According to statistics from the International Agency for Research on Cancer, the incidence of cervical cancer was 604,000 in 2020, making it the fourth most common gynecological cancer worldwide (1). Radical hysterectomy (RH) with lymphadenectomy remains one of the preferred treatments for patients with cervical cancer diagnosed at the International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIA (2). In recent decades, minimally invasive surgery (MIS) has become more common, displacing the use of traditional open surgery for early-stage cancer. However, the Laparoscopic Approach to Cervical Cancer (LACC) trial observed that disease-free survival (DFS) at 4.5 years and overall survival (OS) at three years of MIS were significantly lower than those of open surgery among women with stage IA1-IB1 cervical cancer, which remains controversial (3). Potential explanations include increasing tumor spillage due to the application of a uterine manipulator, the effect of CO₂ insufflation, the volume of surgery, and the surgeon’s proficiency (4–7). Several studies have focused on the correlation between surgeon proficiency and clinical outcomes in recent years. Lan Ying Li et al. found that compared to open surgery, more cases were required for surgeons performing minimally invasive RH to reach an acceptable five-year DFS (8). Kim et al. demonstrated that surgeons’ proficiency in the MIS group significantly affected progression-free survival (PFS) (9). Liu et al. concluded that the learning curve could be a probable reason for poor outcomes of MIS by analyzing stage IB cervical cancer patients treated with RH by one surgeon for 15 years (10). Nevertheless, existing studies have limitations such as low sample sizes, incomplete follow-up information, and the absence of clinicopathological features of patients. There is still insufficient evidence regarding whether a surgeon’s proficiency is associated with survival outcomes in MIS. We aimed to explore the effects of surgeons’ proficiency in MIS on short- and long-term clinical outcomes and whether it accounts for the clinical outcomes of MIS.

The World Health Organization proposed that patients with cervical cancer must be managed appropriately to accelerate the elimination of the disease, prompting more attention to the treatment of cervical cancer in recent years. Previous studies demonstrated that MIS and open surgery had comparable oncological outcomes (14–16). In contrast, several recent studies showed poorer oncological outcomes, especially lower DFS in patients treated with MIS (3, 17–19). As the findings were conflicting, the superiority or inferiority of MIS remains unclear. In our study, there were no statistical differences in the MIS and open surgery groups with regard to three- and five-year OS and DFS, and the subgroup analysis performed by different surgeons reached the same conclusion. However, when we compared different phases in MIS with open surgery, the OS and DFS of phase one were in line with those of the LACC trial. The perioperative outcomes such as hospital stay and blood loss were significantly better in the MIS group, whereas the duration of surgery was significantly shorter in the open surgery group, which is in accordance with many other studies.

According to the NCCN guideline (2), the standard approach for RH is the open surgery, and the oncologic risks of MIS should be informed carefully to patients given the findings of poorer survival outcomes of MIS recently. The development of MIS was affected by relevant research works. Therefore, it is essential to clear the reasonable application of MIS to achieve maximum benefits for patients. Pedestrian et al. showed that patients with tumor dimension less than two centimeters still suitable for MIS, but more studies are needed to refine on criteria (20).

Several potential reasons may explain the limitations of MIS, such as the use of a uterine manipulator, insufflation gas, intracorporeal colpotomy under CO₂ pneumoperitoneum, and the proficiency of the surgeon (7, 21–23). Gynecologic oncologists have designed innovative techniques and devices to reduce the potential negative consequences of these risks in recent years. For example, Hiroyuki Kanao et al. devised the “no-look, no-touch” technique for preventing intraoperative tumor spillage (24). Moreover, Peng Yuan et al. performed abdominal uterine manipulation and enclosed colpotomy (23). However, prospective studies are needed to evaluate the effects of these surgical techniques on oncological outcomes.

Previous studies have examined the learning curve in terms of some clinical parameters, such as the number of cases needed to reach a stable operation duration or to obtain a relatively low hemorrhage volume (25). Survival outcomes have rarely been reported. A recent study by Kim et al. concluded that improvement of surgical performance could be achieved after 13 cases of MIS (9). Pedestrian et al. demonstrated that the peak of reduction of the recurrence risk was the 19^th MIS (26). Sert et al. showed that there was a higher number of recurrences in the first 50 cases (27). In this regard, our findings were in line with the results of previous studies that the first ten cases were significantly inferior to subsequent cases. Moreover, favorable survival outcomes observed after the first ten cases also demonstrated the effect of surgeon proficiency. There was no statistical significance when comparing the different surgeons, indicating that favorable outcomes can be obtained by practicing the MIS technique after a certain number of cases. Based on our findings, we offer the following suggestions. First, surgeons should undergo standardized training to improve their surgical skills (28). Second, surgeons performing MIS should have some standard qualification. For example, surgeons can only perform laparoscopic surgery after completing a certain number of virtual surgeries through surgery simulators. Third, beginners should be overseen by experienced surgeons, particularly for the first dozen or so cases.

The main strength of this study is the large sample size. In addition, compared with other studies, we analyzed more clinical parameters, making our results more robust and applicable to a larger population. However, our study has several limitations. Due to its retrospective nature, there could be bias in the patient selection. Furthermore, we did not evaluate the effect of different surgical techniques and devices in different phases. More studies on specific surgical approaches and techniques, including conventional multiport laparoscopic and laparo-endoscopic single-site surgery with/without technological innovations, are needed. Although there was no robotic case in our study, some relevant studies showed that robotic and laparoscopic approaches were similar in perioperative and postoperative outcomes (29), future studies could consider this aspect.

In conclusion, our retrospective study demonstrated that phase one cases of MIS had lower OS and DFS than those in later phases or that underwent open surgery. Thus, we suggest that the proficiency of the operating surgeon is associated with the survival outcomes of MIS. More favorable outcomes can be obtained after a certain number of MIS cases have been performed.

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by the Institutional Ethics Committee of West China Second University Hospital. The patients/participants provided their written informed consent to participate in this study.

YY and ZYL contributed to data collection and study design. YY and YH contributed to data analysis. All authors contributed to the article and approved the submitted version.

This study was supported by grants from the Sichuan Youth Foundation of Science of Technology (Grant number: 2015JQ0026).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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