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Comparative analysis of hysterectomy types and approaches on oncological survival in 2023 FIGO stage II endometrial carcinoma

BMC Surgery volume 25, Article number: 209 (2025) Cite this article

Abstract

Background

The objective is to investigate the relationship between the type and approaches of hysterectomy and the oncological survival outcomes in women diagnosed with stage II endometrial carcinoma (EC), as classified by the 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system.

Methods

A retrospective analysis was conducted on patients with 2009 FIGO early-stage (stages I and II) EC who underwent surgical treatment between 2018 and 2019. These patients were reclassified in accordance with the 2023 FIGO staging system, and those diagnosed with stage II EC under this system were selected as the study population. A non-inferiority test was employed for the analysis, with disease-free survival (DFS) serving as the primary outcome measure. DFS was evaluated using Kaplan-Meier curves, and comparisons were conducted through the log-rank test.

Result

A cohort of 288 patients diagnosed with early-stage EC according to the 2009 FIGO staging system were re-evaluated and reclassified. Ultimately, the study encompassed a cohort of 80 patients diagnosed with stage II EC, as classified according to the 2023 FIGO staging system. 52 individuals underwent radical hysterectomy or modified radical hysterectomy (RH/mRH), while 28 patients received a simple hysterectomy (SH). The 5-year DFS was 84.62% for the RH/mRH group vs. 92.86% for the SH group (difference, 8.24% [95% CI, -5.44–21.92%]), which met the noninferiority criterion. Between the groups, the difference in 5-year DFS (p = 0.255) was not statistically significant. The laparoscope group comprised 62 cases, whereas the laparotomy group consisted of 18 cases. Between the groups, the difference in 5-year DFS (88.55% versus 83.33%, p = 0.538) was not statistically significant. This finding aligns with our observations of patients diagnosed with 2009 FIGO Stage II EC.

Conclusion

In comparison to SH, RH/mRH did not confer a survival advantage for patients diagnosed with 2023 FIGO stage II EC.

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Introduction

Endometrial carcinoma (EC) represents the most prevalent gynecological malignancy in high-income nations, with its incidence rates escalating annually and an observable trend towards younger age groups, the risk factors associated with EC include obesity, metabolic conditions, reproductive factors, and genetic predispositions [1]. With the rapid advancement of molecular genetics, our comprehension of the pathology and molecular characteristics of EC has significantly expanded. Consequently, the exclusive reliance on the International Federation of Gynecology and Obstetrics (FIGO) 2009 staging system is now inadequate for accurately reflecting patient risk levels and guiding prognostic outcomes. In response to this evolving landscape, FIGO revised the 2009 staging system in June 2023 to better align with contemporary clinical and pathological research advancements, particularly in molecular pathology and its applications [2].

Compared to the 2009 FIGO staging system, the 2023 FIGO staging system incorporates a greater number of prognostic factors, including histological type, molecular typing, and the degree of lymph-vascular space involvement (LVSI). The results indicated that the prediction accuracy of the 2023 FIGO staging system surpassed that of the 2009 FIGO staging system [3,4,5,6,7,8,9]. Notably, in the 2023 FIGO staging system [2], EC has been categorized into aggressive and non-aggressive histological subtypes, with histological types incorporated into the staging system. Specifically, when the tumor is confined to the endometrium without myometrial invasion, it is classified as stage IA1 under the non-aggressive histological subtype. Conversely, when the aggressive histological subtype is restricted to endometrial polyps or remains within the endometrium, it is designated as stage IC. In cases where the tumor exhibited muscle invasion, the non-aggressive histological subtypes were classified into stages IA2 and IB based on whether the invasion depth was ≥ 1/2. Concurrently, the aggressive subtypes were reclassified to stage IIC. Furthermore, according to the 2023 FIGO classification, non-aggressive histological subtypes of stage I tumors should be evaluated to ensure the absence or presence of only focal LVSI. In cases where there is extensive LVSI, the tumors should be reclassified as stage IIB. According to the 2023 FIGO staging system, the phenomenon of stage migration is most prominently observed in EC classified as stage I and stage II [8].

The primary therapeutic approach for early-stage EC is predominantly surgical, categorized into three types based on the extent of the hysterectomy: simple hysterectomy (SH), radical hysterectomy (RH), and modified radical hysterectomy (mRH). Currently, partial retrospective studies examining the role of hysterectomy in patients with 2009 FIGO stage II EC have demonstrated that RH/mRH does not confer additional survival benefits and is associated with a higher incidence of complications compared to SH [10,11,12,13]. Before the introduction of the 2023 FIGO staging system, numerous medical societies advocated for the minimally invasive surgery (MIS) to EC treatment. This recommendation was based on earlier studies indicating that laparoscope surgery was as safe as conventional laparotomy surgery for EC [14,15,16]. Additionally, laparoscopy has been demonstrated to accelerate postoperative recovery, reduce surgical pain and analgesic consumption, and attenuate inflammatory responses compared to open procedures [17, 18]. Nevertheless, no research has been conducted on the type and approaches of hysterectomy in patients diagnosed with 2023 FIGO Stage II EC at present. Consequently, the study aimed to assess the impact of varying extents of hysterectomy and surgical approach on the prognosis of patients diagnosed with 2023 FIGO stage II EC.

Materials and methods

Study design and participant overview

This retrospective, single-center, comparative cohort study included patients diagnosed with 2009 FIGO stage I and II EC who were admitted to the Maternal and Child Health Hospital of Gansu Province between January 2018 and December 2019. The inclusion criteria were defined as follows: Firstly, patients received primary surgical intervention as initial therapy; Secondly, absence of extrauterine metastasis confirmed through comprehensive preoperative assessment and intraoperative findings; Third, surgical procedures included SH, RH, or mRH; Lastly, histopathological verification of FIGO 2009 stage I-II disease encompassing all histological subtypes. The exclusion criteria were established as follows: Firstly, patients with a follow-up period of less than three months or with incomplete survival data were excluded from the study; Secondly, patients with concurrent other malignant tumors were excluded. A total of 288 patients diagnosed with 2009 FIGO early-stage were ultimately selected based on the predetermined inclusion and exclusion criteria. In this study, patients with stage I and II EC, initially classified according to the 2009 FIGO staging system, were subsequently reclassified based on the 2023 FIGO, and those diagnosed with stage II EC under 2023 FIGO staging system were selected as the study population. The study was conducted with the informed consent of the participants and received approval from the Medical Ethics Committee of the Maternal and Child Health Hospital of Gansu Province (2022-48).

Sample size calculation

A non-inferiority test was employed in this study, with the experimental cohort designated as the SH group and the control cohort as the RH/mRH group. The primary outcome measure for observation was the Disease-free survival (DFS) of the participants. According to literature review [11], the DFS for the RH group was reported as 94.1%, while the RH/mRH group demonstrated a DFS of 88.7%. The statistical power (1-β) was set at 0.8, with a sample size allocation ratio of 0.5:1 between the experimental and control groups. The non-inferiority margin was established at -0.15. Utilizing the Ye method [19], the R programming language was employed to determine the sample sizes for the experimental and control groups, which were calculated to be 20 and 40 cases, respectively. Accounting for a 10% attrition rate due to missed or refused visits, it was concluded that a minimum of 23 cases for the experimental group and 45 cases for the control group are necessary, resulting in a total required sample size of at least 68 cases.

Surgical grouping and key technical points of different procedures

Based on the extent of surgical resection, patients were categorized into RH/mRH and SH groups. RH: This procedure involves ligating and transecting the uterine artery at its origin from the superior vesical artery. The ureteral tunnel is fully opened up to the ureterovesical junction. The cardinal ligament is transected near the pelvic sidewall, the uterosacral ligament is excised close to the sacrum, and the uterine cervicovesical ligament is severed near the bladder. Additionally, the upper half of the vagina is removed. mRH: Unlike RH, which emphasizes complete radical excision, mRH involves transecting and ligating the uterine artery at the level of its intersection with the ureter. The ureteral tunnel is only partially opened, and the ureter is gently mobilized laterally. Resection of the paracervical tissue is limited to the lateral parametrium at the level of the ureter. The anterior cervicovesical ligament and the posterior uterosacral ligament are only partially resected, reducing damage to the neurovascular structures within the parametrial tissue. SH: Performed through lateral clamping and transection of paracervical and paravaginal tissues along the uterine wall, without extensive parametrial dissection.

Data collection

Standardized patient data were systematically collected by two researchers who received uniform training. Ultimately, the collected general clinical data included age and postoperative adjuvant therapy. Surgical-related data encompassed: surgical approaches, surgical scope, operative time, intraoperative blood loss, postoperative hospital stay, and postoperative complications. Pathological data comprised: flushing fluid cytology, pathological type, histological grade, tumor diameter, invasion of the myometrium, invasion of cervical stroma, LVSI, postoperative pathological status of P53, and Ki-67 index.

Follow-up and observation indicators

Patients were followed up through outpatient visits and telephone consultations. The follow-up schedule was structured as follows: quarterly assessments during the first two years, semiannual evaluations for the subsequent three years, and annual reviews thereafter. The surveillance protocol included gynecological examinations, serum tumor marker evaluations, and color Doppler ultrasonography, supplemented by computed tomography (CT) and magnetic resonance imaging (MRI) when necessary. The documentation of EC recurrence in our study was systematically conducted through a multimodal approach integrating radiographic assessments and serum tumor marker analysis, with definitive confirmation achieved via histopathological verification.

The primary study endpoint was the 5-year DFS rate, while secondary study endpoints included the 5-year overall survival (OS) rate. DFS was defined as the interval from the date of surgical intervention for EC to either confirmed recurrence or death attributable to EC. OS was calculated as the duration from the date of EC surgery to death from any cause.

Statistical analysis

The measurement data were systematically classified. In accordance with prior research, age was categorized into two groups: individuals under 65 years of age and those aged 65 years and older, in order to delineate the elderly population [20]. Tumor size was classified as either less than 5 cm or greater than or equal to 5 cm [12]. Given the absence of a standardized reference value for the Ki67 index, we utilized X-tile software (Yale University, New Haven, Connecticut, USA) to analyze DFS as the dependent variable, with the Ki67 index as a continuous independent variable. This analysis determined that the optimal cut-off point for the Ki67 index is 70. Statistical analyses were conducted using R software (version 3.6.1). Descriptive statistics for categorical data were presented as frequencies and percentages. Group differences were assessed using the Chi-square test or Fisher’s exact test, as appropriate. The Kaplan-Meier method was employed to construct survival curves and estimate the 5-year DFS rates. Differences in survival between the two groups were evaluated using the log-rank test. A p-value of < 0.05 was considered indicative of statistical significance.

Results

Reclassification of EC patients according to the 2023 FIGO staging system

A total of 288 patients with early-stage EC, initially classified under the 2009 FIGO staging system, were re-evaluated using the 2023 FIGO criteria. Among these, 52 patients experienced stage upgrades, primarily from 2009 FIGO stages IA and IB to higher substages under the 2023 system (e.g., IC, IIB, and IIC). Additionally, the 2023 FIGO system subdivided patients previously classified as 2009 FIGO Stage II into three distinct substages (IIA, IIB, IIC), reflecting refined risk stratification. For detailed numerical distributions of stage reclassifications, see Table 1; Fig. 1.

Table 1 Stage changes between 2009 and 2023 FIGO staging systems for IA-II patients
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Fig. 1
figure 1

Stage changes between 2009 and 2023 FIGO staging systems for IA-II patients

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Demographic and clinicopathological analysis by 2023 FIGO stage II EC subclassification

Eighty patients diagnosed with stage II EC, as classified by the updated 2023 FIGO staging system, were incorporated into this study. The distribution of stages among the subjects comprised 26 cases of stage IIA, 18 cases of stage IIB, and 36 cases of stage IIC. As illustrated in Table 2, the demographic and clinicopathological characteristics of the study subjects, categorized according to the 2023 FIGO staging system, were analyzed. The comparison included variables such as surgical approach, pathological type, histological grade, invasion of cervical stroma, LVSI, and postoperative pathological status of P53 and Ki-67 index. The results indicated statistically significant differences among these characteristics(p < 0.05). However, an analysis of additional clinicopathological variables among patients at various stages, including age, surgical scope, cytological analysis of flushing fluid, tumor diameter, invasion of the myometrium, as well as chemotherapy and radiotherapy treatments, revealed no statistically significant differences(p > 0.05).

Table 2 Demographic and clinicopathological data for stage II EC patients per the 2023 FIGO staging system
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Clinicopathological characteristics by hysterectomy type and surgical approach in 2023 FIGO stage II EC

Eighty patients diagnosed with 2023 FIGO stage II EC were categorized into two groups based on the extent of hysterectomy: the RH/mRH group, comprising 52 cases, and the SH group, consisting of 28 cases. Compared to the SH group, patients in the RH/mRH group exhibited a larger tumor diameter (median: 3.5 cm vs. 4 cm, p = 0.003) and the incidence of cervical interstitial infiltration was higher in the RH/mRH group (53.85% vs. 21.43%, p = 0.005). The two groups were otherwise comparable across other measured parameters (p > 0.05). Furthermore, participants were categorized into two groups according to the surgical approach: the laparoscope group, comprising 62 cases, and the laparotomy group, consisting of 18 cases. Patients in the laparotomy group demonstrated a significantly larger tumor diameter compared to those in the laparoscope group (median: 5.75 cm vs. 3.5 cm, p = 0.006). The two groups were otherwise comparable across other measured parameters (p > 0.05). Table 3 summarizes the clinicopathological characteristics by hysterectomy type and surgical approach.

Table 3 Characteristics of patients with 2023 FIGO stage II EC stratified by hysterectomy type and surgical approach
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Comparison of perioperative indicators and postoperative complication among different surgical type for 2023 FIGO stage II EC

We compared the perioperative indicators and postoperative complications between the 2023 FIGO stage II EC RH/mRH group and SH group, as shown in Table 4. The results demonstrated that the RH/mRH group had longer operative time than the SH group (p = 0.020), while no statistically significant differences were observed in intraoperative blood loss or postoperative hospital stay (p > 0.05). Using the Clavien-Dindo classification of surgical complications, postoperative complications were identified in 39 of 52 patients (75.0%) in the RH/mRH group: Grade I (n = 21); Grade II (n = 15); Grade III (n = 2); and Grade IV (n = 1). In contrast, 9 of 28 patients (32.14%) in the SH group experienced complications: Grade I (n = 6); Grade II (n = 3). A statistically significant difference in postoperative complication rates was observed between the two groups (p = 0.003).

Table 4 Perioperative and postoperative outcomes by surgical type for 2023 FIGO stage II EC
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Survival outcomes by hysterectomy type and surgical approach in 2009 FIGO stage II EC

We investigated the association between the type and approaches of hysterectomy and tumor survival outcomes in a cohort of 34 patients diagnosed with 2009 FIGO Stage II EC. As illustrated in Fig. 2A, the Kaplan-Meier survival curve and log-rank test indicate that the 5-year cumulative DFS rates for the RH/mRH and SH groups were 85.30% and 83.3%, respectively. A comparative analysis between the two groups revealed no statistically significant differences (p = 0.968). Similarly, as illustrated in Fig. 2B, the Kaplan-Meier survival analysis and log-rank test reveal 5-year cumulative DFS rates of 86.36% for the laparoscope group and 81.82% for the laparotomy group. Statistical analysis indicated no significant difference between the two groups (p = 0.678).

Fig. 2
figure 2

Disease-free survival in patients with 2009 FIGO stage II endometrial carcinoma stratified by type of hysterectomy(A) and surgical approach(B). RH/mRH: radical hysterectomy/modified radical hysterectomy, SH: simple hysterectomy, MIS: minimally invasive surgery, Open: laparotomy surgery

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Survival outcomes by hysterectomy type and surgical approach in 2023 FIGO stage II EC

We examined the relationship between the type and approaches of hysterectomy and tumor survival outcomes in patients diagnosed with 2023 FIGO Stage II EC. During the follow-up period, disease progression was documented in 10 out of 80 patients diagnosed with 2023 FIGO Stage II EC. This cohort comprised 2 patients from the SH group and 8 patients from the RH/mRH group. Of these, 7 patients underwent laparoscopic surgery, while 3 underwent laparotomy surgery. Given the limited number of patient deaths observed during the follow-up period (only 3 cases), further analysis of overall survival was not pursued in this study. The 5-year cumulative DFS rates for the SH and RH/mRH groups were 92.86% and 84.62%, respectively. The corresponding 95% confidence intervals (CIs) were 75.04–98.75% for the SH group and 71.37–92.66% for the RH/mRH group. As illustrated in Fig. 3, the 5-year DFS rate difference between the SH and RH/mRH groups was 8.24%, with a 95% CI ranging from − 5.44 to 21.92%. Notably, the lower limit of the 95% CI for the rate difference, -5.44%, exceeds the non-inferiority margin of -15%, thereby supporting the conclusion of non-inferiority. As illustrated in Fig. 4A, the Kaplan-Meier survival curve and log-rank test indicate that a comparative analysis between RH/mRH and SH groups revealed no statistically significant differences (p = 0.255). Similarly, as illustrated in Fig. 4B, the Kaplan-Meier survival analysis and log-rank test reveal 5-year cumulative DFS rates of 88.55% for the laparoscope group and 83.33% for the laparotomy group. Statistical analysis indicated no significant difference between the two groups (p = 0.538).

Fig. 3
figure 3

95% confidence interval for the difference in the rate of comprehensive evaluation of effectiveness between mRH/RH group and SH group 5-year disease-free survival

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Fig. 4
figure 4

Disease-free survival in patients with 2023 FIGO stage II endometrial carcinoma stratified by type of hysterectomy(A) and surgical approach(B). RH/mRH: radical hysterectomy/modified radical hysterectomy, SH: simple hysterectomy, MIS: minimally invasive surgery, Open: laparotomy surgery

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In Fig. 4A, the 5-year DFS rate was notably lower in the RH/mRH group compared to the SH group. Therefore, we conducted an in-depth investigation into the association between the type of hysterectomy and tumor survival outcomes in EC patients classified under the 2023 FIGO Stage II subtype. The Kaplan-Meier survival analysis and log-rank test indicated that there was no statistically significant difference between the RH/mRH group and the SH group in patients with 2023 FIGO stage IIA (p = 0.595) and IIB (p = 0.317) EC. Notably, as illustrated in Fig. 5, the 5-year DFS rate for the 2023 FIGO stage IIC EC patients undergoing RH/mRH was significantly lower (72.73% compared to 100.00%, p = 0.037) than that observed in the SH group. To investigate the variations in DFS rates among 2023 FIGO stage IIC EC patients undergoing different surgical modalities, we conducted a detailed analysis of the impact of these treatment approaches on DFS in this patient cohort. As illustrated in Supplementary Fig. 1A, the Kaplan-Meier survival analysis and log-rank test indicated no statistically significant difference between the RH/mRH group and the SH combined radiotherapy group among 2023 FIGO Stage IIC EC patients(p = 0.336). Nonetheless, the figure clearly demonstrates that the 5-year DFS rate is superior in the SH combined radiotherapy group compared to the RH/mRH group alone (100.00% compared to 78.57%). Comparable outcomes were observed for 2023 FIGO Stage II EC patients, as depicted in Supplementary Fig. 1B(p = 0.646).

Fig. 5
figure 5

Disease-free survival in patients with 2023 FIGO stage IIC endometrial carcinoma stratified by type of hysterectomy. RH/mRH: radical hysterectomy/modified radical hysterectomy, SH: simple hysterectomy

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Discussion

Subsequent to the publication of the 2023 FIGO staging system, research has demonstrated a noticeable stage migration in EC patients initially classified as Stage I and Stage II. This is particularly evident in the substantial increase observed in the population classified under the 2023 FIGO Stage II EC [8]. While numerous previous studies have examined the relationship between the type and approaches of hysterectomy and oncological survival in women with stage II EC, it became necessary to investigate the impact of these variables on patients with stage II EC in accordance with the updated 2023 FIGO staging system. Our study revealed that, for patients with 2023 FIGO stage II EC, those undergoing RH/mRH exhibited comparable tumor survival outcomes to those undergoing SH. In the context of 2023 FIGO stage IIC EC, it is noteworthy that RH/mRH was correlated with decreased survival rates in comparison to SH. Furthermore, our findings indicate that the choice of surgical approach does not influence disease recurrence in patients with 2023 FIGO stage II EC. This finding aligns with our observations of patients diagnosed with 2009 FIGO Stage II EC.

Before the introduction of the 2023 FIGO staging system, the necessity of performing RH/mRH in women diagnosed with 2009 FIGO Stage II EC was a subject of considerable debate. Takano conducted a multicenter retrospective study involving 300 patients diagnosed with stage II EC, comprising 74 patients who underwent RH, 112 who underwent mRH, and 114 who underwent SH. The multivariate Cox proportional hazards regression analysis indicated that, in comparison to SH, neither RH (95% CI: 0.67–3.62) nor mRH (95% CI: 0.76–4.07) significantly enhanced patient survival outcomes [10]. In a study utilizing the SEER database, no statistically significant differences were observed in the 3-year cancer‑specific survival rates and 3-year overall survival rates between 273 patients receiving RH and 546 patients undergoing SH with a 1:2 dosage ratio (all p > 0.05) [11]. A meta-analysis encompassing 10 retrospective cohort studies with a total enrollment of 2,866 patients revealed that those who underwent RH did not exhibit a statistically significant improvement in either overall survival (p = 0.484) or progression-free survival (p = 0.378) [21]. Nevertheless, alternative perspectives exist. A retrospective cohort study comprising 577 cases indicated that, among patients with high-risk stage II EC, RH was associated with a reduced survival outcome compared to SH combined with vaginal brachytherapy [22]. In a similar vein, our investigation revealed diminished survival outcomes for mRH/RH in the 2023 FIGO Stage IIC EC when compared to the SH group. Subsequent analysis, however, indicated no statistically significant difference between the RH/mRH and SH combined radiotherapy groups (p = 0.336). Notably, the 5-year DFS rate was superior in the SH group receiving combined radiotherapy compared to the RH/mRH group without radiotherapy (100.00% vs. 78.57%). However, this difference may reflect the impact of adjuvant radiotherapy. Future studies with expanded sample sizes may be necessary to validate these findings. For patients with early-stage EC, comprehensive analyses of high-quality clinical studies comparing MIS to laparotomy surgery procedures have demonstrated that MIS is oncologically safe [23, 24]. Our investigation into the type and approaches of hysterectomy for patients with stage II EC, as classified by the 2023 FIGO staging system, aligns with the majority of prior research concerning EC conducted under the 2009 FIGO staging system.

The rationale for employing RH/mRH in patients with 2009 FIGO stage II EC may be attributed to the increased likelihood of extrauterine and distant metastasis when EC lesions involve the cervix. This is facilitated through the parametrial lymphatic vasculature. RH/mRH involves the excision of a greater portion of the vaginal wall and surrounding ligamentous tissue, thereby maximizing the removal of parametrial tissue. This approach aims to reduce the risk of recurrence at the vaginal stump and within the parametrial region. This reason is believed to parallel the impact of the type of hysterectomy on survival outcomes in the surgical management of cervical cancer [25]. The divergence in outcomes can be attributed to the differing primary invasion pathways of endometrial and cervical cancers. Specifically, endometrial cancer predominantly metastasizes via lymphatic routes, whereas cervical cancer primarily disseminates through direct extension [14]. Disaia found that 334 EC patients undergoing RH and identified that 28 patients exhibited parametrial involvement (PMI). Among these, only 10 cases involved cervical involvement. Notably, all instances of PMI were associated with LVSI, primarily through lymphatic and vascular pathways [26]. Therefore, PMI not only disseminates directly through the cervix but also exhibits a significant correlation with deep muscular invasion and LVSI [26, 27]. It is important to acknowledge that the classification of stage IIB and IIC within the 2023 FIGO staging system for stage II EC does not inherently imply cervical involvement. Consequently, the ongoing application of RH/mRH to prevent parametrial dissemination in patients with 2023 FIGO stage II endometrial cancer may constitute overtreatment.

This study provides the first comprehensive analysis of hysterectomy types and approaches in 2023 FIGO stage II EC, indicating that SH combined with adjuvant therapy may offer oncological outcomes comparable to those of RH/mRH, while potentially reducing surgical morbidity. It is incontrovertible that our study is subject to certain limitations. These include a relatively small sample size, constrained by a two-year inclusion period intended to minimize surgical variability; incomplete recurrence data from external follow-up institutions; and biases inherent in the retrospective design, such as selection and recall biases. Importantly, the inability of SEER and other public databases to stratify LVSI status and accurately identify stage IIB cases underscores the unique contribution of our institutional dataset. Consequently, further investigation into the type and approaches of hysterectomy for 2023 FIGO stage II EC is warranted through multicenter collaboration and prospective studies with larger sample sizes, emphasizing the urgent need for standardized surgical protocols and adjuvant therapy regimens to validate these findings.

Conclusion

In conclusion, the findings of this study indicate that RH/mRH do not confer a survival advantage over SH for patients with 2023 FIGO stage II EC. Considering the long-term adverse effects associated with RH/mRH [10, 28], the use of these procedures should be carefully evaluated in clinical practice for patients with 2023 FIGO stage II EC.

Data availability

The manuscript contains all the data related to this study. Additional datasets used and analyzed during the study are available from the corresponding author upon reasonable request.

References

  1. Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet. 2022;399(10333):1412–28.

    Article  PubMed  Google Scholar 

  2. Berek JS, Matias-Guiu X, Creutzberg C, Fotopoulou C, Gaffney D, Kehoe S, Lindemann K, Mutch D, Concin N. FIGO staging of endometrial cancer: 2023. Int J Gynaecol Obstet. 2023;162(2):383–94.

    Article  PubMed  Google Scholar 

  3. Matsuo K, Klar M, Song BB, Roman LD, Wright JD. Validation of the 2023 FIGO staging schema for advanced endometrial cancer. Eur J Cancer. 2023;193:113316.

    Article  PubMed  Google Scholar 

  4. Schwameis R, Fanfani F, Ebner C, Zimmermann N, Peters I, Nero C, Marth C, Ristl R, Leitner K, Grimm C, et al. Verification of the prognostic precision of the new 2023 FIGO staging system in endometrial cancer patients– an international pooled analysis of three ESGO accredited centres. Eur J Cancer. 2023;193:113317.

    Article  PubMed  Google Scholar 

  5. Schilling JM, Shaker N, Shaker N, Fadare O. The 2023 FIGO staging system for endometrial carcinoma: predicted impact on stage distribution based on a retrospective analysis of 1169 cases. Am J Surg Pathol. 2024;48(1).

  6. Haight PJ, Riedinger CJ, Backes FJ, O’Malley DM, Cosgrove CM. The right time for change: a report on the heterogeneity of IVB endometrial cancer and improved risk-stratification provided by new 2023 FIGO staging criteria. Gynecol Oncol. 2023;175:32–40.

    Article  PubMed  Google Scholar 

  7. Kobayashi-Kato M, Fujii E, Asami Y, Ahiko Y, Hiranuma K, Terao Y, Matsumoto K, Ishikawa M, Kohno T, Kato T, et al. Utility of the revised FIGO2023 staging with molecular classification in endometrial cancer. Gynecol Oncol. 2023;178:36–43.

    Article  CAS  PubMed  Google Scholar 

  8. Gravbrot N, Weil CR, DeCesaris CM, Gaffney DK, Suneja G, Burt LM. Differentiation of survival outcomes by anatomic involvement and histology with the revised 2023 international federation of gynecology and obstetrics staging system for endometrial cancer. Eur J Cancer. 2024;201:113913.

    Article  PubMed  Google Scholar 

  9. Yu C, Yuan X, Yao Q, Xu Y, Zhou X, Hu X, Yang H, Wang H, Zhu X, Ren Y. Clinical application of FIGO 2023 staging system of endometrial cancer in a Chinese cohort. BMC Cancer. 2024;24(1):862.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Takano M, Ochi H, Takei Y, Miyamoto M, Hasumi Y, Kaneta Y, Nakamura K, Kurosaki A, Satoh T, Fujiwara H, et al. Surgery for endometrial cancers with suspected cervical involvement: is radical hysterectomy needed (a GOTIC study)? Br J Cancer. 2013;109(7):1760–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Phelippeau J, Koskas M. Impact of radical hysterectomy on survival in patients with stage 2 Type1 endometrial carcinoma: a matched cohort study. Ann Surg Oncol. 2016;23(13):4361–7.

    Article  PubMed  Google Scholar 

  12. Nasioudis D, Sakamuri S, Ko EM, Haggerty AF, Giuntoli RL 2nd, Burger RA, Morgan MA, Latif NA. Radical hysterectomy is not associated with a survival benefit for patients with stage II endometrial carcinoma. Gynecol Oncol. 2020;157(2):335–9.

    Article  PubMed  Google Scholar 

  13. Lennox GK, Clark M, Zigras T, Rouzbahman M, Han G, Bernardini MQ, Gien LT. Does radical hysterectomy for clinically apparent stage II endometrial cancer affect risk of local recurrence? J Obstet Gynecol Canada: JOGC = J D’obstetrique Et Gynecologie Du Can: JOGC. 2021;43(5):564–70.

    Google Scholar 

  14. Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet (London England). 2022;399(10333):1412–28.

    Article  PubMed  Google Scholar 

  15. Makker V, MacKay H, Ray-Coquard I, Levine DA, Westin SN, Aoki D, Oaknin A. Endometrial cancer. Nat Reviews Disease Primers. 2021;7(1):88.

    Article  PubMed  Google Scholar 

  16. Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, Ledermann J, Bosse T, Chargari C, Fagotti A, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer: Official J Int Gynecol Cancer Soc. 2021;31(1):12–39.

    Article  Google Scholar 

  17. Crippa J, Mari GM, Miranda A, Costanzi AT, Maggioni D. Surgical stress response and enhanced recovery after laparoscopic surgery - a systematic review. Chirurgia (Bucharest, Romania: 1990). 2018;113(4):455–463.

  18. Leissner KB, Shanahan JL, Bekker PL, Amirfarzan H. Enhanced recovery after surgery in laparoscopic surgery. J Laparoendoscopic Adv Surg Techniques Part A. 2017;27(9):883–91.

    Article  Google Scholar 

  19. Ye H, Xue K, Zhang P, Chen R, Zhai X, Ling L, Xiao W, Tang L, Wang H, Mao Y et al: Three vs 6 Cycles of Chemotherapy for High-Risk Retinoblastoma: A Randomized Clinical Trial. Jama 2024, 332(19):1634-1641.

  20. De Marzi P, Ottolina J, Mangili G, Rabaiotti E, Ferrari D, Viganò R, Candiani M. Surgical treatment of elderly patients with endometrial cancer (≥ 65 years). J Geriatric Oncol. 2013;4(4):368–73.

    Article  Google Scholar 

  21. Liu T, Tu H, Li Y, Liu Z, Liu G, Gu H. Impact of radical hysterectomy versus simple hysterectomy on survival of patients with stage 2 endometrial cancer: a meta-analysis. Ann Surg Oncol. 2019;26(9):2933–42.

    Article  PubMed  Google Scholar 

  22. Wang M, Ran R, Wu Y. Radical hysterectomy versus simple hysterectomy and brachytherapy for stage II endometrial cancer. J Obstet Gynaecol Res. 2021;47(11):3943–50.

    Article  PubMed  Google Scholar 

  23. Vardar MA, Gulec UK, Guzel AB, Gumurdulu D, Khatib G, Seydaoglu G. Laparoscopic surgery for low, intermediate and high-risk endometrial cancer. J Gynecologic Oncol. 2019;30(2):e24.

    Article  Google Scholar 

  24. Uccella S, Bonzini M, Palomba S, Fanfani F, Malzoni M, Ceccaroni M, Seracchioli R, Ferrero A, Berretta R, Vizza E, et al. Laparoscopic vs. open treatment of endometrial cancer in the elderly and very elderly: an age-stratified multicenter study on 1606 women. Gynecol Oncol. 2016;141(2):211–7.

    Article  PubMed  Google Scholar 

  25. Johnson CA, James D, Marzan A, Armaos M. Cervical cancer: an overview of pathophysiology and management. Semin Oncol Nurs. 2019;35(2):166–74.

    Article  PubMed  Google Scholar 

  26. Disaia PJ. Predicting parametrial involvement in endometrial cancer: is this the end for radical hysterectomies in stage II endometrial cancers? Obstet Gynecol. 2010;116(5):1016–7.

    Article  PubMed  Google Scholar 

  27. Singh N, Hirschowitz L, Zaino R, Alvarado-Cabrero I, Duggan MA, Ali-Fehmi R, Euscher E, Hecht JL, Horn LC, Ioffe O, et al. Pathologic prognostic factors in endometrial carcinoma (Other than tumor type and grade). Int J Gynecol Pathology: Official J Int Soc Gynecol Pathologists. 2019;38(Suppl 1):S93–113.

    Article  Google Scholar 

  28. Barquet-Muñoz SA, Cantú-de-León D, Bandala-Jacques A, González-Enciso A, Isla-Ortiz D, Prada D, Herrera LA. Salcedo-Hernández RA: what is the impact of radical hysterectomy on endometrial cancer with cervical involvement? World J Surg Oncol. 2020;18(1):101.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We extend our gratitude to all the patients and their families who participated in this study, as well as to the investigators and support staff for their invaluable contributions.

Funding

This research was partially funded by the National Natural Science Foundation of China (No. 82072088), the Natural Science Foundation of Gansu Province (No. 22JR5RA718 and 24JRRA621), and the Postgraduate Research & Practice Innovation Program of Jiangsu Province.

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Author notes

  1. Jianhao Sun and Zhenzhen Wu contributed equally to this work.

Authors and Affiliations

  1. Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China

    Jianhao Sun, Ji Xia & Dan Lu

  2. Institute of Translational Medicine, Medical College, Yangzhou University, Yangzhou, 225001, China

    Jianhao Sun, Ji Xia & Dan Lu

  3. Gansu Provincial Maternity and Child-care Hospital, Lanzhou, Gansu Province, 730000, China

    Jianhao Sun, Zhenzhen Wu, Yaqin Zhao, Juan Li, Jie Huang, Xinjuan Jiao & Qing Liu

  4. Gansu University of Chinese Medicine, Lanzhou, 730000, China

    Zhenzhen Wu, Jiayu Chen, Yaqin Zhao, Xiaoli Zhao, Xinjuan Jiao & Qing Liu

  5. Department of Clinical Medicine, Medical College, Key Laboratory of Jiangsu Province University for Nucleic Acid & Cell Fate Manipulation, Yangzhou University, Yangzhou, 225001, China

    Qinglei Hang

Authors
  1. Jianhao Sun
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Contributions

J.H.S and Z.Z.W wrote the manuscript and designed the research; J.H.S, Z.Z.W, and J.Y.C collected and curated the data; Q.L.H, Y.Q.Z, and J.L conducted the investigation and developed the methodology; J.H, X.L.Z, J.X, and X.J.J supervised and validated the research; Q.L reviewed and edited the manuscript and contributed to visualization; D.L conceptualized the study, acquired funding, and administered the project.

Corresponding authors

Correspondence to Qing Liu or Dan Lu.

Ethics declarations

Ethics approval and consent to participate

This retrospective study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Ethics Committee of the Gansu Provincial Maternity and Child-care Hospital, China (2022-48). Written informed consent was obtained from all participants prior to their inclusion in the study.

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Not applicable.

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The authors declare no competing interests.

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Sun, J., Wu, Z., Chen, J. et al. Comparative analysis of hysterectomy types and approaches on oncological survival in 2023 FIGO stage II endometrial carcinoma. BMC Surg 25, 209 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-025-02937-2

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Keywords

BMC Surgery

ISSN: 1471-2482

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