Which is the best for ovarian reserve preservation? Hemostatic agent or coagulation?

Coagulative procedures decrease AMH levels in patients with endometriosis but not in other cyst types.

Key Points

Highlights:

            Ovarian cystectomy has a potential risk for ovarian damage, resulting in a decrease in ovarian reserve and infertility.

Importance:

• It is important to clarify the differentiate the effects of coagulation or hemostatic agents on operative outcomes, complications, and ovarian reserve during ovarian cystectomy procedures.

What's done here:

• The study was conducted as a single-blinded, prospective randomized trial.
• Women who underwent laparoendoscopic single-site (LESS) ovarian cystectomy due to benign unilateral ovarian cyst were enrolled, patients were divided into two groups based on the use of hemostatic agent (oxidized cellulose polymer) or coagulative techniques.
• Groups were compared patients’ demographic characteristics, cyst type, operative parameters, complications, hemostatic outcomes, and follow-up results including ovarian volume, anti-Müllerian hormone (AMH) level, and hemoglobin level.

Key Results:

• Eventually, 48 patients who matched the inclusion criteria were evaluated according to follow-up outcomes.
• Demographic characteristics, operation duration, blood loss, hospitalization period, hemostasis time, and additional suturing for inadequate hemostasis were similar between groups.
• Comparison of AMH level, hemoglobin level, and ovarian volume between preoperative period, postoperative 2nd day, postoperative 1st week, and postoperative 3rd months, revealed no significant differences in the patients with pathologies other than endometriosis.
• In the postoperative period, AMH level and ovarian volume decreased over time but hemoglobin level decreased early postoperative period, then increased progressively.
• The decrease in the ratio of hemoglobin level and ovarian volume was similar between groups, but a decrease in AMH ratio was significantly higher at 3rd month after surgery in the coagulation group in patients with endometriosis.

Limitations:

• The absence of long-term results and lacking cost-effectiveness of hemostatic agent and coagulation technique in LESS ovarian cystectomy surgery could be considered as limitations for study.
• The study included data from single-center, and the experience of the surgeon(s) was not detailed.

Lay Summary

The way of ovarian parenchymal bed hemostasis following ovarian cystectomy is crucial for ovarian reserve protection, and discussions about different techniques on this issue are ongoing.

Multiport laparoscopic surgery is the standard method for ovarian surgeries, but laparoendoscopic single-site cystectomy became popular in the treatment of benign ovarian conditions. Studies which evaluated the impact of different hemostasis technique on ovarian reserve following laparoendoscopic single-site ovarian cystectomy were limited.

Park and colleagues used coagulation and hemostatic agent during the laparoendoscopic single-site ovarian cystectomy procedure, and authors investigated the effect of these techniques on operative outcomes and ovarian reserve.

Operation duration, estimated blood loss, hospitalization period, hemostasis time, and additional suturing for inadequate hemostasis did not show a significant difference between groups. In addition, if the cyst pathology is not endometrioma, AMH level, hemoglobin level, and ovarian volume between preoperative period, postoperative 2nd day, postoperative 1st week, and postoperative 3rd months, were similar.

In contrast, Park et al. stated that a decrease in AMH ratio was significantly higher at 3rd month after surgery in patients with endometriosis who achieved hemostasis with coagulation.

The authors concluded that the use of oxidized cellulose polymer for hemostasis should be considered during if there is a suspect for endometriosis, especially in reproductive-age women during laparoendoscopic single-site cystectomy.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33875738/