EC is the most common gynecologic malignancy in developed countries, accounting for over 60.000 cases each year in the United States [77]. Five-year overall survival (OS) ranges from 74 to 91% in patients without distant metastasis. Surgery is the main treatment for early-stage EC cases. Obesity and older age are the main risk factors for EC. Other risk factors for EC include nulliparity, unopposed estrogen intake, and late menopausal state.

Thanks to the early presentation of symptoms and a prompt diagnosis, surgery is often curative [78]. Surgical staging for EC includes hysterectomy, salpingo-oophorectomy, and lymph node assessment [79, 80, 81, 82]. At present, MIS is the gold standard approach in the case of EC confined to the uterus [83, 84]. Traditionally surgery was performed in laparotomy, but since the advent of laparoscopy in 1990, several studies demonstrated that laparoscopic surgery is a feasible option.

Current guidelines published in 2020 by the European Society of Gynaecological Oncology, the European Society for Radiotherapy and Oncology, and the European Society of Pathology (ESGO/ESTRO/ESP) [85] define minimally invasive approach as the preferred surgical option in early-stage EC, while, extension outside the uterus and cervix are contraindication to MIS [86, 87, 88]. According to the American College of Obstetricians and Gynecologists and the National Comprehensive Cancer Network (NCCN), MIS should be the standard surgical approach for EC [89].

Several RCT compared laparotomy to laparoscopy. In a systematic review conducted by Hong Ying He, considering 9 RCT, laparoscopy is associated with a longer operating time and a minor length of hospital stay [25]. Furthermore, a higher rate of intraoperative complications was reported in patients who underwent MIS. In the Authors’ opinion, the higher rate of intraoperative complications may be due to the little experience with laparoscopy at the time of the study (1996). Moreover, the high number of patients assigned to the “laparoscopy group” enrolled in the LAP2 study (1696 vs 920 assigned to the laparotomy group), influenced the results of all systematic reviews citing this data [5].

On the other hand, when considering major intraoperative complications, such as bladder, ureteric, bowel, and vascular injury, a Cochrane published in 2018 showed no differences between laparoscopy and laparotomy [26].

In 2009 a randomized prospective study on 2600 patients was conducted. The LAP2 study demonstrated that laparoscopy is associated with a lower rate of complications, low intraoperative blood loss, and a minor length of hospital stay compared to laparotomy [5, 27].

Laparoscopy has benefits also in short-term outcomes, such as recovery after surgery, hospital stay, adverse events, and quality of life after the intervention [4, 90, 28].

In 2012 an ancillary analysis of the LAP2 trial was conducted [27]. The authors reported only small differences in laparoscopy compared to laparotomy and a slight increase in recurrence rate for patients treated with laparoscopy, not statistically significant. No differences were shown in OS, recurrence-free survival (RFS), and patterns of recurrent disease.

Recently, the LACE trial compared total laparoscopic hysterectomy (n = 353) with total abdominal hysterectomy (n = 407) in the stage I EC treatment [4]. The results showed equivalent survival outcomes in the two groups [29].

Regarding the pattern of recurrence, concerns were raised for the hypothetic risk of augmented frequency of vaginal cuff recurrence and the possible localization at the port site [91]. In the analysis conducted in 2012 on recurrence and OS in patients enrolled in the LAP2 study, no statistically significant difference was found in vaginal recurrence between laparoscopy and laparotomy [27].

Iavazzo et al. [30] reported no clear correlation between the uterine manipulator and recurrence. Different authors suggested sealing the tubes and minimizing the movements of the uterine manipulator during the intervention to overcome this risk.

A recent prospective randomized clinical trial (ROMANHY trial) investigated the influence of the use of intrauterine manipulators (IUM) on lymphovascular space invasion (LVSI) status and peritoneal cytology. However, no difference was found between the two groups with no adverse impact of IUM on OS and disease free survival (DFS) [31].

Concerning port site metastasis, they may be related to understaging of microscopic EC localization and not to laparoscopy per se [32]. On the other hand, safe deflation through the trocars has been suggested by some authors to reduce the risk of port-site metastasis [33]. In the LAP2 study, 4 port-site recurrences were described, and ¾ occurred in patients with advanced disease [5].

At present, no prospective trials are investigating the safety of robotic surgery in the treatment of EC patients. However, data from retrospective case series and metanalysis reported similar advantages for robotic surgery and laparoscopy in the reduction of intraoperative complications compared to laparotomy, without detriment of oncological outcomes [34, 35].

Moreover, recent retrospective studies showed that robotic surgery may be a better choice compared to laparoscopy in EC treatment, with a lower rate of conversion to laparotomy, and a higher rate of nodal assessment accomplished especially in obese patients [23, 36].

After the publication of the LAP2 trial, laparoscopy became the gold standard for EC treatment [5, 27]. While several clinical trials demonstrated the safety and effectiveness of MIS for low-risk EC [37, 38], only a few retrospective studies have been published regarding safety in high-risk EC cases. A minimally invasive approach may be extremely beneficial in this set of patients, thanks to enhanced recovery and reduced morbidity.

Monterossi et al. [39] conducted a wide retrospective analysis on patients with type II EC, 141 patients underwent laparotomic surgery and 142 patients underwent MIS. The Authors concluded MIS was a safe approach also in this setting of patients, with favorable oncological outcomes. Conversely, patients with stage III who underwent laparotomy had a better OS than the MIS group.

In 2018 an analysis on the National Cancer Database was conducted, to assess the use of MIS in uterine cancers (n = 94,507) in the subset of high-risk histologic subtypes. The authors found no difference in OS in patients who underwent MIS compared to the laparotomic approach [40].

In conclusion, current evidence regarding the safety and feasibility of MIS in the setting of high-risk EC is limited and comes exclusively from retrospective trials. Available data suggest that high-risk EC is not a contraindication to an MIS approach and oncological outcomes appear not to be affected [41]. Nevertheless, strong evidence from large prospective trials is still lacking.

OC accounts for almost 20,000 new cases per year in the United States [77]. Differently from EC, OC is associated with high mortality rates and advanced stage at diagnosis. Globally, OC is the eighth most common cause of cancer-related death in women, with a five-year survival rate below 45% .

The OC standard treatment includes surgery plus intravenous chemotherapy. The main prognostic factor in ovarian cancer treatment is a complete cytoreduction at primary debulking surgery (PDS). However, in almost 80% of cases, OC is at advanced stage at the time of presentation.

Often, due to the spreading of the disease at the time of diagnosis, upfront surgery may require invasive and destructive surgery, with inacceptable morbidity, or a complete resection of gross tumor may not be feasible at upfront surgery. In these cases, patients are candidate to neoadjuvant chemotherapy followed by interval debulking surgery (IDS), to remove bulky disease and improve response to adjuvant chemotherapy.

In order to maximise benefits from chemotherapy on tumor burden and microscopic residual disease on peritoneal surfaces, the use of hypertermic intraperitoneal chemotherapy (HIPEC) and, more recently, of pressurised intraperitoneal aerosol chemotherapy (PIPAC) has been proposed at the time of primary or secondary cytoreductive surgery for OC [92]. However, currently there are no large, prospective randomized trials supporting their use in the routine practice [93].

Currently, there is equivocal and limited evidence about the use of MIS in OC patients [42, 94].

According to the current guidelines [93], the standard procedure for OC treatment and staging is open surgery. The open approach allows better macroscopical exploration and removal of the gross tumor without mass rupture. Laparotomy is believed to be superior at identifying occult metastasis through increased exposure and palpation that could otherwise be missed by MIS [95]. In clinical practice, MIS has been considered with encouraging results for early-stage ovarian carcinomas in high volume centres with experienced surgeons [43, 44, 45]. Available data show that MIS represents a safe option for the diagnosis and staging of early-stage OC [46]. However, nowadays no prospective randomized trials have been published yet about the safety of MIS in OC treatment [47, 48, 96].

Possible limitations of a minimally invasive approach derive from the risk of cyst rupture with cells spillage and a hypothetical suboptimal evaluation of the abdominal cavity. A careful selection of eligible patients and the use of a protected bag may overcome the risk of cells tumor spreading [49]. Gallotta et al., [50] in a large retrospective trial, reported an enhanced recovery after MIS compared to open surgery, an optimal retroperitoneal assessment, and an MIS non-inferiority in terms of oncological outcomes with respect to laparotomy.

In the context of advanced stage OC, staging laparoscopy is a largely accepted tool to candidate patients to upfront surgery or neoadjuvant chemotherapy. Fagotti et al. [51] proposed a laparoscopic scoring system to evaluate the feasibility of an optimal cytoreduction. This scoring system has been validated in prospective trials. Furthermore, an accurate selection of patients is crucial to avoid unnecessary laparotomy when optimal cytoreduction is not achievable.

Current international guidelines mention the execution of a diagnostic laparoscopy as a part of the diagnostic workup in advanced ovarian cancer, to obtain detailed information about the intra-abdominal disease burden and a histopathological diagnosis [93].

Concerning MIS as a treatment option in advanced stage OC, only a few, retrospective, non-randomized studies have been published on this topic. The need for an accurate assessment of residual disease and for the performance of major surgical procedures, such as bowel resection and upper abdominal surgery, limits the employment of minimally invasive approach.

However, the possibility for a successful laparoscopic approach also in case of diaphragmatic involvement has been reported [97].

Nezhat et al. [52] reported a case series on 32 patients with advanced ovarian cancer who underwent laparoscopic staging. In 17 cases a laparoscopic cytoreduction was performed, 11 patient underwent laparotomic cytoreduction. The assignment to laparoscopic debulking surgery vs open surgery was left to surgeon judgement. The results showed an higher rate of complete cytoreduction and a longer DFS in the laparoscopy group. However a bias of selection must be considered, since patients were not randomized to laparoscopic vs laparotomic cytoreduction.

Fanning et al. [53] published a study of 25 patients with advanced stage ovarian cancer who underwent laparoscopic PDS. Only in in the 36% of cases a complete cytoreduction was achieved.

In conclusion, currently there is not enough evidence to consider MIS a safe option for PDS in advanced stage OC. Moreover, there is a lack of objective criteria to select patients who may benefit from this approach, without detriment of oncological outcomes.

There are also some concerns in the employment of MIS in IDS, such as the inability to assess completely the abdominal cavity, which raises the question of whether the approach can yield the same rates of complete resection compared with an open approach.

The feasibility of minimally invasive IDS in selected patients, with optimal response to chemotherapy, has been explored in small, non-randomized, retrospective studies [54]. IDS is the main option in patients with unresectable disease at the time of diagnosis or in patients with poor physical conditions, who may benefit from a less extensive surgical treatment [98, 99]. IDS increases the rates of optimal cytoreduction with less surgical morbidity and without affecting oncological outcomes [55, 56].

Currently, there are no strict recommendations about the ideal patient to candidate to IDS or the best surgical approach, nevertheless, MIS is not the standard treatment. The international MISSION study, which included 127 OC patients with partial and complete response to neoadjuvant chemotherapy, showed no differences in OS in the case of low complexity cytoreductive surgery between MIS and laparotomy [57].

However, in the absence of large prospective randomized trials, nowadays there is no strong evidence available regarding an adequate assessment of residual disease in IDS with MIS compared to laparotomy, as a consequence there is not enough reassuring evidence about the oncological safety of MIS in this setting of patients. Moreover, a minimally invasive approach would not be the preferred choice in case of complex surgery, such as bowel resection, diaphragm stripping, and retroperitoneal dissection.

In a recent meta-analysis comparing the performance of IDS with MIS, the author affirmed that optimal cytoreduction can be accomplished via MIS in patients with complete clinical response to chemotherapy and low tumor load on diagnostic laparoscopy [56].

Currently, the LANCE trial is an ongoing international, prospective, multicentre randomized phase III trial comparing MIS interval cytoreductive surgery vs open surgery in terms of DFS. Results from this study may offer more definitive evidence about the MIS role in OC patients [100]. Considering the feasibility of MIS as a staging procedure in advanced OC and the potential survival benefit deriving from intraperitoneal chemotherapy, the association of MIS and HIPEC or PIPAC during surgery for OC has been explored. Currently, intraperitoneal chemotherapy should not be considered a standard procedure, however MIS is not a contraindication for intraperitoneal chemotherapy [58].

Concerning recurrent OC, surgical treatment plus chemotherapy has no clear benefit in terms of OS and RFS compared to chemotherapy alone. Surgical treatment should be considered only in case of complete cytoreduction at cytoreductive surgery, good performance status of the patient and platinum-sensitivity [101].

In recurrent OC, MIS is a useful tool to assess the extension of recurrent disease and the feasibility of a surgical treatment [101, 102]. In a recent retrospective study, the potential role of MIS has been evaluated in 58 patients with single relapse, platinum sensitive OC, with evidence of safety and optimal secondary cytoreduction [59].

A recent systematic review of the literature including 372 patients with OC recurrence [60], affirms that MIS is a safe and feasible option compared to laparotomy in selected patients, with single-site recurrent disease or few localizations of relapses, in the context of highly specialized centres with skilled surgeons.

Fagotti et al. [58] conducted a retrospective analysis on 22 patients with recurrent OC, eligible for surgery, who underwent MIS secondary cytoreductive surgery (SCS) or open SCS with HIPEC. The results showed evidence of benefit in terms of postoperative outcomes in the MIS group. However, oncological outcomes were not discussed in this study.

CC is the fourth most common malignancy in the world. In 2020 CC accounted for 13,800 new cases in the United States [77]. Differently from other malignancies, due to the implementation of tools for prevention and early detection, its incidence and related mortality have dramatically decreased in the last 50 years, but only in those countries with access to cytological screening programs [103].

CC is still the most common gynecologic malignancy in low-income countries and an important cause of morbidity and mortality, due to the lack of resources to support screening and local prevention programs.

The standard treatment for CC is radical hysterectomy and pelvic lymphadenectomy. In 1992 MIS was introduced in CC treatment. For 25 years, multiple retrospective publications reported the feasibility, advantages, and oncologic safety of the minimally invasive approach .

Radical hysterectomy was reported to be safely accomplished with MIS, with better postoperative outcomes compared to open surgery [62]. Moreover, promising results were reported with robotic radical hysterectomy compared to laparoscopy, thanks to a major dexterity, of great value in radical procedures, less intraoperative complications and apparently, good oncological outcomes [104].

Before 2018, international guidelines [105, 106] recommended both open surgery and MIS for early-stage CC patients.

The publication of the LACC trial in 2018 imposed a change in the recommendation for CC surgical treatment approach [61]. This prospective randomized trial showed that MIS had lower DFS and OS compared to the open approach. Unexpectedly, randomization and recruitment were suspended because of a higher rate of recurrences and death in the group randomized for MIS. Women randomized to the minimally invasive arm experienced almost 4 times the risk of recurrence and 6 times the risk of death compared with women randomized to laparotomy.

The reasons for the MIS inferior outcomes are not known yet. The use of IUM, the effect of CO2 insufflation on tumor cells’ spread, and open colpotomy have been discussed as possible causes [63, 64]. In the hypothesis of tumor spreading during cervical manipulation, various surgical strategies have been proposed, including the Kohler vaginal cuff performed before surgical treatment [65]. Anyway, definitive oncological safety must be proven with prospective trials.

A recent metanalysis [63] aimed to discuss the results from the LACC trial with available “real world metanalysis”, comparing the risk of recurrence and death between patients who underwent minimally invasive vs open radical hysterectomy for early-stage CC. The selection included only higher quality observational studies and the results confirmed the LACC trial’s results. Furthermore, several retrospective trials corroborated these findings and the international guidelines were updated according to the most recent evidence [66, 67].

In the SUCCOR study, an observational multicentre European retrospective cohort study, the authors confirmed the MIS inferiority compared to open surgery. On the other hand patients with previous conisation and with tumor size 2 cm did not show statistically DFS differences in MIS vs open approach [68].

Regarding the relation between tumor size and the detrimental effect of MIS, different retrospective trials reported the MIS non-inferiority compared to open radical hysterectomy in terms of DFS and/or OS for tumor size 2 cm [69, 70, 71]. However, the evidence is not conclusive, and large epidemiological studies report a higher risk of death after MIS vs open surgery even in case of tumor size 2 cm [66, 67].

In conclusion, MIS may be considered is in case of tumor size 2 cm only with the adoption of preventive measures, in reference centres, and after counselling the patients about the lack of prospective safety data supporting this treatment choice [71].

Currently, MIS is an accepted option when fertility-sparing surgery is feasible, such as laparoscopic-assisted vaginal radical trachelectomy and laparoscopic radical trachelectomy [72, 73, 74]. Laparoscopy is also the preferred surgical route for nodal surgical staging, before concurrent chemo/radiotherapy and in case of fertility-sparing surgery [75].

Furthermore, a minimally invasive approach may be considered after conisation without residual disease (stage IA1, IA2 cervical cancer), in patients requiring hysterectomy [76].

Two prospective randomized trials exploring the role of MIS in patients with CC have recently been initiated. The first is the RACC trial, a Swedish multicentre prospective trial comparing robotic vs open surgery for the treatment of early-stage CC [107]. The use of an IUM is not allowed, and the closure of the vagina before colpotomy is recommended but not mandatory. The second one is a multicentre randomized controlled trial designed in China, with a planned enrolment of 1448 patients [108]. In their protocol, the use of an IUM and the method of vaginal excision are to be reported. These trials may provide stronger evidence concerning the safest treatment of early-stage CC patients.