Minimally invasive surgery in gynecologic oncology: a narrative review of controversies and clinical implications

Introduction

Minimally invasive surgery (MIS) has become a cornerstone in the surgical management of many gynecologic malignancies. Patients benefit from shorter hospital stays, reduced blood loss, quicker recovery, and fewer perioperative complications (1). Over the past two decades, the gynecologic oncology community has adopted laparoscopic and robotic-assisted techniques for certain indications in the management of cervical, endometrial and epithelial ovarian, fallopian tube and primary peritoneal cancers (1).

The use of MIS in early-stage cervical cancer remains controversial. Data has raised concerns about higher recurrence rates and reduced survival with minimally invasive approaches for early-stage disease (2-4). However, newer studies suggest potential comparable outcomes in selected patients and additional studies are ongoing (5). Laparoscopic and robotic-assisted surgical techniques are well-established in the surgical treatment for endometrial cancer, but are still being explored in interval cytoreductive surgery for patients with epithelial ovarian, fallopian tube or primary peritoneal cancer (6-9).

The objective of this review paper is to examine the key controversies, recent data, and future perspectives on the use of MIS in cervical, endometrial and epithelial ovarian, fallopian tube, and primary peritoneal malignancies. We will review all relevant phase 3 clinical trial data on surgical approaches in gynecologic malignancies as well as selected retrospective database studies. Ongoing pertinent clinical trials and potential future implications will be reviewed as well. While there are existing literature reviews on MIS in gynecological cancers, our review integrates high-level evidence from recent phase III and population-based studies organized by cancer type. In doing so, we discuss how MIS is the standard for endometrial cancer, remains controversial in cervical cancer, and is still investigational in ovarian cancer. We present this article in accordance with the Narrative Review reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-19/rc).

Methods

A literature review was performed using PubMed to identify peer-reviewed articles from January 2000 through April 2025. Only publications in English were included. Ongoing clinical trials were identified through clinicaltrials.gov. Both prospective randomized controlled trials and retrospective cohort studies were included. Studies were selected based on relevance to minimally invasive surgical outcomes in the gynecologic oncology space based on expert clinical opinion (Table 1).

Cervical cancer

Historical surgical treatment of cervical cancer

In the 18th and early 19th centuries, cervical cancer was typically diagnosed at a late stage and considered incurable. In 1801, Friedrich Benjamin Osiander performed the first cervical excision for malignancy, similar to a vaginal hysterectomy (10). Throughout the 19th century, others adopted his approach, often encountering complications such as pain, hemorrhage and infection (10). The radical hysterectomy was first described by Wilhelm Alexander Freund in 1898 (11). It involved en bloc removal of the uterus, cervix, upper vagina and bilateral parametria (11). In the 1930s, Joe Vincent Meigs expanded this to include pelvic lymphadenectomy, forming the Wertheim-Meigs procedure for early-stage cervical cancer (12). Maurice Dargent developed the radical trachelectomy in 1987, which provided a fertility-preserving option for young women with early stage cervical cancer (13). MIS was introduced in the 1990s and gradually evolved to become the standard approach for performing a radical hysterectomy in early-stage cervical cancer (14).

In the 1990s, Nezhat et al. reported the first case of laparoscopic radical hysterectomy to treat early stage cervical cancer (15). This demonstrated that a laparoscopic approach was feasible and potentially beneficial to the patient (15). By the early 2000s, Sert et al. showed that a robotic-assisted laparoscopic radical hysterectomy for early stage cervical carcinoma was technically feasible and produced comparable or better results to the conventional laparoscopic approach (16). They found that the amount of parametrial tissue removed was comparable between the two groups; however, the robotic approach was associated with reduced blood loss and a shorter hospital stay compared to laparoscopy (16).

Key studies informing a minimally invasive surgical approach

The role of MIS in the management of early-stage cervical cancer has undergone significant change in the last decade. Initially, laparoscopic radical hysterectomy was adopted as an alternative to laparotomy to offer the patients the benefits of reduced morbidity associated with MIS compared to laparotomy (17). The drawbacks to laparoscopy, such as poor surgical ergonomics, 2-dimensional image, and non-articulating instruments, were made apparent with the development of the DaVinci robotic platform (17). The robotic system allows for a 3-dimensional surgical field, tremor reduction, and articulating instruments (18). With the widespread use of the DaVinci robot system, both laparoscopic and robotic-assisted approaches became standard practice for performing a radical hysterectomy in the treatment of early-stage cervical cancer, albeit with limited data on safety (14). This changed significantly after the publication of the Laparoscopic Approach to Cervical Cancer (LACC) Trial (NCT00614211), which demonstrated decreased progression-free and overall survival for patients who underwent a minimally invasive approach to radical hysterectomy (2,19). The LACC trial included patients with stage IA1 (lymphovascular space invasion), IA2 or IB1 cervical cancer (2). Patients were randomized to undergo a minimally invasive versus open radical hysterectomy with pelvic lymphadenectomy. Those who underwent a MIS approach had a 274% increased risk of recurrence compared to those who underwent laparotomy [hazard ratio (HR) 3.74; 95% confidence interval (CI): 1.63–8.58] (2). Furthermore, a MIS approach was associated with a 500% increased risk of death from any cause at 3 years (HR 6.0; 95% CI: 1.77–20.3) (2). Final analysis from the LACC trial demonstrated lower disease-free survival (HR 3.91; 95% CI: 2.02–7.58; P<0.01) and overall survival (HR 2.71; 95% CI: 1.32–5.59; P=0.007) in the MIS arm compared to the open surgery arm (19). Subgroup analysis revealed the rate of locoregional recurrence at 4.5 years was 4.9% in the MIS arm and 1.8% in the laparotomy arm (HR 4.70; 95% CI: 1.95–11.37; P=0.001) (19). They also conducted a subgroup analysis based on prior conization to evaluate whether this preoperative intervention influenced outcomes. There was no significant difference in recurrence between the MIS and open arms among patients who had had prior conization (HR 1.27; 95% CI: 0.39–4.17; P=0.69) (19). However, in patients without prior conization, MIS was associated with an increased risk of recurrence (HR 5.85; 95% CI: 2.47–13.9; P<0.01) (19). Table 2 highlights pivotal clinical trials informing the use of MIS in gynecologic oncology. These outcomes have been replicated in a population-based cohort study using the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) database, and in an international, retrospective cohort study, the Surgery in Cervical Cancer, Observational, Retrospective (SUCCOR) study (4,20). The SUCCOR study examined disease-free survival in patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1 cervical cancer undergoing open versus minimally invasive radical hysterectomy (20). The authors found that patients who underwent MIS had twice the risk of recurrence (HR 2.07; 95% CI: 1.35–3.15; P<0.01) and risk of death (HR 2.45; 95% CI: 1.30–4.60; P<0.01) compared to those who underwent open surgery (20). Furthermore, they found that in patients who had a uterine manipulator placed had an increased hazard of relapse (HR 2.76; 95% CI: 1.75–4.33; P<0.01) (20). Lastly, those who underwent MIS with protective vaginal closure had similar rates of relapse to those who received laparotomy (HR 0.63; 95% CI: 0.15–2.59; P<0.52) (20). The protective vaginal closure involved creating an incision in the vaginal epithelium, dissecting the vaginal apex, and closing it prior to making the colpotomy (20). Another protective vaginal closure involves using a suture through the vaginal walls in order to close the vagina prior to colpotomy (20,21).

Theories for poorer oncologic outcomes after minimally invasive radical hysterectomy include tumor dissemination from uterine manipulation and aerosolization of cancer cells from carbon dioxide insufflation (22,23). It was thought that because the uterine manipulators are passed transcervically, this could lead to tumor disruption and dissemination into the peritoneal cavity (22,23). These theories are discussed in greater depth in section 3.4.

The LACC trial sparked debate and immediately shifted clinical practice patterns across the United States. The use of minimally invasive radical hysterectomy sharply declined after the LACC trial’s results were presented (24). A longitudinal analysis by Chao et al., found that the rates of MIS decreased by 3% per month in patients with a BMI ≥40 kg/m², and by 18% per month in patients with BMI <40 kg/m² (24). Contrary to the randomized clinical data published, several additional population-based studies showed no survival differences between an open and minimally invasive approach (4,5,25).

The recently published Simply Hysterectomy And Pelvic Node Assessment (SHAPE) trial (NCT01658930) has influenced the surgical management of early-stage cervical cancer. This study demonstrated that in low-risk, early-stage cervical cancer, simple hysterectomy is non-inferior to radical hysterectomy with respect to pelvic disease-free survival (2.17% vs. 2.52%; 90% CI: −1.62 to 2.32) (26). Patients enrolled in this study were diagnosed with FIGO 2009 stage IA2 or IB1 cervical cancer, with lesions measuring no more than two centimeters and a maximum depth of cervical stromal invasion of 10 mm (26). A total of 700 patients were randomized to simple versus radical hysterectomy, and the surgical approach was left to the discretion of the surgeon. Approximately 80% of patients who underwent simple hysterectomy and 70% of those who underwent radical hysterectomy received a minimally invasive approach (26). Although MIS was not a primary endpoint of the trial, an exploratory analysis suggested that there was no significant increase in disease recurrence or overall survival among patients who underwent MIS compared to those who received open surgery (27). Active clinical trials, discussed below, aim to address this ongoing debate. Currently, clinical practice is to offer patients with early-stage cervical cancer who could be treated with radical hysterectomy an open approach.

Current clinical trials evaluating minimally invasive surgery in cervical cancer

Clinical trials continue to investigate the role of MIS in the gynecologic oncology field by addressing safety, efficacy and optimal indications across malignancies (Table 3). A key controversy remains whether robotic-assisted radical hysterectomy can offer comparable oncologic outcomes to open surgery in early-stage disease. The Randomized Controlled Trial of Robotic versus Open Radical Hysterectomy for Cervical Cancer (ROCC/GOG-3043) (NCT04831580) and Robotic-assisted Approach to Cervical Cancer (RACC) (NCT03719547) trials aim to address this question (28,29). ROCC is a randomized non-inferiority trial comparing robotic versus open radical hysterectomy for early-stage cervical cancer (28). Patients with FIGO 2018 stage 1A2-1B2 adenocarcinoma, squamous cell, and adenosquamous cell carcinoma of the cervix are included. All patients must have a preoperative pelvic MRI confirming the tumor size is <4 cm in size without obvious extracervical extension or metastasis. This study does not allow for the use of intraoperative transcervical uterine manipulators, and requires surgeons to employ specific surgical techniques for tumor containment (28). These stringent requirements were implemented to minimize surgical variability and to control for potential confounding factors, addressing some of the key criticisms raised in response to the LACC trial. The RACC trial is also a randomized non-inferiority trial with similar inclusion criteria to the ROCC trial: patients with FIGO 2018 stage 1B1, 1B2, and IIA1 squamous, adenocarcinoma, or adenosquamous carcinoma of the cervix without metastatic disease are included (29). This trial does not specifically restrict the type of uterine manipulation, but does call for utilizing surgical practices that minimize tumor contamination during colpotomy (29). Techniques to reduce surgical spill include performing an extracorporeal colpotomy, restricting use of a transcervical uterine manipulator, and using a protective closure of the vagina over the tumor prior to colpotomy (29,33). Results from these two trials aim to help define the optimal surgical approach for women with early stage cervical cancer.

Current debates in the management of cervical cancer

Large phase III trials, including the LACC trial, have shown higher recurrence rates and lower survival rates in patients undergoing MIS compared to open surgery (4,20). The reasons remain unclear and are under investigation. While the radicality of the surgical specimen appears similar between approaches, theories for inferior MIS outcomes include tumor disruption from uterine manipulators, CO₂ insufflation, and colpotomy-related peritoneal contamination (34,35).

Several theories have been proposed to explain the potential role of CO₂ insufflation in increased recurrence rates. Volz et al. suggest that high-pressure pneumoperitoneum may disrupt the mesothelial layer, facilitating widespread tumor cell implantation (35). Another theory suggests that CO₂ insufflation may create a locally acidic microenvironment that enhances metabolic activity of tumor cells and promotes tumor growth (34). As discussed previously, the SUCCOR study evaluated the impact of vaginal closure and the use of a uterine manipulator in minimally invasive radical hysterectomy (20). The vaginal closure technique was described by Köhler et al. who described the technique as the vaginal creation of a tumor-covering vaginal cuff (23). The surgeon uses a vaginal-assisted laparoscopic approach to create and close the vaginal cuff prior to parametrial resection laparoscopically (23). It is thought that this method prevents tumor dissemination within the peritoneal cavity. Lastly, surgeon experience may also play a role in increased recurrence rates. Kim et al. found that surgical proficiency for robotic radical hysterectomy may require greater than 20 cases, with higher recurrence observed earlier in the learning curve (36). This raises questions about surgeon preparedness in trials like LACC, where only 10 documented cases were required (2,19).

Comparisons between laparoscopic and robotic approaches remain ongoing. A 2024 meta-analysis of twenty clinical trials demonstrated comparable recurrence (OR 1.19; 95% CI: 0.91–1.55; P=0.61) and survival outcomes (OR 0.96; 95% CI: 0.65–1.42; P=0.56) (37). A study by Zhang et al. reported that robotics outperform laparoscopic surgery in terms of intraoperative bleeding, length of hospital stay, and operative time (38). However, this study did find an increased risk of cancer recurrence and increased costs with robotic surgery compared to laparoscopic surgery (38). Prospective data are needed to evaluate efficacy and safety between these two approaches.

The management of early-stage cervical cancer is shifting toward a more conservative, patient-center approach (39). Less radical procedures, such as simple hysterectomy or conization with nodal assessment have been proposed as alternatives to preserve fertility and improve quality of life in appropriately selected patients (39). Improved screening and broader access to preventative vaccination have also reduced the number of cases requiring surgery, thereby limiting opportunities for trainees to perform minimally invasive radical hysterectomies (40). In parallel, advances in targeted therapies, immunotherapies, and second-generation HPV vaccines are changing approaches to diagnosis, surgery, and adjuvant treatment (41). Ongoing prospective trials, such as Cervical Cancer Treated with Neoadjuvant Chemotherapy followed by Fertility Sparing Surgery (CONTESSA/GOG-278) (NCT04046185), Neoadjuvant Chemotherapy and Conservative Surgery in Cervical Cancer to Preserve Fertility (NEOCON-F) (NCT03852979), and Fertility Sparing Surgery in cervical cancer patients outside controlled trials (FERTISS) (NCT04016389) are further evaluating oncologic and obstetric results of fertility-sparing treatments in early-stage cervical cancer (39,41,42). It is important to note, however, that many of these studies enrolled patients prior to publication of the LACC trial, at a time when MIS was more commonly practiced (27,42). Consequently, a proportion of procedures were performed minimally invasively, which introduces uncertainty, given that the LACC trial demonstrated inferior outcomes with MIS for radical hysterectomy. Whether these findings extend to highly selected patients with stage IB1 disease who have already undergone a negative cone biopsy with clear margins remains unclear. Additional research is needed to determine the safety of MIS in this specific context.

Given these findings, the Society of Gynecologic Oncology (SGO) encourages thorough discussion and counseling with patients and shared decision making when choosing surgical approach, and current National Comprehensive Cancer Network (NCCN) guidelines continue to recommend open radical hysterectomy as the standard of care for early-stage cervical cancer (43,44).

Surgical management recommendations

Based on the supporting data above, we recommend an open surgical approach as the standard of care for patients with early-stage cervical cancer undergoing radical hysterectomy (FIGO 2018 stage IA2–IB2), particularly outside of clinical trial settings (Figure 1). MIS, including laparoscopic or robotic-assisted radical hysterectomy may be considered only in highly selected patients who meet strict criteria and are treated within the context of a controlled clinical protocol. This guidance reflects concerns about inferior oncologic outcomes with MIS in observed studies like the LACC trial. Until prospective evidence supports its safety, adherence to current guidelines favoring open surgery remains essential.

Figure 1 Decision tree outlining the recommended surgical approach for early-stage cervical cancer (FIGO 2018 stage IA2-IB2). FIGO, International Federation of Gynecology and Obstetrics; MIS, minimally invasive surgery.

Endometrial cancer

Historical surgical treatment of endometrial cancer

Similar to cervical cancer, uterine cancer remained poorly understood throughout the 19th century. After Freund performed the first successful abdominal hysterectomy, advancements in anesthesia and aseptic technique laid the foundation for safer and more effective surgical management (45). In the mid to late 20th century, authors such as Leijon et al. demonstrated that total abdominal hysterectomy and bilateral salpingo-oophorectomy is an adequate treatment for patients with low-risk endometrial cancer (46). In 1987, Gynecologic Oncology Group (GOG) 33 evaluated surgical staging with pelvic and para-aortic lymphadenectomy for uterine cancer. This study found that lymph node involvement correlated with tumor grade and depth of invasion (47). These findings formed the basis of the 1988 FIGO endometrial cancer staging system (47). In the 2000s, MIS gained traction in gynecologic oncology, offering smaller incisions, less blood loss, and faster recovery (6). Today, robotic-assisted and laparoscopic surgery are the standard surgical approaches for patients with early-stage endometrial cancer.

Key studies informing a minimally invasive surgical approach

MIS has become the standard of care for early-stage, uterine confined endometrial cancer. This is supported by large, prospective trials such as the Gynecologic Oncology Group Laparoscopic Approach to Carcinoma of the Endometrium (LAP2) (NCT00002706) and Laparoscopic Approach to Cancer of the Endometrium (LACE) (NCT00096408) trials (Table 2). The LAP2 trial was a randomized controlled trial that compared the feasibility of laparoscopy versus laparotomy for surgical staging of uterine cancer (6). Laparoscopy was successfully used without conversion in 1,248 (74.2%) of 1,682 enrolled patients (6). The study demonstrated that compared to laparotomy, laparoscopy resulted in fewer postoperative adverse events (14% vs. 21%; P<0.0001) and no difference in overall detection of advanced stage (17% vs. 17%; P=0.841) (6). Furthermore, the number of patients that were hospitalized for more than two days was significantly lower in the laparoscopy versus laparotomy arm (52% vs. 94%; P<0.0001) (6). Similarly, the LACE trial confirmed the safety and feasibility of laparoscopic hysterectomy in early-stage endometrial cancer (7). This study included 760 patients with 4.5 years of follow up (7). Laparoscopic hysterectomy was non-inferior to abdominal hysterectomy in terms of disease-free survival (81.6% vs. 81.3%, respectively; 95% CI: −5.5, 6.1; P=0.007) and overall survival (7.4% vs. 6.8%, respectively; 95% CI: −3.0, 4.2; P=0.76) (7). MIS is particularly valuable in the management of endometrial cancer in obese and morbidly obese patients, a population disproportionately affected by this disease process. Ancillary analyses of LAP2 data have shown that even though obesity increases the complexity of surgery, the overall benefits of MIS, such as reduced blood loss and shorter recovery, remains consistent across BMI classes (48). Research has shown a correlation between the use of minimally invasive techniques and improved surgical outcomes in obese patients (49). Harvey et al. studied the utility of MIS in morbidly obese patients (BMI ≥50 kg/m²) and found that MIS hysterectomy for endometrial pathology can be performed with favorable outcomes (50).

Casarin et al. reported that between 2008 and 2014 in the United States, the use of MIS for early-stage endometrial cancer significantly increased from 24.1% to 71.4%, while the rate of open surgery concurrently declined from 71.1% to 26.4% (both P<0.01) (51). Abel et al. examined trends in adoption of MIS in patients with stage II uterine cancer (52). A total of 2,949 patients were included, and 41.8% of patients received robotic, 13.9% laparoscopic, and 44.3% open surgery (52). The study demonstrated that between 2010 and 2015, the proportion of robotic hysterectomies increased by an average of 10.1% per year (P<0.05), open hysterectomies decreased by 12.5% per year (P<0.05%), and laparoscopic hysterectomies increased by 11.2% per year, although this change was not statistically significant (52).

Current clinical trials evaluating minimally invasive surgery in endometrial cancer

Since the publication of the LAP2 and LACE trials, laparoscopy has been considered the gold standard for surgical management of patients with early-stage endometrial cancer. There are no randomized controlled trials specifically examining outcomes in patients at high risk of recurrent endometrial cancer, such as those with non-endometrioid histology or advanced stage. An ongoing study being performed in Italy, Laparoscopy versus Laparotomy (LPSvsLPT) trial (NCT06790004) is recruiting patients to evaluate the safety of MIS for the treatment of endometrial cancer in patients at low, intermediate or high risk of recurrence (30). This study’s main objective is to examine peri and postoperative complications and long-term oncologic outcomes (Table 3) (30).

Current debates in the management of endometrial cancer

American College of Obstetrics and Gynecology (ACOG) and SGO outlined in a joint practice bulletin that MIS is the preferred approach for comprehensive surgical staging in early-stage endometrial cancer (53). A 2025 study using data from the SGO Clinical Outcomes Registry reported a low MIS-to-open conversion rate of 3.4% in endometrial cancer surgeries (54). The authors found that conversions were more common in patients with morbid obesity, prior abdominal surgeries, non-endometrioid histology, and higher FIGO stage (54). These results highlight the importance of considering factors such as surgeon experience, uterine size, prior abdominal surgeries, surgical complexity, tumor grade, and histologic type when selecting surgical approach (54). SGO states that there are advantages to robotic surgery, such as its utility in obese or high-risk surgical patients where traditional laparoscopy may be technically challenging (55). Overall, the advantages between robotic-assisted versus conventional laparoscopy and the guidelines of robotic surgery training remain to be defined.

Surgical management recommendations

For patients with early-stage endometrial cancer (FIGO 2009 stage I–II), MIS is the recommended standard of care (Figure 2). Surgical planning begins with an assessment of patient operability, including an evaluation of patient comorbidities. In patients who are deemed medically operable and whose disease is localized or with minimal extra-uterine spread, MIS is preferred (Figure 2). Laparoscopy versus robotic surgery is left to the discretion of the surgeon based on preference and surgical expertise. It is the authors’ belief that open surgery should be reserved for cases with extensive disease, suspected metastatic spread, or when MIS is contraindicated due to patient or institutional factors.

Figure 2 Decision tree outlining the recommended surgical approach for early-stage endometrial cancer. BMI, body mass index; FIGO, International Federation of Gynecology and Obstetrics; MIS, minimally invasive surgery.

Epithelial ovarian, fallopian, and primary peritoneal cancer

Historical surgical treatment of ovarian cancer

In the 1800s, Ephraim McDowell performed the first successful ovarian tumor removal via laparotomy (11). By the 1930s, ovarian cancer was recognized as a distinct malignancy, however, its treatment and prognosis remained poorly understood. The 1973 FIGO staging system introduced standardized classification based on primary surgical findings (56). In 1975, Griffiths demonstrated that a smaller residual tumor volume after surgery correlated with improved survival, and that cytoreduction could be enhanced by chemotherapy (57). The goal of primary cytoreductive surgery in ovarian cancer is the removal of as much tumor as possible at the time of initial surgery (58).

Optimal cytoreduction at the time of primary surgery is not always feasible in advanced ovarian cancer, leading to the development of interval debulking surgery (IDS) following neoadjuvant chemotherapy (NACT). The European Organisation for Research and Treatment of Cancer (EORTC) 55971 trial (NCT00003636), the Medical Research Council Chemotherapy Or Upfront Surgery (CHORUS) trial (ISRCTN74802813), and the Trial of Radical Upfront Surgical Therapy in advanced ovarian cancer (TRUST) trial (NCT02828618) were all randomized controlled studies that demonstrated NACT followed by IDS is noninferior to primary debulking surgery in patients with advanced ovarian cancer (59-61). The use of NACT may result in complete or significant pathologic response prior to IDS, fueling an interest in MIS in ovarian cancer. In recent years, multiple systematic reviews and meta-analyses have evaluated the role of MIS in early-stage ovarian cancer (62-64). Matsuo et al. reported a significant rise in MIS use in the United States in the 2000s, with evidence suggesting improved short-term perioperative outcomes (65). MIS is now considered a valuable approach for early-stage cases. The utility of MIS in the advanced stage patient will be discussed below.

Key studies informing a minimally invasive surgical approach

The role of MIS in the treatment of ovarian cancer has garnered increasing attention, particularly in the setting of NACT followed by IDS. Traditionally, laparotomy has been the standard approach to ovarian cancer debulking due to the complex nature of achieving complete gross resection. However, newer evidence suggests that in carefully selected patients, MIS may offer comparable oncologic outcomes with the additional benefit of reduced perioperative morbidity (9,66). Pivotal trials informing this approach are discussed in Table 2. The Laparoscopic Cytoreduction After Neoadjuvant Chemotherapy (LANCE) trial (NCT04575935) is a randomized controlled non-inferiority study that compared MIS to laparotomy for interval cytoreductive surgery in patients with epithelial ovarian, fallopian or primary peritoneal carcinoma (8). Patients were eligible if they demonstrated a complete radiologic response to disease outside of the abdominal cavity after NACT, had normalization of cancer antigen (CA-125) levels, and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2 (8). Complete gross resection was achieved in 88% vs. 83% (95% CI: −9.7, 18.8) in the MIS and laparotomy arms, respectively (8). Other retrospective and observational studies have complimented the findings of the LANCE trial, affirming a role for MIS in a subpopulation of patients with epithelial ovarian cancer (9,66,67). Fagotti et al. performed a retrospective study in patients with advanced epithelial ovarian, fallopian tube, or primary peritoneal carcinoma who had undergone NACT and subsequent MIS (66). Eligible patients included those with FIGO stage III–IV epithelial ovarian cancer deemed unresectable at primary surgery. Patients were required to have received any number of NACT cycles, and to have undergone interval surgery within 45 days after completing chemotherapy. They found that all 127 patients had optimal cytoreduction at the time of interval surgery, and 96.1% of patients achieved complete gross resection. When taking a closer look at the surgical data, 111/127 (87.4%) of patients received an omentectomy, 38/127 (29.9%) underwent pelvic/para-aortic lymphadenectomy, 6/127 (4.7%) underwent diaphragmatic stripping, and 3/127 (2.4%) underwent a bowel resection (66). Furthermore, the conversion rate to laparotomy was 3.9%, median time to discharge was 2 days, and median time to start chemotherapy was 20 days (66). Similarly, other retrospective studies demonstrate that MIS for interval debulking is associated with decreased surgical morbidity, reduced intensive care utilization, faster postoperative recovery and similar survival outcomes to patients who underwent laparotomy (9,67,68).

Current clinical trials evaluating minimally invasive surgery in ovarian cancer

The role of MIS in ovarian cancer continues to be explored, specifically in the setting of interval cytoreductive surgery. Several ongoing trials aim to assess the oncologic safety and feasibility of robotic or laparoscopic surgery in select patients (Table 3). A prospective, single-arm, phase II clinical trial in Mexico (NCT06883409) is recruiting patients to demonstrate the non-inferiority of MIS versus open surgery in patients with advanced ovarian cancer who have received NACT (31). Inclusion criteria include patients with stage III–IV epithelial ovarian cancer with a partial or complete response to NACT, CA-125 less than 200, and ECOG status of 0–2 (31). The Minimally Invasive Robotic Surgery, Role in Optimal Debulking Ovarian Cancer, Recovery, and Survival (MIRRORS-RCT) trial (NCT05960630) is a randomized controlled trial currently recruiting patients in the United Kingdom (32). The aim is to evaluate the role of robotic interval cytoreductive surgery in advanced ovarian cancer. This study builds upon the earlier MIRRORS Feasibility study (NCT04402333), which demonstrated that patients undergoing MIS experienced enhanced recovery, including shorter hospital stays, reduced blood loss, and quicker return to chemotherapy (69). These studies demonstrate a growing global interest in determining whether MIS can maintain oncologic efficacy while reducing perioperative morbidity in appropriately selected patients.

Current debates in the management of ovarian cancer

There are several unresolved limitations regarding the use of a minimally invasive approach for cytoreductive surgery. There are anatomical areas in the abdomen that are notoriously difficult to access without tactile sensation, such as the posterior diaphragm, posterior spleen, Morrison’s pouch, the lesser sac, porta hepatis and the caudate lobe of the liver. The studies above were not designed as validation studies. To ensure that patients truly achieved complete gross resection following a minimally invasive approach, a confirmatory laparotomy would have been necessary. However, this was not performed, limiting the ability to verify oncologic completeness with certainty. Future trials addressing this question should incorporate confirmatory laparotomy to strengthen the validity of their findings.

Surgical management recommendations

In patients with advanced-stage epithelial ovarian, fallopian tube, or primary peritoneal cancer, we recommend that the surgical approach is dependent on tumor burden and response to NACT (Figure 3). Patients with high tumor burden or those who are poor candidates for primary cytoreduction should undergo NACT followed by interval debulking surgery. Post-treatment assessment should include CA-125 level, performance status and radiologic imaging to determine resectability (Figure 3). It is our opinion that in carefully selected patients with resectable disease, no evidence of bulky abdominal or diaphragmatic involvement, a minimally invasive approach to interval surgery can be considered (Figure 3). However, laparotomy remains the standard of care for primary and interval cytoreduction. Complete gross resection remains the most important prognostic factor, and intraoperative conversion to laparotomy should be performed if complete gross resection cannot be achieved via a minimally invasive approach.

Figure 3 Decision tree outlining the recommended surgical approach for advanced-stage epithelial, ovarian, fallopian tube cancer. CA-125, cancer antigen 125; ECOG, Eastern Cooperative Oncology Group; MIS, minimally invasive surgery; NACT, neoadjuvant chemotherapy.

Global accessibility and barriers to minimally invasive surgery

Despite the well-established benefits of MIS, its adoption in gynecologic oncology remains unevenly distributed globally, particularly in the low- and middle-income countries. Globally, one third of the population lives in a low- or middle-income country, however, only 6% of surgeries are performed in these regions (70). Barriers to implementation include limited access to laparoscopic equipment, insufficient surgeon training, and high upfront cost of implementation (71). These limitations are compounded by a low number of formal gynecologic oncology training programs, causing many cancer-related surgeries to be performed by general gynecologists without formal fellowship training (71).

Even in developed countries there are disparities in the receipt of MIS. A retrospective cohort study by Fader et al. found that patients with endometrial cancer receiving Medicaid were less likely to receive MIS versus those with private insurance (OR 0.67; 95% CI: 0.62–0.72) (72). This study also found that disparities in minimally invasive surgical options exist based on hospital type and patient sociodemographic factors (72). This suggests how access challenges and disparities are magnified in resource-limited settings, even within high-income countries like the United States. Potential strategies to increase access to MIS in gynecologic oncology include tailoring interventions to local surgical cultures, implementing education programs, and forming international collaborations.

Technical considerations and future directions

Robotic surgery has transformed gynecologic oncology by improving precision, reducing blood loss and recovery time. Single-port robotic systems, such as the da Vinci Single Port, have shown improved cosmetic outcomes, decreased pain and shorter hospital stay; although, more research is needed to confirm its feasibility in oncologic settings (73). The integration of artificial intelligence (AI) in surgical planning is also increasing, with potential to predict adverse events and aid in surgical planning (74). Its role and application in gynecologic oncology has not yet been defined.

Advancements in sentinel lymph node (SLN) mapping using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging have improved nodal detection and decreased the need for full or extensive lymphadenectomy (75). This technique requires specialized training and equipment and carries a risk of false negatives, particularly in cervical tumors ≥2 cm or those with parametrial involvement (76,77).

While these advancements provide a clinical benefit to the patient, robotics also poses economic and training challenges. A study published in the Journal of Clinical Oncology (JCO), found that robotic surgery is on average $1,291 more expensive per case than laparoscopic surgery (78). Other studies indicate that although robotic surgery incurs higher initial costs, the shortened hospital stay and reduced complication rate potentially offsets the increased expenses (79,80). Training to perform advanced procedures robotically remains inconsistent. One study published in the Journal of Robotic Surgery notes that the ability to perform a robotic omentectomy is limited by the surgeon’s learning curve and the availability of specialized equipment and training (81). Another study demonstrated that open (OR =0.64; 95% CI: 0.43–0.94) and robotic (OR =0.60; 95% CI: 0.37–0.97) approaches for lower anterior resections in patients with colorectal cancer were associated with decreased likelihood of successful oncologic resection compared to a laparoscopic approach (82). It is evident that robotic surgery has its advantages in decreasing blood loss and recovery time. However, further research is needed to compare robotic, laparoscopic and open approaches for advanced procedures in gynecologic oncology. Outcomes can vary depending on surgeon experience, patient factors and institutional resources.

Strengths and limitations

Strengths of this review include its integration of recent phase III trials and its cancer-specific organization. Limitations include its narrative, rather than systematic design, restriction to English-language studies, and reliance on retrospective data in settings where long-term outcomes remain uncertain.

Conclusions

MIS offers reduced morbidity, shorter hospital stays, and quicker recovery in appropriately selected patients. Its evolution has been driven by technological innovation and pivotal clinical trials that have advanced and challenged its role in cancer care. Its role in gynecologic oncology remains debated, particularly following landmark studies such as the LACC trial, which raised concerns about oncologic outcomes in cervical cancer. The ethical and clinical adoption of MIS depend on surgical complexity, surgeon expertise, cost-effectiveness, and resource accessibility. Ongoing and future clinical trials will continue to refine patient selection and clarify long-term outcomes to ensure safe cancer care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-19/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-19/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-19/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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