We appreciate the interest and comments by Dr Heitz et al regarding our article.

The purpose of our study was to report the outcomes of laparoscopic staging surgery in early-stage ovarian cancer because the merit of laparoscopic surgical approach for ovarian cancer is highly debatable. However, laparoscopic surgery is limited in comparison with cervical or endometrial cancers, despite recent advancements in technology and surgical skills. We are convinced that progress on the rapidly growing surgical technology already has and will likely have a major impact on the development of endoscopic surgery in the future. Therefore, surgeons should be vigilant, yet innovative, in implementing new methods of patient care.

It is clear that the use of laparoscopy is increasing not only in the field of fertility-sparing surgery for borderline ovarian malignancy and nonepithelial ovarian cancer staging but also for early-stage epithelial ovarian malignancies according to literature. These studies have shown that the accuracy and adequacy of laparoscopic surgical staging were comparable with a laparotomic approach, although the oncologic safety of laparoscopic staging was not certain. In this context, we believe that it is now time for a comprehensive review regarding this subject, especially when recalling that, in November 2007, only a qualitative review could be conducted because of the availability of only low quantity of studies in the literature.

We do acknowledge that our conclusion was drawn mostly from observational studies with heterogeneous designs. We also agree with the concern of Dr Heitz et al that full surgical staging is crucial if we are to ascertain oncologic safety for patients. However, the authors do not advocate the replacement of surgical staging by laparotomy with laparoscopy based on the findings in our article. Despite the rapid increase in laparoscopic surgery, the current evidence is limited because of a lack of prospective randomized trials, as shown in a recent Cochrane review. Despite our effort to apply stricter inclusion/exclusion criteria for the metaanalysis and manage separate data analyses according to the existing literatures’ study designs, we agree with the commentary that larger scale prospective studies are needed to support fully the conclusion of this metaanalysis, especially with regards to oncologic efficacy in targeted populations.