Cervical cancer (CC) remains the most prevalent malignancy of the female reproductive system and is a leading cause of mortality among women worldwide. Standardized treatment protocols for CC, particularly surgical interventions, generally achieve favorable therapeutic outcomes (Melamed et al. 2018; Hongladaromp et al. 2014; Derks et al. 2016). Studies report 5-year survival rates following surgery to range from 83 to 94.6%. In the present study, the 5-year overall survival (OS) rates for open and laparoscopic surgery were 87.2% and 90.4%, respectively. Univariate analysis indicated that the choice of surgical approach was not a prognostic factor for early-stage CC, aligning with findings from both domestic and international retrospective studies (Kanao et al. 2019).

Open and laparoscopic surgeries each have distinct advantages and limitations. Before 2018, laparoscopic surgery gained popularity due to its technical advantages, such as reduced trauma, better visualization, less blood loss, and faster recovery. Evidence from multiple studies supported its safety (Wang et al. 2016; Nam et al. 2012; Conrad et al. 2015). However, randomized controlled trials (RCTs) and retrospective studies published in the New England Journal of Medicine revealed that laparoscopic radical hysterectomy was associated with higher recurrence rates and lower overall survival compared to traditional open surgery (Ramirez et al. 2018; Melamed et al. 2018). The underlying reasons for the increased risks associated with laparoscopic surgery remain unclear. Thus, a complete abandonment of laparoscopic surgery for CC may be premature. For instance, a South Korean multi-center study demonstrated that when the local CC lesion size was ≤ 2 cm, laparoscopic surgery did not adversely affect prognosis (Kim et al. 2021).

Scholars attribute the higher recurrence and mortality rates in laparoscopic radical hysterectomy to three primary factors: disruption of tumor-free principles, the establishment of CO2 pneumoperitoneum, and the surgeon’s learning curve (Association of Radical Hysterectomy Surgical Volume and Survival for Early-Stage Cervical Cancer: Correction 2024; Chiva et al. 2020).

One hypothesis is that uterine manipulator use contributes to parametrial migration, lymphovascular space invasion, pelvic metastasis, and distant metastasis (Krizova et al. 2011; Logani et al. 2008; Uppal et al. 2020). Studies indicate that the proportion of “tissue structure fragmentation and detachment of cancer cells from the stroma” was significantly higher in pathological specimens from laparoscopic surgery groups compared to open surgery groups (45.0% vs. 12.6%) (Krizova et al. 2011). Uppal et al. (Janda et al. 2017) found no recurrence in patients who underwent laparoscopic surgery without a uterine manipulator, while recurrence rates reached 7% in patients using intrauterine manipulators and 11% in those using vaginal manipulators. Interestingly, in early-stage endometrial and ovarian cancer cases, manipulator use during laparoscopic surgery showed no significant differences in prognosis compared to open surgery (Gueli et al. 2021; Lin et al. 2014). In this study, the laparoscopic group used manipulators, yet the proportions of interstitial infiltration and paruterine invasion were not significantly higher than in the open surgery group (P > 0.05). Moreover, the prognosis was comparable between the groups. The specific mechanism contributing tumor dissemination requires further investigation and validation through extensive trials.

The use of CO2 pneumoperitoneum distinguishes laparoscopic surgery from open surgery. Evidence suggests that performing vaginal incisions under pneumoperitoneum conditions may increase postoperative recurrence rates compared to surgeries without pneumoperitoneum (Loureiro and Oliva 2014). This could be due to the following factors: CO2 may enhance tumor cell proliferation, pneumoperitoneum pressure may dislodge cancer cells into the abdominal or pelvic cavities, and pressure fluctuations during surgery may promote cancer cell migration and dissemination (Loureiro and Oliva 2014; Nelson et al. 2004). In this study, recurrences and metastases were primarily localized to the vaginal stump, with no significant increase in distant metastases in the laparoscopic group. A prospective study on colon cancer also showed no significant difference in long-term prognosis between surgical approaches (Yang et al. 2021). Current findings on CO2 pneumoperitoneum effects are largely based on laboratory studies, and no clinical evidence has been reported of CO2 pneumoperitoneum promoting distant CC metastasis.

The surgeon's learning curve plays a significant role in influencing patient outcomes (Pedone et al. 2021). Pedone et al. (Zhang et al. 2024) conducted a retrospective analysis of 243 early-stage cervical cancer (CC) patients undergoing minimally invasive radical hysterectomy. Their multivariate logistic regression analysis revealed that surgeons' learning curves had a significant impact on patient outcomes. The 3-year tumor-free survival rate increased from 75.4 to 91.6% (P = 0.005) as surgeons gained sufficient experience. Another study demonstrated that survival rates of patients treated with open surgery were similar, regardless of whether they were treated at university-affiliated or non-university-affiliated hospitals. However, patients in the laparoscopic group treated at university cancer centers had higher survival rates than those treated at non-university cancer centers, suggesting that the treatment center level is a critical factor for patients undergoing radical hysterectomy for early-stage CC (Association of Radical Hysterectomy Surgical Volume and Survival for Early-Stage Cervical Cancer 2024). This single-center study initiated laparoscopic surgery in 2008, requiring surgeries to be led by associate senior surgeons with more than five years of gynecological oncology surgical experience. Consequently, it was found that the choice of surgical approach did not affect early-stage CC prognosis.

The study identified clinical stage, interstitial infiltration, paruterine invasion, lymph node metastasis, tumor diameter, and vascular invasion as significant prognostic factors for early-stage CC, which is consistent with other findings. Multivariate Cox regression analysis confirmed that clinical stage IIA, vascular invasion, and tumor diameter are independent risk factors affecting survival (P < 0.05).

The main reasons for this are as follows: (1) Clinical stage remains a pivotal factor influencing CC prognosis. Literature indicates that higher clinical stages correspond to lower OS and DFS rates (Shinagare et al. 2024). Advanced stages are associated with larger tumor volumes, greater invasion, and poorer biological behavior of tumor cells (Shinagare et al. 2024; Liu et al. 2024). These factors increase the likelihood of invading surrounding tissue, leading to a higher risk of postoperative recurrence and poorer outcomes. (2) This study reported a 5-year survival rate of 79.6% in patients with vascular invasion, compared to 92.2% in those without vascular invasion. Patients with vascular invasion exhibited a death risk 0.483 times higher than those without vascular invasion, thereby highlighting it as a significant prognostic risk factor. Vascular invasion often signals increased tumor invasiveness and represents an early stage of metastatic progression, heightening the risk of lymph node metastasis (Balaya et al. 2018; Gulack et al. 2015). Most studies agree that vascular invasion adversely impacts prognosis in early-stage CC(Gulack et al. 2015) 0.3) Tumor diameter > 4 cm was identified as an independent risk factor for CC prognosis. Studies of malignant tumors, including lung, breast, gastric, and renal cancers, consistently demonstrate a correlation between larger tumor sizes and poorer prognosis (Gulack et al. 2015). In gynecological malignancies, smaller tumor diameters correlate with reduced interstitial vasculature invasion and metastasis, yielding better postoperative outcomes. For instance, Mahdi et al. [34] reported that after adjusting for factors such as age, grade, lymph node status, and adjuvant therapy, tumor diameter remained a strong predictor of specific survival in endometrial cancer (HR = 1.13, 95% CI = 1.08–1.18, P < 0.001). In CC, tumor size forms a primary basis for the FIGO staging system, with larger tumors indicating later stages, greater severity, and increased risks of paracervical tissue infiltration and lymph node metastasis, all of which adversely affect prognosis.

According to this study, we found that for patients with early—stage cervical cancer, when there is no pneumoperitoneum, there is no uterine manipulation, and the tumor volume is less than 4 cm, it is a safe practice for experienced gynecological oncologists to choose minimally invasive abdominal surgery.

This study, being a retrospective analysis, has inherent limitations. The proportion of cases with deep stromal infiltration and tumor diameters > 4 cm was significantly higher in the open surgery group than in the laparoscopic group. This discrepancy may have led to greater caution among surgeons when selecting laparoscopic surgery for cervical cancer patients, potentially creating an imbalance between the conditions of the two groups. Simultaneously,this research is primarily centered around the study of survival outcomes and relevant clinical parameters. However, it falls short in terms of conducting follow—up on patients' subjective experiences. In future follow—up studies, significant efforts should be made to strengthen the assessment of patients' satisfaction with surgical outcomes, quality of life, and other such aspects. Despite these confounding factors, the findings of this study provide evidence supporting the value of laparoscopy in radical surgery for early-stage cervical cancer.

Under specific conditions, laparoscopic surgery remains a promising option for early-stage cervical cancer. Clinical stage, vascular invasion, and tumor diameter > 4 cm were identified as independent risk factors influencing postoperative survival in patients with early-stage cervical cancer. To ensure the safety and efficacy of laparoscopic surgery, as well as to guide the choice of surgical approaches for early-stage cervical cancer, future research should include more detailed subgroup analyses, larger multicenter datasets, longer follow-up durations. At the same time, it is crucial to strengthen the follow—up on patient satisfaction and quality of life so that we can conduct a more comprehensive analysis when choosing different surgical methods and thus provide more personalized treatment plans for patients.