Interpretation
This meta-analysis justifies comprehensive staging surgery in early-stage EOC patients, given that 18.7% will ultimately be upstaged, consequently influencing adjuvant treatment and prognosis. Although the clinical benefits and implications regarding comprehensive staging or restaging surgeries are well defined, it should be clear that these procedures also carry significant risks for complications. Intra- and postoperative complications occur in up to 15.8% of the patients, including internal bleeding, injuries to the urinary tract or intestines, infections, and complications of wound healing40. Its long-term sequelae, such as lymphedema caused by lymphadenectomy, manifest in over 30% of the patients, and negatively influence the quality of life41,42. A laparoscopic approach could reduce some of the surgical morbidity, though further trials would be required before a definitive statement can be made about the clinical value of laparoscopic staging43–45.
While all staging surgery components were found to have upstaging value, some contributed only in a limited amount. Conceptually, the benefits have to outweigh the associated disadvantages of each component. Kleppe et al. suggest omitting a systematic lymphadenectomy in grade I mucinous EOC since the incidence of positive lymph nodes is low, and the morbidity as a direct consequence of lymphadenectomy high46. We could not perform an analysis in this specific subgroup, as insufficient data of this patient group could be extracted. Therefore, we were unable to corroborate this statement with the group level data retrieved from the included studies. Previous reports have estimated the lymphadenopathy risk in apparent stage I-II mucinous EOC at 0.8%. In the Netherlands, lymph node assessment is currently no longer a required part of the staging surgery in patients with mucinous histology.