Total mesometrial resection for cervical cancer: a systematic review of oncological outcomes and comparative analysis with radical hysterectomy

Background: This systematic review aims to assess the oncologic efficacy and safety of Total Mesometrial Resection (TMMR) in cervical cancer, focusing on 3-year disease-free survival (DFS) and overall survival (OS). Additionally, TMMR outcomes are compared with open radical hysterectomy, the current standard of care, as reported in the Locally Advanced Cervical Cancer (LACC) trial. Methods: A systematic search was conducted in PubMed and Scopus following Preferred Reported Instruments for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies evaluating TMMR in cervical cancer were included if they reported DFS, OS, recurrence patterns, and perioperative complications. Newcastle-Ottawa Scale (NOS) was used for quality assessment, and hazard ratios (HR) were computed for comparative analysis. Results: Seven studies met the inclusion criteria, including 1071 patients treated with TMMR. The 3-year DFS ranged from 85% to 97.1%, and OS from 87.9% to 100%. TMMR showed a higher recurrence risk compared to open radical hysterectomy (HR 4.89, 95% CI: 2.42-9.88, p <0.001) and a significantly increased mortality risk (HR 16.48, 95% CI: 4.08-65.99, p < 0.001). However, in a subgroup analysis restricted to patients with disease stages below IB3 (n = 447), the HR for recurrence was 1.32 (95% CI: 0.57-3.07, p = 0.57), for local recurrence 2.31 (95% CI: 0.76-7.01, p = 0.14), and for OS 0.70 (95% CI: 0.10-4.92, p = 0.72), suggesting no statistically significant difference compared to standard radical hysterectomy. Conclusions: While TMMR demonstrates favorable survival rates, its higher recurrence and mortality risks compared to standard radical hysterectomy raise concerns. Further prospective multicenter studies are needed to determine its role in clinical practice. The PROSPERO Registration: CRD420251125129.