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\begin{document}

\title{Comparison of oncology outcome between laparotomy and laparoscopy in
early cervical squamous cell carcinoma without any high risk
pathological factors}



\author[1]{Xiaolin Chen}%
\author[2]{lu yijia}%
\author[1]{Hongwei Zhao}%
\author[1]{Lixin Sun}%
\author[3]{Shan Kang}%
\author[1]{Zhumei Cui}%
\author[1]{Biliang Chen}%
\author[4]{Mei Ji}%
\author[1]{Weidong Zhao}%
\author[1]{Ping Liu}%
\author[1]{Chunlin Chen}%
\affil[1]{Affiliation not available}%
\affil[2]{southern medical university}%
\affil[3]{Fourth Hospital，Hebei Medical University}%
\affil[4]{The First Affiliated Hospital of Zhengzhou University}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective Explore the difference of oncology outcome of laparotomy and
laparoscopy in the new FIGO2018 stage of early cervical squamous cell
carcinoma without any high risk pathological factors. Methods The
5-years OS and DFS of cervical squamous cell carcinoma undergoing
laparotomy and laparoscopy from 2004 to 2018 were compared by the total
study population and propensity score from China. Result There was no
difference in 5-year OS between laparotomy (2,478 cases) and laparoscopy
(1,504 cases), but the 5-year DFS of laparotomy was higher (92.2 \%vs.
90.4\%, P=0.022). Cox analysis showed that laparoscopy was not an
independent risk factor for the death of cervical squamous cell
carcinoma (OS: P=0.598), but it was an independent risk factor for the
recurrence/death (HR = 1.468,95\% CI 1.131 \textasciitilde{} 1.906,
P=0.004). There was no difference in 5-year OS between laparotomy (2,391
cases) and laparoscopy (1,495 cases) after 1:2 PSM, but the 5-year DFS
of laparotomy was higher (92.7\% vs. 90.8\%, P = 0.006), Cox analysis
showed that laparoscopy was not an independent risk factor for the death
of cervical squamous cell carcinoma (OS: P=0.521), but it was an
independent risk factor for the recurrence/death (HR=1.512, 95\%CI
1.151\textasciitilde{}1.971, P=0.002). Conclusion There is no difference
in 5-year OS between these groups for early cervical squamous cell
carcinoma in new stage of FIGO2018 without any high-risk pathological
factors, the 5-year DFS of laparotomy is higher than that of laparoscopy
group, and laparoscopy is an independent risk factor for
recurrence/death, so laparoscopy has a higher risk of recurrence.%
\end{abstract}%



\sloppy


Comparison of oncology outcome between laparotomy and laparoscopy in
early cervical squamous cell carcinoma without any high risk
pathological factors

Xiaolin Chen\textsuperscript{1}* , Yijia Lu\textsuperscript{1}*, Hongwei
Zhao\textsuperscript{2}*, Lixin Sun\textsuperscript{3}*, Shan
Kang\textsuperscript{4}, Zhumei Cui\textsuperscript{5}, Biliang
Chen\textsuperscript{6}, Mei Ji\textsuperscript{7}, Weidong
Zhao\textsuperscript{8}, Pin Liu\textsuperscript{1\#}, Chunlin
Chen\textsuperscript{1\#}

\textsuperscript{1}Department of Obstetrics
and~Gynecology,~Nanfang~Hospital, Southern

Medical University, Guangzhou 510515, China;

\textsuperscript{2,3}Department of Gynecologic Oncology, Shanxi
Provincal Cancer Hospital, Taiyuan 030000, China;

\textsuperscript{4}Department of~Gynecology, Fourth Hospital Hebei
Medical~University, Shijiazhuang~050019, China;

\textsuperscript{5}Department of Gynecology, The Affiliated Hospital of
Qingdao University, No. 16 Jiangsu Road, Shinan District, Qingdao,
Shandong Province 266000, China;

\textsuperscript{6}Department of Obstetrics and Gynecology , Xijing
Hospital of Airforce Medical University 710000, China;

\textsuperscript{7}Department of Obstetrics and Gynecology , The First
Affiliated Hospital of Zhengzhou University 450000, China;

\textsuperscript{8}Department of Gynaecology Anhui Cancer Hospital, No.
17 Lujiang Avenue, HeFei 230001,China

\textbf{*These authors contributed equally to this work.}

\textbf{Correspondence} :~Pin Liu;~Chunlin~Chen; Department of
Obstetrics and~Gynecology,~Nanfang~Hospital, Southern Medical
University, No.1838, Guangzhou Avenue, Guangzhou 510515, People's
Republic of China

\textbf{Tel/Fax} +86 206 278 7562

\textbf{Email} :~lpivy@126.com;~ccl1~@ smu.edu.cn

\textbf{Abstract}

\textbf{Objective} Explore the difference of oncology outcome of
laparotomy and laparoscopy in the new FIGO2018 stage of early cervical
squamous cell carcinoma without any high risk pathological factors.

\textbf{Methods} The 5-years OS and DFS of cervical squamous cell
carcinoma undergoing laparotomy and laparoscopy from 2004 to 2018 were
compared by the total study population and propensity score from China.

\textbf{Result} There was no difference in 5-year OS between laparotomy
(2,478 cases) and laparoscopy (1,504 cases), but the 5-year DFS of
laparotomy was higher (92.2 \%vs. 90.4\%, P=0.022). Cox analysis showed
that laparoscopy was not an independent risk factor for the death of
cervical squamous cell carcinoma (OS: P=0.598), but it was an
independent risk factor for the recurrence/death (HR = 1.468,95\% CI
1.131 \textasciitilde{} 1.906, P=0.004). There was no difference in
5-year OS between laparotomy (2,391 cases) and laparoscopy (1,495 cases)
after 1:2 PSM, but the 5-year DFS of laparotomy was higher (92.7\% vs.
90.8\%, P = 0.006), Cox analysis showed that laparoscopy was not an
independent risk factor for the death of cervical squamous cell
carcinoma (OS: P=0.521), but it was an independent risk factor for the
recurrence/death (HR=1.512, 95\%CI 1.151\textasciitilde{}1.971,
P=0.002).

\textbf{Conclusion} There is no difference in 5-year OS between these
groups for early cervical squamous cell carcinoma in new stage of
FIGO2018 without any high-risk pathological factors, the 5-year DFS of
laparotomy is higher than that of laparoscopy group, and laparoscopy is
an independent risk factor for recurrence/death, so laparoscopy has a
higher risk of recurrence.

\textbf{Key words} : Cervical cancer; Laparotomy; Laparoscopy; Tumor
outcome; no high-risk factors after surgery.

\begin{enumerate}
\tightlist
\item
  \textbf{Introduction}A multicenter laparoscopic cervical cancer
  surgery (LACC) study published in New England Journal of Medicine in
  October, 2018 pointed out that the overall survival rate (OS) and
  disease-free survival rate (DFS) of cervical cancer patients who
  underwent laparoscopic surgery in stage IA1(LVSI+)\textasciitilde{}IB1
  were lower than those who underwent open surgery, and had a higher
  local recurrence rate\textsuperscript{{[}1{]}}. A real-world study
  published in the same period further confirmed this conclusion.
  Minimally invasive surgery is associated with a worse oncology
  prognosis\textsuperscript{{[}2{]}}. This is contrary to previous
  related research and has caused widespread international controversy.
  In 2020, national comprehensive cancer network (NCCN) cervical cancer
  guideline\textsuperscript{{[}3{]}} changed open surgery to the
  standard surgical approach. Later, many studies thought that there was
  no difference in oncology outcome between laparotomy and laparoscopic
  surgery for some cervical cancer staging \textsuperscript{{[}4-5{]}}.
  In the limitations of LACC research, it was mentioned that this
  research failed to further analyze the differences of oncology
  outcomes between the two surgical approaches possibly caused by
  pathological factors, and the conclusion could not be extended to the
  oncology outcomes of low-risk cervical cancer patients. The cases
  included in this study include squamous cell carcinoma, adenocarcinoma
  and adenosquamous carcinoma. However, in recent years, the research
  results on the oncological outcome and prognosis of cervical squamous
  cell carcinoma and adenocarcinoma are inconsistent. Some studies think
  that there is no difference between them \textsuperscript{{[}6-8{]}},
  and some studies think that adenocarcinoma has a worse oncological
  outcome and a higher recurrence rate than squamous cell
  carcinoma\textsuperscript{{[}9-10{]}}. Noh et al.
  \textsuperscript{{[}6{]}}found that histological type was the only
  independent risk factor for cervical cancer in IB1\textasciitilde{}IIA
  stage. The staging of LACC study is limited to FIGO2009 staging i A1
  (LVSI+) \textasciitilde{} i B1 cervical cancer cases, and NCCN
  guidelines indicate that cervical adenocarcinoma may be a new ''medium
  risk factor''. Then, whether the conclusion of this study is equally
  applicable to the new stage early cervical squamous cell carcinoma of
  FIGO2018 without any high-risk pathological factors, and what is the
  oncological prognosis of such patients undergoing
  laparotomy/laparoscopy? At present, there is still a lack of
  multi-center large sample research. Therefore, this study is based on
  the clinical diagnosis and treatment for cervical cancer in China
  (Four C) to screen out the cases of early cervical squamous cell
  carcinoma in the new stage of FIGO2018 who underwent
  laparotomy/laparoscopy, and compare the oncology outcomes of the
  patients who underwent laparotomy and laparoscopy by the total study
  population and propensity score matching.
\item
  \textbf{Methods}
\item
  \textbf{Data Collection}Four C adopted a multicenter, retrospective
  cohort study, which was approved by the ethics committee of Nanfang
  Hospital, Southern Medical University (ethics No. NFEC-2017-135) and
  international clinical trial registration No. CHiCTR1800017778
  International Clinical Trials Registry Platform Search
  Port,http//apps.who.int/trialsearch/). See the published articles of
  our team for data collection methods \textsuperscript{{[}11-14{]}}.
  Due to the long time span of entering cases, the cases before 2009 in
  this database are staged according to FIGO1994, and the cases after
  2009 are staged according to FIGO2009. After all cases are put into
  storage, the staging shall be corrected again according to the revised
  version of FIGO2018.
\item
  \textbf{Inclusion and Exclusion Criteria}Inclusion criteria: (1) age [?]
  18 years old; (2) Pathological diagnosis of cervical cancer by
  cervical biopsy; (3) Postoperative histopathological type of squamous
  cell carcinom; (4) There was no adjuvant treatment before operation;
  (5) FIGO stage (2018): IA2, IB1, IB2, IIA1; (6) Surgical approach:
  laparotomy / laparoscopy; (7) QM-B or QM-C hysterectomy, pelvic
  lymphadenectomy\selectlanguage{ngerman}±para-aortic lymphadenectomy/biopsy; (8) The
  postoperative pathological report was complete, with lymph node status
  and negative; (9) No other high-risk pathological factors; (10) No
  adjuvant treatment after operation; (11) Follow-up. Exclusion
  criteria: (1) do not meet the above inclusion criteria; (2) Pregnancy
  complicated with cervical cancer, stump cancer or other malignant
  tumors.
\item
  \textbf{Propensity Score Matching}In order to eliminate the influence
  of baseline differences, this paper will include the following
  variables for propensity score matching (PSM): age and FIGO stage
  (2018) make the baseline balance between groups and reduce the
  influence of possible bias and confounding factors.
\item
  \textbf{Observation Indicators}The main long-term oncological outcome
  indicators were OS and DFS. The fifth year after the operation was
  taken as the cut-off point. OS was defined as the date of diagnosis to
  death of any cause or the last effective follow-up; DFS was defined as
  death/recurrence of any cause or the last effective follow-up from the
  date of diagnosis to the occurrence of any cause.
\item
  \textbf{Statistical Analysis}SPSS 23.0 software (IBM Corporation,
  Armonk, NY, USA) was used for statistical analysis. The measurement
  data are expressed as the mean ± standard deviation, Student's t-test
  was used for inter-group comparisons, the counting data are expressed
  as percentages (\%), and the inter-group rates were compared by the
  chi-square test or Fisher's exact probability method. The follow-up
  time was expressed as the median; survival curves for the two groups
  were generated by the Kaplan-Meier (K-M) method and compared by the
  log-rank test; the independent risk factors were analysed by a
  multi-factor Cox regression model, and the related hazard ratios and
  confidence intervals were calculated. The PSM score was determined by
  a logical regression model. Differences with P \textless{} 0.05 were
  considered statistically significant. The specific statistical methods
  can be found in the articles published by our
  team\textsuperscript{{[}7-10{]}}.\textbf{3.Results} \textbf{3.1 Study
  Population}Data for a total of 63926 patients with cervical cancer in
  47 hospitals in China from 2004 to 2018 were collected. Among them,
  2478 patients aged 47.72 ± 10.090 years underwent laparotomy, and 1504
  patiens aged 47.92 ± 9.743 years underwent laparoscopy. The median
  follow-up time was 49 months (laparotomy group vs laparoscopy group:
  57 months vs 36 months). The data filtering process is shown in
  figure1. According to the results of the baseline analysis between the
  two groups, there was a significant difference in FIGO stage (2018)
  between the two groups. An additional 1:2 PSM step was performed
  between the two groups, and a total of 3886 patients were included
  after matching. A total of 2391 patients aged 47.59 ± 10.054 years
  were included in the laparotomy group. 1495 patients aged 47.93 ±9.757
  years were included in the laparoscopy group. The median follow-up
  time was 49 months (laparotomy group vs laparoscopy group: 57 months
  vs 36 months). The baseline between the two groups was balanced.
  (Table 1).\textbf{Figure 1. Data Screening Flow ChartTable 1
  Characteristics of Patients with FIGO 2018 early Stage Cervical Cancer
  Before and After 1:2 PSM}
\end{enumerate}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
Variables & The total study population & The total study population & P
value & 1:2PSM & 1:2PSM & P value\tabularnewline
& Laparotomy group(N=2478) & Laparoscopy group(N=1504) & & Laparotomy
group(N=2391) & Laparoscopy group(N=1495) &\tabularnewline
Age, years & 47.72\selectlanguage{ngerman}±10.090 & 47.92\selectlanguage{ngerman}±9.743 & 0.063 & 47.59\selectlanguage{ngerman}±10.054 &
47.93\selectlanguage{ngerman}±9.757 & 0.113\tabularnewline
FIGO2018 & & & 0.004 & & & 0.185\tabularnewline
IA2 & 165(6.7\%) & 117(7.8\%) & & 165(6.9\%) & 108(7.2\%)
&\tabularnewline
IB1 & 954(38.5\%) & 645(42.9\%) & & 954(39.9\%) & 645(43.1\%)
&\tabularnewline
IB2 & 883(35.6\%) & 504(33.5\%) & & 856(35.8\%) & 504(33.7\%)
&\tabularnewline
IIA1 & 476(19.2\%) & 238(15.8\%) & & 416(17.4\%) & 238(15.9\%)
&\tabularnewline
\bottomrule
\end{longtable}

\textbf{3.2 Comparison of Oncology Outcomes Between the total study
population and 1:4 PSM in the early FIGO2018 stage oflaparotomy group
and laparoscopy group}

In the total study population, K-M survival analysis showed that there
was no significant difference in the 5-year OS between the laparotomy
group and laparoscopy group (96.2\% vs. 96.0\%, P = 0.989) (Table 2 and
figure 2A).The 5-year DFS in laparotomy group was higher than that in
laparoscopy group (92.2\% vs. 90.4\%, P = 0.022). (Table 2 and figure
2B).Cox analysis showed that laparoscopic surgery was not an independent
risk factor for death in patients with cervical squamous cell carcinoma
(OS: P = 0.598), but it was an independent risk factor for recurrence /
death in patients with cervical squamous cell carcinoma (HR = 1.468,
95\% CI 1.131 \textasciitilde{} 1.906, P = 0.004).(Table 2).

The results of K-M survival analysis after 1:2 PSM showed that there was
no significant difference in 5-year OS between the laparotomy group
(2391 cases) and laparoscopy group (1495 cases) (96.5\% vs. 96.0\%, P =
0.684). (Table 2 and figure 2C). The 5-year DFS in laparotomy group was
higher than that in laparoscopy group (92.7\% vs. 90.8\%, P = 0.006).
See Table 2 and figure 2D. Cox multivariate analysis showed that
laparoscopic surgery was not an independent risk factor for death in
patients with cervical squamous cell carcinoma (OS: P = 0.521), but it
was an independent risk factor for recurrence / death in patients with
cervical squamous cell carcinoma (HR = 1.512, 95\% CI 1.151
\textasciitilde{} 1.971, P = 0.002).(Table 2).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

*Figure2 a, b The 5-year OS and DFS of the total study population;
Figure2 c, d the 5-year OS and DFS after 1:2 PSM

\textbf{Figure 2. FIGO2018 new stage early cervical squamous cell
carcinoma: comparison of overall study population and 1:2PSM survival
analysis between laparotomy group and laparoscopy group}

\textbf{Table 2 Survival analysis of figo2018 new stage early cervical
squamous cell carcinoma in laparotomy group and laparoscopy group}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& Group & Number of cases & Number of end events & Survival analysis
(K-M method) & Cox regression multivariate analysis\tabularnewline
& & & & Cumulative survival rate(\%) P value & risk ratio 95\%CI
Pvalue\tabularnewline
Unadjusted OS DFS & laparotomy vs. laparoscopy laparotomy vs.
laparoscopy & 2478 vs.1504 2478 vs.1504 & 71 vs.31 150 vs.95 & 96.2\%
vs.96.0\% 0.989 92.2\% vs.90.4\% 0.022 & 1.122 0.732-1.719 0.598 1.468
1.131-1.906 0.004\tabularnewline
Adjusted OS DFS & laparotomy vs. laparoscopy laparotomy vs. laparoscopy
& 2391 vs.1495 2391 vs.1495 & 63 vs.31 136 vs.95 & 96.5\% vs.96.0\%
0.684 92.7\% vs.90.8\% 0.006 & 1.153 0.747-1.780 0.521 1.512 1.159-1.971
0.002\tabularnewline
\bottomrule
\end{longtable}

\textbf{4.Discussion}

The results of a multicenter and retrospective study showed that there
were no high-risk and high-risk pathological factors in Four C. There
was no significant difference in 5-year OS between the laparotomy group
and the laparoscopy group, but the 5-year DFS in the laparotomy group
was higher than that in the laparoscopy group; Cox multivariate analysis
showed that laparoscopic surgery was an independent risk factor for
recurrence / death in patients with early cervical squamous cell
carcinoma without high and medium risk factors. In order to further
reduce bias and confounding factors, 1:2PMS was carried out and the same
conclusion was reached.

The results of this study found that there was no difference in 5-year
OS between open surgery and laparoscopic surgery, which was different
from the LACC study of Ramirez et al\textsuperscript{{[}1{]}}, which
believed that laparoscopic surgery was 4.5\% for patients with stage
IA1(LVSI+)\textasciitilde{}IB1 cervical cancer the 5-year OS was lower
than that in the laparotomy group (86.0\% vs. 96.5\%). Considering the
different stages of cervical cancer included, there were about 91.5\% in
the LACC study of Ramirez et al 9\% of cervical cancer patients are in
stage IB1. The stage included in this study also includes stage IIA1
cervical cancer cases. The survival analysis before and after matching
in Uppal et al. \textsuperscript{{[}15{]}} research showed that there
was no difference in the overall survival rate of patients with stage
IA1(LVSI+)\textasciitilde{}IB1 cervical cancer undergoing laparoscopic
surgery and laparotomy.

In terms of DFS, it is consistent with the results of LACC. It is found
that the DFS of laparoscopic surgery is lower than that of laparotomy
surgery. Cox multivariate analysis suggests that laparoscopic surgery is
an independent risk factor for recurrence / death of cervical cancer
patients. Chenx et al. \textsuperscript{{[}16{]}} found that there was
no difference between the 5-year OS of laparoscopic surgery and
laparotomy surgery for cervical cancer patients with stage IB1 in FIGO
2009, but the 5-year DFS was significantly lower than that of laparotomy
group. Cox multivariate analysis showed that laparoscopic surgery was
associated with lower tumor-free survival rate, which was consistent
with the results of this research, but the study did not conduct
postoperative pathological review of surgical specimens and the sample
size was limited, This may cause selection bias and confounding factors.

Different from the results of this study, Ratiud et
al.\textsuperscript{{[}17{]}} analyzed the cervical cancer patients who
underwent laparotomy surgery or laparoscopic surgery in figo2009 stage
IA1 \textasciitilde{} IIB and found that there was no significant
difference in 5-year OS between the laparoscopic group and the
laparotomy group (94.1\% vs 85.4\% P = 0.311), but found that the 5-year
DFS in the laparoscopic group was higher than that in the laparotomy
group (94.1\% vs 75.6\% P = 0.049), It is considered that minimally
invasive surgery for patients with stage IA1 \textasciitilde{} IIB
cervical cancer can improve the tumor-free survival rate. This is
different from the results of this study. The reasons are as follows:
first, this study does not strictly limit the presence or absence of
adjuvant therapy and the number of times before operation. Second: the
difference between the two groups was statistically significant in terms
of baseline lymphatic vascular infiltration. However, due to the small
number of cases included in the study, a total of 75 cases were not
controlled by PSM. Third: the histological types of the study are
different. In addition to squamous cell carcinoma, the study also
includes adenocarcinoma and adenosquamous cell carcinoma. Fourth: the
study stage is figo2009 stage IA1 \textasciitilde{} IIB, which is not
specifically for early cervical cancer cases.

At present, the conclusions of oncological prognosis of laparotomy and
laparoscopy are different in patients with different histological types
of cervical cancer. Kimsi \textsuperscript{{[}18{]}} found that when the
histological type is cervical squamous cell carcinoma, the 5-year PFS of
laparoscopic surgery is lower than that of laparotomy surgery, but there
is no difference between the two groups in non cervical squamous cell
carcinoma, while other studies found no difference in oncological
outcomes between the two subtypes \textsuperscript{{[}6-8,19{]}}.
Leeyy\textsuperscript{{[}10{]}} included 775 cases of stage IB
\textasciitilde{} IIA cervical cancer in FIGO2009, including 636 cases
of squamous cell carcinoma and 139 cases of adenocarcinoma. The results
showed that compared with squamous cell carcinoma, adenocarcinoma before
and after matching was associated with worse survival outcome and higher
distant recurrence rate. Mabuchis et al. \textsuperscript{{[}20{]}}found
that the prognosis of cervical adenocarcinoma is worse than that of
cervical squamous cell carcinoma when there are any high and medium risk
pathological factors. When the histological type is adenocarcinoma, it
may affect the oncological outcome of laparotomy surgery and
laparoscopic surgery. In order to make this study more convincing, the
histological type is limited to cervical squamous cell carcinoma, and
whether the postoperative adjuvant treatment is standardized due to
high-risk pathological factors will lead to the difference of
oncological outcome between the two groups. Therefore, this study limits
the pathological factors and carries out PSM to control the confounding
factors, The results before and after matching showed that laparoscopic
surgery had worse oncological outcomes.

Patients with cervical cancer undergoing laparoscopic surgery have a
high recurrence rate, which may be related to the failure to strictly
implement the tumor free principle during the operation, the promotion
of inflammation and tumor metastasis by CO2 pneumoperitoneum during the
operation, the use of uterine lifting device during the operation, the
gasification of electrical equipment, the way of vaginal disconnection
and suture \textsuperscript{{[}21-24{]}}. Vaginal uterine lifter is
related to direct contact with tumor lesions and long-term compression,
resulting in rupture of tumor cells and artificial diffusion of tumor
cells.

This study has some limitations. Firstly, the case data of 47 hospitals
in China are included in this study, which will lack some clinical data.
Secondly, there are some deviations in the surgical level and experience
of surgeons. Third, the time span of case inclusion is long, and the
surgeon's learning curve should also be one of the factors to be
considered. Although there are some defects in our study, based on the
multi center large sample study, it can effectively reflect the
practical value of figo2018 new stage in the diagnosis and treatment of
cervical cancer in China. PSM is used to strictly control the
confounding factors. At the same time, the included pathological factors
are postoperative pathology, which is more accurate. Therefore, we
believe that the results of this study have high reliability. This study
is also a more detailed supplement to the results of previous
laparoscopic and open studies, and also provides evidence support for
the recommended laparoscopic surgical approach in NCCN guidelines.

In conclusion, for patients with FIGO2018 new stage early cervical
squamous cell carcinoma with any high-risk pathological factors, there
was no significant difference between 5-year OS of laparotomy surgery
and laparoscopic surgery. 5-year DFS of laparoscopic surgery was lower
than that of laparotomy surgery. Laparoscopic surgery was an independent
risk factor for recurrence / death of patients with cervical cancer.

\textbf{Funding~Statement}

This study was initially funded by the National Science and~Technology
Support Program of China (2014BAI05B03),~the National Natural Science
Fund of Guangdong~(2015A030311024), the Science and Technology Plan
of~Guangzhou (158100075), Guangdong Medical Science~and Technology
Research Fund Project (A2020077),~Basic and Applied Basic Research Fund
of Guangdong~Province (2019A1515110337), Chinese Postdoctoral
Science~Foundation (2019M660207), and~Nanfang~Hospital President Fund
(2019C005).

\textbf{Acknowledgement}

We thank Min Hao (The Second Hospital of Shanxi
Medical~University),~Wuliang~Wang (The Second Affiliated Hospital
of~Zhengzhou University), Shan Kang (The Fourth Hospital of~Hebei
Medical University), Bin Ling~(China--Japan Friendship~Hospital),
Lixin~Sun and Hongwei Zhao (Shanxi Cancer~Hospital),~Jihong~Liu
and~Lizhi~Liang (Sun~Yat-sen~University~Cancer~Center), Lihong Lin and
Yu Guo (Anyang~Tumor~Hospital), Li Wang (The Affiliated~Tumor~Hospital
of Zhengzhou~University), Weidong~Zhao (Anhui Provincial Cancer
Hospital),~Yan Ni (The Yuncheng Central Hospital of Shanxi
Province),~Wentong~Liang and~Donglin~Li (Guizhou Provincial
People's~Hospital),~Jianxin~Guo (Daping~Hospital, The Third
Military~Medical University),~Shaoguang~Wang (The Affiliated
Yantai~Yuhuangding~Hospital of Qingdao
University),~Xuemei~Zhan~and~Mingwei~Li (Jiangmen Central
Hospital),~Weifeng~Zhang~(Ningbo Women \& Children's
Hospital),~Peiyan~Du (The~Affiliated Cancer Hospital and Institute of
Guangzhou Medical~University),~Ziyu~Fang (Liuzhou Workers' Hospital),
Rui Yang~(Shenzhen Hospital of Peking University), Long Chen
(Qingdao~Municipal Hospital),~Encheng~Dai and~Ruilei~Liu (Linyi People's
Hospital),~Yuanli~He and~Mubiao~Liu (Zhujiang~Hospital,~Southern Medical
University),~Jilong~Yao and~Zhihua~Liu~(Shenzhen Maternity \& Child
Health Hospital),~Xueqin~Wang~(The Fifth Affiliated Hospital of Southern
Medical University),~Anwei~Lu (Maternal and Child Health Hospital of
Guiyang~Province),~Shuangling~Jin~(Peace Hospital affiliated
to~Changzhi~Medical College), Yan Xu (Guangzhou Pan Yu Central
Hospital),~Ben Ma (Guangzhou First People's
Hospital),~Zhonghai~Wang(Shenzhen Nanshan People's Hospital), Lin Zhu
(The Second~Hospital of~Shandong University),~Hongxin~Pan (The
Third~Affiliated Hospital of Shenzhen University),~Qianyong~Zhu~(No.
153~Center~Hospital of Liberation Army/Hospital No.988 of the Chinese
People's Liberation Army Joint Support~Force), Dingyuan~Zeng and Zhong
Lin (Maternal and Child~Health Care Hospital of Liuzhou),~Xiaohong~Wang
(Laiwu~People's Hospital/Jinan City People's Hospital), and Bin Zhu
(The~Affiliated~Yiwu~Women and Children Hospital of Hangzhou~Medical
College) for their contribution in data collection.

\textbf{Ethical~Statement}

This study was approved by the Ethics Committee of~Nanfang~Hospital,
Southern Medical University (ethics~approval number NFEC-2017-135).

\textbf{Conflict of Interest}

No potential conflict of interest relevant to this article was reported.

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