The survival after a radical hysterectomy for cervical cancer by open surgery is significantly better then after minimal invasive surgery: Evidence beats gut feeling!

Surgery is the golden standard for early stage cervical cancer. Surgery can be done by an open or a closed procedure. A closed procedure or minimal invasive surgery (MIS) reduces the morbidity and retrospective analysis suggested that there was no difference in survival. In daily practice this meant that open surgery was replaced by MIS. The results of the first randomized phase 3 trial comparing open versus closed surgery threw another light on the topic. This well designed RCT revealed that MIS was associated with significant higher recurrence rates and a significant worse overall survival. Changing from MIS to open surgery would reduce the number of recurrences by 6 and the number of deaths by 5 per 100. The study has several strong points and some limitations. The quality of MIS is equal to that of open surgery if you look at the tissue specimens. Explanations has therefore to be sought in the differences between the surgical procedures. Research is needed to test these explanations and to look for other reasons. The RCT is convincing, but there is also need for caution. Since, it is still possible that some fine tuning of the initial data could modify the overall conclusion. The impact of the RCT in daily practice should not be underestimated. As clinicians we have to accept this level 1 evidence. During counselling we have to discuss with the patient that open surgery in early cervical cancer has a survival benefit at the cost of an increased short-term morbidity. The patient herself is the prime and only decision maker. The surgery should be tailored and performed according to the wishes of the patient. Whether this will change current practice has to be seen.