Evolving Surgical Strategies in Early Cervical Cancer: New Review Clarifies Best Practices After LACC Trial Fallout

A new Houston Methodist–led review recommends a shift from one-size-fits-all surgical practices to a more risk-adapted, patient-specific approach to treating early-stage cervical cancer.

The study, recently published in the journal Cancers, offers the clearest picture yet of how surgical management of the common gynecological cancer has evolved since the landmark Laparoscopic Approach to Cervical Cancer (LACC) trial reshaped practice worldwide.

"After LACC, there was understandable fear and confusion about how to operate safely," said Dr. Pedro Ramirez, chair of the Department of Obstetrics and Gynecology at Houston Methodist and primary investigator of both the Cancers review and the LACC trial. "What we've learned since is that cervical cancer is not one disease — and surgical risk must be balanced with patient characteristics, tumor size and histology rather than a one-size-fits-all rule."

The study, which synthesized recent evidence from randomized trials, registry studies and meta-analyses, confirms that the pendulum has swung firmly toward open surgery as the global standard for radical hysterectomy following LACC's 2018 findings that minimally invasive procedures resulted in significantly worse outcomes. The findings were confirmed in a 2024 study led by Dr. Ramirez that found laparoscopic or robot-assisted minimally invasive techniques carry a four times higher risk for disease recurrence and three times higher risk of death compared to open radical hysterectomy.

However, the review also highlights a growing movement toward individualized care, with emerging data suggesting that less radical and, in select cases, some minimally invasive approaches may be appropriate for certain low-risk patients.

From radical to tailored surgery

The review details how recent studies, including the SHAPE trial, have demonstrated equivalent oncologic outcomes between simple and radical hysterectomy in patients with low-risk, small-volume tumors. These findings suggest that many women may be overtreated with radical procedures, which carry higher morbidity.

"The SHAPE trial showed that in select patients, typically low-risk patients, the option of simple hysterectomy was shown to be oncologically safe," Dr. Ramirez said. "That's a paradigm shift — and one that reduces complications, improves quality of life and speeds recovery without compromising cure rates."

While the LACC trial definitively discredited minimally invasive radical hysterectomy for invasive cervical cancer, the new review notes that robotic and laparoscopic techniques remain under investigation for carefully selected patients, particularly when tumor exposure can be prevented. Modified techniques — such as performing surgery without a uterine manipulator or using a vaginal protective closure — are being tested in prospective studies to determine if oncologic safety can be maintained.

"We're seeing important innovation in how these procedures are performed," Dr. Ramirez said. "But until proven otherwise, the open approach remains the benchmark for safety."

A continuing evolution

Beyond surgical technique, the review emphasizes multidisciplinary decision-making, fertility preservation for younger patients and the need for ongoing global training in open radical hysterectomy, which had declined before LACC. It also underscores the importance of prospective trials that measure true oncologic outcomes — not just perioperative benefits.

"Our field learned a hard lesson," Dr. Ramirez said. "Minimally invasive surgery seemed universally better until evidence proved otherwise. Now, we're using data — not assumptions — to refine what's best for each patient."

By summarizing six years of evolving evidence, the new review redefines the surgical roadmap for early-stage cervical cancer, shifting the focus from surgical ideology to evidence-based personalization.