.09-1.56) compared to ORH, particularly with longer follow-up (A. J. Smith et al., 2020; Yizi Wang et al., 2020). Critical effect modifiers were identified: 1) Tumor size: The survival detriment is primarily observed in tumors ≥2 cm (DFS HR 1.65), while outcomes for tumors <2 cm are more equivocal (Mengting Zhang et al., 2022). 2) Surgical expertise: High-volume centers and experienced surgeons achieved comparable outcomes between MIS and open surgery, whereas low-volume centers showed significantly worse outcomes with MIS (HR 1.457) (Si-Da Sun et al., 2022). 3) Protective techniques: Preoperative conization and intraoperative measures (avoiding uterine manipulators, protective colpotomy) mitigated risks, yielding survival outcomes equivalent to open surgery (Yizi Wang et al., 2023; Kampers et al., 2021). 4) Surgical subtype: No consistent survival difference was found between robotic and laparoscopic approaches (Jong Ha Hwang et al., 2023). Fertility-sparing radical trachelectomy and nerve-sparing techniques showed oncologic safety comparable to standard procedures (Li Xu et al., 2011; M.D.J.M. van Gent et al., 2016). Discussion: The apparent contradiction in the literature is explained by effect modification. Inferior outcomes in broader analyses are likely attributable to factors like tumor spillage in larger lesions, a learning curve effect in low-volume settings, and variations in surgical technique rather than an inherent flaw of MIS technology. For carefully selected patients (small tumors) operated on by experts using optimized techniques, MIS remains a viable option without compromising oncologic safety. Conclusion: The association between MIS and survival in cervical cancer is not uniform but is profoundly influenced by tumor size, surgical volume/expertise, and technical modifications. Open radical hysterectomy remains the standard, especially for tumors ≥2 cm and in low-volume settings. In high-volume centers, for tumors ≤2 cm, and when employing stringent protective measures, MIS may offer a safe minimally invasive alternative. Clinical decision-making must be personalized, integrating these key modifiers.]]>
