Morbidity after surgical management of cervical cancer in low and middle income countries: A systematic review and meta-analysis

OBJECTIVE: To investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC). METHODS: The Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1(st) Jan 2000 to 30(th) June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS). FINDINGS: Data were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19–0.41, P = 0.00, I(2) = 97.81), nerve injury 1% (95%CI 0.00–0.03, I(2) 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01–0.01, I(2) = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01–0.02, P = 0.10, I(2) = 32.2), ureteric injury 1% (95%CI 0.01–0.01, I(2) 0.00, P = 0.64), vascular injury 2% (95% CI 0.01–0.03, I(2) 60.22, P = 0.00), fistula 2% (95%CI 0.01–0.03, I(2) = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00–0.01, I(2) 26.69, P = 0.25), and infection 8% (95%CI 0.04–0.12, I(2) 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy. CONCLUSION: This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.