For a woman with FIGO stage IA2–IB1 cervical cancer, tumor ≤2 cm, clinically negative lymph nodes and no desire for fertility preservation, should I perform a minimally invasive simple total hysterectomy with sentinel‑node biopsy instead of an open radical hysterectomy?

Minimally Invasive vs Radical Hysterectomy for Early-Stage Cervical Cancer

For a woman with FIGO stage IA2–IB1 cervical cancer, tumor ≤2 cm, and clinically negative lymph nodes who does not desire fertility preservation, you should perform an open radical hysterectomy with bilateral pelvic lymph node dissection (with or without sentinel lymph node mapping) rather than minimally invasive surgery. 1

Primary Treatment Recommendation

Open radical hysterectomy with bilateral pelvic lymph node dissection remains the preferred surgical approach for FIGO stage IA2 through IB1 cervical cancer. 1 The NCCN guidelines explicitly state that radical hysterectomy is preferred over simple hysterectomy due to its wider paracervix margin of resection that includes aspects of the cardinal and uterosacral ligaments, upper vagina, and pelvic nodes. 1

Critical Evidence Against Minimally Invasive Approach

Recent high-quality evidence demonstrates worse oncologic outcomes with laparoscopic radical hysterectomy even in tumors ≤2 cm. 2 A 2020 study specifically examining this low-risk population (stage IB1 with tumor size ≤2 cm) found that:

• Laparoscopic surgery was associated with significantly worse 5-year disease-free survival compared to open surgery (90.4% vs 97.7%; p=0.02) 2
• The adjusted hazard ratio for disease recurrence with laparoscopic surgery was 4.64 (95% CI 1.26-17.06; p=0.02) 2
• Patients with non-squamous cell carcinoma or grade II-III tumors had particularly poor outcomes with laparoscopic surgery (74% vs 100% 5-year disease-free survival, p=0.01) 2

Surgical Technique Specifications

Extent of Resection

The surgical approach should be a type C (radical) hysterectomy using the Querleu and Morrow classification system, which provides wider paracervix margins than modified radical (type B) or simple (type A) hysterectomy. 1

Lymph Node Management

Bilateral pelvic lymph node dissection is the standard of care. 1 You may consider sentinel lymph node (SLN) mapping as an adjunct, particularly for tumors <2 cm where detection rates are optimal. 1, 3

• SLN mapping has detection rates of 89-92% and sensitivity of 89-90% in meta-analyses 3
• Best results occur with tumors <2 cm 1, 3
• SLN mapping should only be performed by surgeons with documented expertise 3
• If SLN mapping is used, complete pelvic lymphadenectomy should still be performed if sentinel nodes cannot be identified 3

Para-aortic Lymph Node Sampling

Para-aortic lymph node dissection is indicated for patients with known or suspected pelvic nodal disease. 1 For stage IA2 and IB1 disease without clinical evidence of nodal involvement, para-aortic sampling is category 2B (optional). 1

Alternative Treatment Option

Pelvic external beam radiation therapy with brachytherapy (total point A dose 80-85 Gy) with concurrent platinum-containing chemotherapy is an acceptable alternative for patients who are medically inoperable or refuse surgery. 1 However, for young, medically fit patients, surgery is generally preferred because it:

• Preserves ovarian function 1, 4
• Avoids vaginal stenosis from radiation 4
• Provides accurate surgical staging 1

Critical Pitfalls to Avoid

Do Not Perform Simple Hysterectomy

Simple (extrafascial) hysterectomy is inadequate for stage IA2-IB1 disease because it does not provide sufficient paracervix margins or include the cardinal and uterosacral ligaments. 1 Simple hysterectomy is only appropriate for stage IA1 disease without lymphovascular space invasion. 1

Do Not Use Minimally Invasive Approach

The evidence clearly demonstrates inferior oncologic outcomes with minimally invasive radical hysterectomy, even in this low-risk population with tumors ≤2 cm. 2 The Society of Gynecologic Oncology and multiple recent studies support open surgery as the standard approach following the LACC trial findings.

Intraoperative Decision-Making

If intraoperative assessment reveals positive sentinel or pelvic lymph nodes, abandon the hysterectomy and proceed with primary chemoradiation to avoid combined-modality morbidity. 3 Performing both surgery and adjuvant radiation significantly increases complications without improving survival.

Specific High-Risk Features Requiring Extra Caution

Adenocarcinoma Histology

Patients with adenocarcinoma, particularly with lymphovascular space invasion (LVSI), are at higher risk for recurrence. 5, 6 These patients had particularly poor outcomes with minimally invasive surgery in recent studies. 2

Lymphovascular Space Invasion

The presence of LVSI increases the risk of pelvic lymph node metastasis and warrants thorough lymph node assessment. 1 LVSI is present in approximately 41% of early-stage cases. 5

Grade II-III Tumors

Patients with grade II-III tumors had significantly worse disease-free survival with laparoscopic surgery (88.8% vs 98.0%, p=0.02). 2

Postoperative Management

Adjuvant therapy decisions are based on surgical pathology findings using the Sedlis criteria for intermediate-risk factors. 1 High-risk features (positive margins, positive lymph nodes, parametrial involvement) mandate adjuvant concurrent chemoradiation. 1