Historically, open surgery has been the standard approach for radical hysterectomy in patients with early cervical cancer, but the use of minimally invasive surgery (MIS) has become an alternative treatment due to improved perioperative outcomes. Some investigators have reported no difference in cancer recurrence rate, site of recurrence, or survival between patients treated with MIS and those treated with open radical hysterectomy [1]. However, results of the LACC (Laparoscopic Approach to Cervical Cancer) trial [2] prompted an investigation of the potential factors responsible for worse oncologic outcomes in patients who undergo MIS, with manipulator use and conization being identified as key possibilities [3,4]. In addition, tumor size larger than 2 cm [[4], [5], [6], [7]] and positive lymph nodes [8] were shown to be strong factors for cervical cancer recurrence.

Most experts agree that conization is a major factor associated with decreased recurrence and improved survival for patients treated with MIS [3,[6], [7], [8], [9], [10], [11], [12]]. In contrast, the use of a manipulator has been associated with an increased risk of recurrence [13], although this observation is not supported by all [4,11,14]. Therefore, further evaluation is needed to examine the interaction of manipulator use and conization in this patient population. We conducted a retrospective study designed to evaluate the effect of conization vs no conization, manipulator use vs no manipulator use, and their interaction on patients with cervical cancer who underwent MIS or open surgery for a radical hysterectomy.