Preserving Ovarian Reserve During Ovarian Cystectomy
Preserving Ovarian Reserve During Ovarian Cystectomy
Study Question: Is hemostasis by hemostatic sealant superior to that achieved by bipolar coagulation in preserving ovarian reserve in patients undergoing laparoscopic ovarian cystectomy?
Summary Answer: Post-operative ovarian reserve, determined by serial serum anti-Müllerian hormone (AMH) levels, was significantly less diminished after ovarian hemostasis when hemostatic sealant was used rather than bipolar coagulation.
What is Known Already: Hemostasis achieved with bipolar coagulation at ovarian bleeding site results in damage to the ovarian reserve.
Study Design, Size, Duration: A prospective, multi-center randomized trial was conducted on 100 participants with benign ovarian cysts, between December 2012 and October 2013.
Participant/Materials, Setting, Methods: Participants were randomized to undergo hemostasis by use of either hemostatic sealant (FloSeal™) or bipolar coagulation during laparoendoscopic single-site (LESS) ovarian cystectomy. The primary end-point was the rate of decline of ovarian reserve calculated by measuring serum AMH levels preoperatively and 3 months post-operatively.
Main Results and the Role of Chance Age, parity, socio-demographic variables, preoperative AMH levels, procedures performed and histologic findings were similar between the two groups of patients. There were also no differences in operative outcomes, such as conversion to other surgical approaches, operative time, estimated blood loss, or perioperative complications between the two groups. In both study groups, post-operative AMH levels were lower than preoperative AMH levels (all P < 0.001). The rate of decline of AMH levels was significantly greater in the bipolar coagulation group than the hemostatic sealant group (41.2% [IQR, 17.2–54.5%] and 16.1% [IQR, 8.3–44.7%], respectively, P = 0.004).
Limitations, Reasons for Caution: Some caution is warranted because other ovarian reserve markers such as serum markers (basal FSH and inhibin-B) or sonographic markers were not assessed.
Wider Implications of the Findings: The present study shows that the use of a hemostatic sealant during laparoscopic ovarian cystectomy should be considered, as hemostatic sealant provides the additional benefit of preservation of ovarian reserve.
Study Funding/Completing of Interest(s): This study was supported by the Medical Research Funds from Kangbuk Samsung Hospital. No conflict of interest is declared.
Laparoscopy has become the gold standard for surgical treatment of benign ovarian cysts and is usually performed by stripping the ovarian cyst wall, followed by bleeding control of the ovarian wound ground using bipolar coagulation. However, hemostasis achieved with bipolar coagulation could result in damage to the ovarian reserve (Tsolakidis et al., 2010; Coric et al., 2011; Hirokawa et al., 2011; Var et al., 2011; Sonmezer et al., 2013) and decrease the response of the ovaries to hormonal stimulation for assisted reproductive technologies (Esinler et al., 2006; Almog et al., 2010; Benaglia et al., 2010). It is thought that excessive use of bipolar coagulation for hemostasis purposes may result in thermal destruction of normal ovarian follicles. Some cases of premature ovarian failure have also been reported after bilateral ovarian cystectomy (Busacca et al., 2006; Di Prospero and Micucci, 2009; Hwu et al., 2011).
To avoid damage to healthy ovarian tissue, hemostasis using various topical hemostatic agents has been introduced to control post-cystectomy ovarian wound bleeding (Angioli et al., 2009; Ebert et al., 2009). Among these, FloSeal (Baxter Healthcare Corporation, Deerfield, IL, USA) is a hemostatic sealant composed of a gelatin-based matrix and thrombin solution. Upon coming into contact with blood after application at a bleeding site, the gelatin particles swell and tamponade the bleeding. The bulk of the gelatin matrix-thrombin composite has the effect of slowing the blood flow and providing exposure to a high thrombin concentration, thus hastening clot formation. This treatment may be particularly suitable for use in post-cystectomy ovarian wound bleeding, where there is a superficially pervasive focus of bleeding.
Although the use of FloSeal for ovarian hemostasis during laparoscopic ovarian cystectomy may preserve ovarian reserve, no data on its effectiveness were available at the commencement of this study. Therefore, we conducted a multi-center, randomized controlled trial to investigate whether hemostasis by use of FloSeal was superior to that achieved by bipolar coagulation in preserving ovarian reserve. This was assessed by comparing the rate of decline of post-operative serum anti-Müllerian hormone (AMH) levels in patients undergoing laparoscopic ovarian cystectomy for benign ovarian cysts.
Abstract and Introduction
Abstract
Study Question: Is hemostasis by hemostatic sealant superior to that achieved by bipolar coagulation in preserving ovarian reserve in patients undergoing laparoscopic ovarian cystectomy?
Summary Answer: Post-operative ovarian reserve, determined by serial serum anti-Müllerian hormone (AMH) levels, was significantly less diminished after ovarian hemostasis when hemostatic sealant was used rather than bipolar coagulation.
What is Known Already: Hemostasis achieved with bipolar coagulation at ovarian bleeding site results in damage to the ovarian reserve.
Study Design, Size, Duration: A prospective, multi-center randomized trial was conducted on 100 participants with benign ovarian cysts, between December 2012 and October 2013.
Participant/Materials, Setting, Methods: Participants were randomized to undergo hemostasis by use of either hemostatic sealant (FloSeal™) or bipolar coagulation during laparoendoscopic single-site (LESS) ovarian cystectomy. The primary end-point was the rate of decline of ovarian reserve calculated by measuring serum AMH levels preoperatively and 3 months post-operatively.
Main Results and the Role of Chance Age, parity, socio-demographic variables, preoperative AMH levels, procedures performed and histologic findings were similar between the two groups of patients. There were also no differences in operative outcomes, such as conversion to other surgical approaches, operative time, estimated blood loss, or perioperative complications between the two groups. In both study groups, post-operative AMH levels were lower than preoperative AMH levels (all P < 0.001). The rate of decline of AMH levels was significantly greater in the bipolar coagulation group than the hemostatic sealant group (41.2% [IQR, 17.2–54.5%] and 16.1% [IQR, 8.3–44.7%], respectively, P = 0.004).
Limitations, Reasons for Caution: Some caution is warranted because other ovarian reserve markers such as serum markers (basal FSH and inhibin-B) or sonographic markers were not assessed.
Wider Implications of the Findings: The present study shows that the use of a hemostatic sealant during laparoscopic ovarian cystectomy should be considered, as hemostatic sealant provides the additional benefit of preservation of ovarian reserve.
Study Funding/Completing of Interest(s): This study was supported by the Medical Research Funds from Kangbuk Samsung Hospital. No conflict of interest is declared.
Introduction
Laparoscopy has become the gold standard for surgical treatment of benign ovarian cysts and is usually performed by stripping the ovarian cyst wall, followed by bleeding control of the ovarian wound ground using bipolar coagulation. However, hemostasis achieved with bipolar coagulation could result in damage to the ovarian reserve (Tsolakidis et al., 2010; Coric et al., 2011; Hirokawa et al., 2011; Var et al., 2011; Sonmezer et al., 2013) and decrease the response of the ovaries to hormonal stimulation for assisted reproductive technologies (Esinler et al., 2006; Almog et al., 2010; Benaglia et al., 2010). It is thought that excessive use of bipolar coagulation for hemostasis purposes may result in thermal destruction of normal ovarian follicles. Some cases of premature ovarian failure have also been reported after bilateral ovarian cystectomy (Busacca et al., 2006; Di Prospero and Micucci, 2009; Hwu et al., 2011).
To avoid damage to healthy ovarian tissue, hemostasis using various topical hemostatic agents has been introduced to control post-cystectomy ovarian wound bleeding (Angioli et al., 2009; Ebert et al., 2009). Among these, FloSeal (Baxter Healthcare Corporation, Deerfield, IL, USA) is a hemostatic sealant composed of a gelatin-based matrix and thrombin solution. Upon coming into contact with blood after application at a bleeding site, the gelatin particles swell and tamponade the bleeding. The bulk of the gelatin matrix-thrombin composite has the effect of slowing the blood flow and providing exposure to a high thrombin concentration, thus hastening clot formation. This treatment may be particularly suitable for use in post-cystectomy ovarian wound bleeding, where there is a superficially pervasive focus of bleeding.
Although the use of FloSeal for ovarian hemostasis during laparoscopic ovarian cystectomy may preserve ovarian reserve, no data on its effectiveness were available at the commencement of this study. Therefore, we conducted a multi-center, randomized controlled trial to investigate whether hemostasis by use of FloSeal was superior to that achieved by bipolar coagulation in preserving ovarian reserve. This was assessed by comparing the rate of decline of post-operative serum anti-Müllerian hormone (AMH) levels in patients undergoing laparoscopic ovarian cystectomy for benign ovarian cysts.
