BACKGROUND: Laparoscopic radical hysterectomy with Karez technique (LRH-Karez) is a practical method which is based on special space anatomy. This study investigates the efficacy and safety of LRH-Karez against traditional surgical methods including abdominal radical hysterectomy (ARH) and conventional minimally invasive surgery (MIS). METHODS: A multicenter retrospective cohort study was conducted, involving 413 eligible patients diagnosed with 2018 FIGO stage IB3 and IIA2 cervical cancer treated from January 2012 to January 2022. Among these, 66 patients underwent LRH-Karez, 56 patients underwent conventional laparoscopic or robotic surgery (Conventional MIS) and 291 patients received ARH. Patient data were obtained from three tertiary hospitals in China. Surgical outcomes, pathological results, and follow-up data were analyzed using SPSS and R statistical software. Kaplan-Meier survival analysis was performed alongside univariate and multivariate Cox regression analyses. RESULTS: LRH-Karez has less intraoperative blood loss but longer operative time. The five-year progression-free survival (PFS) rates were 85% for LRH-Karez, significantly higher than the 53.6% from conventional MIS (P = 0.002) and comparable to ARH (78.3%, P = 0.898). In terms of overall survival, the five-year overall survival (OS) rate for the LRH-Karez group was 92.2%, compared to 51.9% for the conventional MIS group and 78.3% for the ARH group. Patients who underwent conventional MIS had significantly lower OS compared to those in the LRH-Karez group (P <
0.002). The log-rank test indicated no significant difference in OS between the LRH-Karez group and the ARH group (P = 0.218). However, the Gehan-Breslow-Wilcoxon test revealed a significant difference between the two groups during the early follow-up period (P = 0.047). CONCLUSIONS: The LRH-Karez technique has demonstrated superior intraoperative safety and survival prognosis compared to conventional MIS in patients with locally advanced cervical cancer (FIGO stages IB3 and IIA2), with its long-term survival outcomes comparable to ARH. This practical technique, based on refined understanding of surgical space anatomy, may represent a valuable minimally invasive surgical option that warrants further exploration.