Oxidized cellulose polymer outperforms traditional hemostasis in preserving ovarian reserve during LESS cystectomy: a prospective comparative study

In laparoendoscopic single-site ovarian cystectomy, oxidized cellulose polymer provides hemostatic efficacy comparable to bipolar coagulation and suturing, while offering superior preservation of ovarian reserve. This technique represents a practical fertility-preserving hemostatic option, particularly for women of reproductive age and patients with endometriosis.

This study was conducted with approval from the Institutional Review Board of Chengdu Integrated TCM & Western Medicine Hospital (Chengdu first people's hospital) (IRB ID: 2022.KT.039). This trial was retrospectively registered in the Chinese Clinical Trial Registry (ChiCTR) under the registration number ChiCTR2500102270, with the first registration on 12/05/2025. Written informed consent was obtained from all participants prior to surgical interventions. Trial registration: To study the safety and influence on ovarian function of different hemostasis methods in single-port laparoscopic ovarian cystectomy; ChiCTR2500102270; first registered on 12/05/2025 ( https://www.chictr.org.cn/showproj.html?proj=270949 ). From June 2023 to December 2024, we consecutively enrolled patients with benign ovarian diseases who met the following inclusion criteria: age between 18 and 45 years, regular menstrual cycles without hormonal therapy in the preceding 6 months, unilateral benign ovarian cyst confirmed by transvaginal ultrasound with cyst size less than 8 cm, preoperative serum AMH level ≥ 0.50 ng/mL, scheduled for LESS ovarian cystectomy, ASA physical status class 1–2, provision of written informed consent, and completion of follow-up. Patients were excluded if imaging suggested ovarian malignancy, if they had bilateral ovarian disease, preoperative AMH < 0.50 ng/mL, planned multiport laparoscopic cystectomy, current pregnancy or lactation, concurrent endocrine disorders such as thyroid dysfunction or hyperprolactinemia, or recent hormonal therapy within 6 months. Transvaginal ultrasound was used for initial cyst characterization, with benign features defined as unilocular cysts, solid components smaller than 7 mm, smooth multilocular cysts under 10 cm, and absence of Doppler flow. Malignant features included irregular margins, ascites, more than three papillary structures, and presence of Doppler flow. All patients underwent LESS ovarian cystectomy performed by a single gynecologist (Yuan-hong Li) with 10 years of experience, who performs over 500 single-port laparoscopic procedures annually. Following anesthesia induction, patients were placed in the supine position with Trendelenburg tilt (head down and hips elevated). A Hangt Port (Beijing Hangtian Kadi) was inserted through the umbilicus. For cases where the ovarian cyst was adherent to surrounding tissues, it was first mobilized. The ovarian cortex was then incised longitudinally using monopolar scissors along the antimesenteric border. The cleavage plane between the ovarian cortex and cyst wall was identified, and the cyst wall was carefully dissected away from the ovarian parenchyma for complete cyst excision. After completing cyst enucleation, different hemostatic techniques were applied according to group assignment: Bipolar coagulation group: hemostasis was achieved using bipolar forceps at 30W power, applied minimally to preserve ovarian tissue. If inadequate hemostasis occurred, laparoscopic suturing was performed as rescue therapy. Oxidized cellulose polymer group: a single piece of oxidized regenerated cellulose (2.5 × 5.1 cm, Ethicon) was placed on the bleeding ovarian cortex and compressed for 5–10 min. Suturing was implemented if hemostasis failed within 10 min. Suture group: continuous suturing of residual ovarian tissue was performed using 2–0 V-Loc™ (Covidien™) absorbable barbed suture. Serum anti-Müllerian hormone (AMH) levels were measured during days 3–5 of the menstrual cycle at three time points: preoperatively, and at 1-month and 6-month postoperative follow-ups. The AMH decline rate was calculated using the following formula: [100 × (postoperative AMH level − preoperative AMH level) / preoperative AMH level] (%). Transvaginal color Doppler ultrasound examinations were performed preoperatively and at 6 months postoperatively during day 5 of the menstrual cycle. The following parameters were assessed bilaterally: Antral follicle count (AFC): Defined as the number of follicles measuring < 10 mm in diameter during the early follicular phase. Peak systolic velocity (PSV): Representing the maximum blood flow velocity in ovarian stromal vessels. When suboptimal signal clarity was encountered, the sample volume was repositioned until optimal waveforms were obtained. After five consecutive stable Doppler waveforms were recorded, PSV measurements were performed twice per ovary, with the final value representing the average of two measurements. The secondary endpoints included surgical outcome measures: complete hemostasis time, hemostatic success rate at 10 min, operative time, intraoperative blood loss, transfusion requirements, postoperative hemoglobin decline, length of hospital stay, and complications. Continuous variables across the three groups were compared using Student's t test or Mann–Whitney U test as appropriate, while categorical variables were analyzed with Fisher's exact test or χ 2 test. Repeated-measures analysis of variance (ANOVA), including Pillai's trace and Wilks' lambda, was employed to evaluate outcomes across different time points. All statistical tests were two-tailed, with P values < 0.05 considered statistically significant. All analyses were performed using SPSS version 27.0 (SPSS Inc., Chicago, IL, USA).

Between June 2023 and December 2024, a total of 90 eligible patients were enrolled in this study. Participants were equally divided into three groups ( n  = 30 per group) based on hemostatic methods: the oxidized cellulose polymer group, the bipolar coagulation group, and the suture group. Baseline characteristics, including age (median 32.8 years, IQR 28–37), BMI (mean 21.7 ± 2.4 – 23.2 ± 2.9 kg/m 2 ), cyst diameter (mean 60.0 ± 5.6–62.8 ± 5.2 mm), histology (endometriosis: 51–63% per group), and preoperative AMH levels (mean 3.51 ± 1.34–3.88 ± 1.43 ng/mL), were comparable across groups (all P > 0.05; Table  1 ). Table 1 Patient clinical characteristics Oxidized cellulose polymer group ( n  = 30) Bipolar coagulation group ( n  = 30) Suture group ( n  = 30) P value Baseline characteristic Age, years 32 (28.25–35) 33.5 (30–35) 33.5 (31–37) 0.346 a Body mass index, kg/m 2 22.8 ± 2.3 21.7 ± 2.4 23.2 ± 2.9 0.061 b Location of ovarian cyst 0.954 c Right 18 19 18 Left 12 11 12 Maximum cyst diameter, mm 60.0 ± 5.6 62.8 ± 5.2 61.9 ± 4.9 0.109 b Histology 0.9252 c Endometriosis 19 17 15 Mature cystic teratoma 4 5 6 Serous cystadenoma 2 3 2 Mucinous cystadenoma 3 1 2 Functional cyst 2 2 3 Borderline tumor 0 2 2 Preoperative AMH (ng/ml) 3.76 ± 1.03 3.88 ± 1.43 3.52 ± 1.35 0.54 b Operative outcomes Operation time (min) 31 (25–37.5) 31.5 (22.25–35.5) 39 (33–42) 0.001 a Estimated blood loss (mL) 35 (30–38.75) 34.5 (27.5–41.5) 37.5 (31.25–49.75) 0.176 a Initial hemoglobin (g/L) 124.6 ± 9.9 123.1 ± 9.1 128.2 ± 8.7 0.089 b Post hemoglobin level (g/L) 108 (103–112) 103 (98.5–108) 100.5 (93.5–107.75) 0.004 a Drop of hemoglobin (g/L) 16.5 ± 9.7 20.4 ± 11.1 27.6 ± 11.9 0.001 b Adhesion 0.443 c No adhesion 23 24 25 Posterior fornix, PCDS 3 1 3 Uterus, PCDS 1 4 1 Rectum, uterus, PCDS 3 1 1 Transfusion 0 0 0 1 Postoperative hospital stay (d) 3 (3–4) 4 (3–4) 4 (4–4.75) 0.000 a Complication 0 0 0 Hemostasis Time (min) 7.5 (5.25–10) 8.5 (5.25–11) 9.5 (7.25–12.75) 0.09 a Ten-min success 23 21 17 0.241 c Additional suturing for incomplete hemostasis after 10 min 0 0 0 1 Ovarian reserve Basal AMH level, ng/mL 3.88 ± 1.43 3.76 ± 1.03 3.51 ± 1.34 0.515 b Basal AFC, n 8.13 ± 0.97 8.8 ± 1.03 8.33 ± 1.4 0.076 b Basal PSV, m/s 0.13 ± 0.04 0.14 ± 0.03 0.14 ± 0.04 0.487 b Data are presented as mean ± standard deviation, median (interquartile ranges) or frequencies. Data are presented as medians (interquartile ranges) a: Kruskal–Wallis; b: Analysis of variance; c: Chi-square. AMH anti-Mullerian hormone, PCDS posterior cul de sac, AFC antral follicle Count, PSV peak systolic velocity Patient clinical characteristics Data are presented as mean ± standard deviation, median (interquartile ranges) or frequencies. Data are presented as medians (interquartile ranges) a: Kruskal–Wallis; b: Analysis of variance; c: Chi-square. AMH anti-Mullerian hormone, PCDS posterior cul de sac, AFC antral follicle Count, PSV peak systolic velocity Operative time was significantly longer in the suturing group (median 39 [IQR 33–42] min) versus oxidized cellulose polymer (31 [25–37.5] min) and bipolar coagulation (31.5 [22.25–35.5] min; P  = 0.001). Although hemostasis time did not differ statistically ( P  = 0.09), suturing showed a trend toward prolonged duration (median 9.5 [7.25–12.75] min). The suturing group exhibited the greatest hemoglobin drop (mean 27.6 ± 11.9 g/L), exceeding both bipolar coagulation (20.4 ± 11.1 g/L; P  = 0.001) and oxidized cellulose polymer (16.5 ± 9.7 g/L; P  = 0.001). Oxidized cellulose polymer was associated with the shortest hospital stay (median 3 [IQR 3–4] days; P  < 0.001). Assessment of ovarian reserve dynamics revealed divergent patterns. At 1 month postoperatively, the oxidized cellulose polymer group showed smaller changes in anti-Müllerian hormone (AMH) levels (mean change Δ–0.58 ng/mL, 95% CI –0.72 to –0.44; 15.4% decrease) compared to both the bipolar electrocoagulation group (Δ–1.64 ng/mL [− 42.3%]) and the suture group (Δ–0.87 ng/mL [− 29.8%]). All groups demonstrated statistically significant changes from baseline ( P  < 0.001 for each comparison). (Tables 2 , 3 , Fig.  1 ). By 6 months, oxidized cellulose polymer demonstrated superior preservation: AMH decline was 5.9% (Δ–0.22 ng/mL; P  = 0.005 vs. baseline) with a 15.4% advantage over bipolar coagulation (mean difference Δ–0.80 ng/mL; P  < 0.001). Although there was no statistically significant difference in the decline of AMH levels between the oxidized cellulose polymer group and the suture group ( P  = 0.749), the suture group still exhibited a greater reduction compared to the oxidized cellulose polymer group (Δ–0.27 ng/mL). However, in the endometriosis subgroup, the suture group demonstrated a significantly greater decline in AMH levels compared to the oxidized cellulose polymer group ( P  = 0.006). Table 2 Ovarian reserve by assessment of AMH levels preoperatively and postoperatively Group Subgroup n Basal AMH level, ng/mL 1 M-POST AMH level, ng/mL 6 M-POST AMH level, ng/mL Oxidized cellulose polymer group All 30 3.76 ± 1.03 3.18 ± 0.88 3.54 ± 0.97 Oxidized cellulose polymer group Endometriosis 19 3.71 ± 1.23 3.09 ± 1.04 3.43 ± 1.14 Oxidized cellulose polymer group Non-endometriosis 11 3.83 ± 0.59 3.33 ± 0.51 3.71 ± 0.56 Bipolar coagulation group All 30 3.88 ± 1.43 2.24 ± 0.82 3.08 ± 1.06 Bipolar coagulation group Endometriosis 17 3.49 ± 1.1 1.96 ± 0.57 2.72 ± 0.75 Bipolar coagulation group Non-endometriosis 13 4.39 ± 1.68 2.6 ± 0.97 3.55 ± 1.24 Suture group All 30 3.51 ± 1.34 2.63 ± 1.1 3.24 ± 1.22 Suture group Endometriosis 15 3.35 ± 1.49 2.27 ± 1.04 2.95 ± 1.28 Suture group Non-endometriosis 15 3.67 ± 1.21 3 ± 1.05 3.53 ± 1.12 Data are presented as mean ± standard deviation, median (interquartile ranges) or frequencies. Data are presented as medians (interquartile ranges) Table 3 Temporal dynamics of serum AMH levels Group Time comparison Mean difference 95% CI Adjusted p value a Significance All Oxidized cellulose polymer group PRE-POST1M 0.580333333 (0.44, 0.72)  < 0.001 *** Oxidized cellulose polymer group PRE-POST6M 0.221 (0.08, 0.36) 0.005 ** Oxidized cellulose polymer group POST1M-POST6M − 0.359333333 (− 0.50, − 0.22)  < 0.001 *** Bipolar coagulation group PRE-POST1M 1.643667 (1.51, 1.78)  < 0.001 *** Bipolar coagulation group PRE-POST6M 0.804333 (0.67, 0.94)  < 0.001 *** Bipolar coagulation group POST1M-POST6M − 0.83933 (− 0.98, − 0.70)  < 0.001 *** Suture group PRE-POST1M 0.873333 (0.74, 1.01)  < 0.001 *** Suture group PRE-POST6M 0.271 (0.13, 0.41)  < 0.001 *** Suture group POST1M-POST6M − 0.60233 (− 0.74, − 0.47)  < 0.001 *** Endometriosis Oxidized cellulose polymer group PRE-POST1M 0.626316 (0.47, 0.78)  < 0.001 *** Oxidized cellulose polymer group PRE-POST6M 0.278421 (0.13, 0.43) 0.002 ** Oxidized cellulose polymer group POST1M-POST6M − 0.34789 (− 0.50, − 0.19)  < 0.001 *** Bipolar coagulation group PRE-POST1M 1.531765 (1.37, 1.69)  < 0.001 *** Bipolar coagulation group PRE-POST6M 0.773529 (0.61, 0.94)  < 0.001 *** Bipolar coagulation group POST1M-POST6M − 0.75824 (− 0.92, − 0.60)  < 0.001 *** Suture group PRE-POST1M 1.081333 (0.91, 1.25)  < 0.001 *** Suture group PRE-POST6M 0.401333 (0.23, 0.57)  < 0.001 ** Suture group POST1M-POST6M − 0.68 (− 0.85, − 0.51)  < 0.001 *** Non-endometriosis Oxidized cellulose polymer group PRE-POST1M 0.500909 (0.26, 0.74)  < 0.001 *** Oxidized cellulose polymer group PRE-POST6M 0.121818 (− 0.12, 0.36) 0.976 ns Oxidized cellulose polymer group POST1M-POST6M − 0.37909 (− 0.62, − 0.14) 0.009 *** Bipolar coagulation group PRE-POST1M 1.79 (1.57, 2.01)  < 0.001 *** Bipolar coagulation group PRE—POST6M 0.844615 (0.62, 1.07)  < 0.001 *** Bipolar coagulation group POST1M-POST6M − 0.94538 (− 1.17, − 0.72)  < 0.001 *** Suture group PRE-POST1M 0.665333 (0.46, 0.87)  < 0.001 *** Suture group PRE-POST6M 0.140667 (− 0.07, 0.35) 0.558 ns Suture group POST1M-POST6M − 0.52467 (− 0.73, − 0.32)  < 0.001 *** Data are presented as mean differences with 95% confidence intervals and adjusted p values. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, ns no significant) a: Linear mixed-effect model; post hoc tests with Tukey and Bonferroni adjustments. PRE preoperatively, POST1M postoperative 1 months, POST6M postoperative 6 months Fig. 1 Temporal dynamics of serum AMH levels in the three groups. Detailed adjusted P values for pairwise group comparisons are provided within each panel. The AMH decline rates for each subgroup at 1 month ( A , B , C ) and 6 months ( D , E , F ) postoperatively. Statistical analysis: Kruskal–Wallis test followed by post hoc Dunn's test with Bonferroni correction for multiple comparisons. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, * < 0.05, ns no significant). OCG Oxidized cellulose polymer group, BCG Bipolar coagulation group, STG Suture group Ovarian reserve by assessment of AMH levels preoperatively and postoperatively Data are presented as mean ± standard deviation, median (interquartile ranges) or frequencies. Data are presented as medians (interquartile ranges) Temporal dynamics of serum AMH levels Data are presented as mean differences with 95% confidence intervals and adjusted p values. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, ns no significant) a: Linear mixed-effect model; post hoc tests with Tukey and Bonferroni adjustments. PRE preoperatively, POST1M postoperative 1 months, POST6M postoperative 6 months Temporal dynamics of serum AMH levels in the three groups. Detailed adjusted P values for pairwise group comparisons are provided within each panel. The AMH decline rates for each subgroup at 1 month ( A , B , C ) and 6 months ( D , E , F ) postoperatively. Statistical analysis: Kruskal–Wallis test followed by post hoc Dunn's test with Bonferroni correction for multiple comparisons. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, * < 0.05, ns no significant). OCG Oxidized cellulose polymer group, BCG Bipolar coagulation group, STG Suture group The oxidized cellulose polymer group exhibited the smallest decline in AFC at 6 months (mean decline ratio 0.11, 95% CI 0.10–0.14). This reduction was significantly smaller than that in bipolar coagulation group (0.29, 95% CI 0.23–0.42; P  < 0.001) and showed a favorable trend compared to the suture group (0.20, 95% CI 0.11–0.25; P  = 0.166; Table  4 , Fig.  2 ). Ovarian blood flow (PSV) reduction was also smallest with oxidized cellulose polymer (mean decline ratio 0.051, 95% CI 0.043–0.062) versus bipolar coagulation (0.21, 95% CI 0.043–0.062; P  < 0.001) and suturing (0.076, 95% CI 0.055–0.083; P  = 0.034; Table  5 , Fig.  3 ). Table 4 Ovarian reserve by assessment of AFC preoperatively and postoperative 6 months Group Basal AFC level 6 M-POST AFC level Decline ratio n All Oxidized cellulose polymer group 8.8 ± 1.03 7.67 ± 1.03 0.11 (0.1–0.14) 30 Bipolar coagulation group 8.13 ± 0.97 5.53 ± 1.07 0.29 (0.23–0.42) 30 Suture group 8.33 ± 1.4 6.87 ± 1.46 0.2 (0.11–0.25) 30 Endometriosis Oxidized cellulose polymer group 8.53 ± 0.9 7.16 ± 0.76 0.12 (0.11–0.21) 19 Bipolar coagulation group 8.12 ± 0.78 4.94 ± 0.66 0.38 (0.33–0.44) 17 Suture group 8.2 ± 0.86 6 ± 0.85 0.25 (0.22–0.29) 15 Non-endometriosis Oxidized cellulose polymer group 9.27 ± 1.1 8.55 ± 0.82 0.1 (0–0.11) 11 Bipolar coagulation group 8.15 ± 1.21 6.31 ± 1.03 0.22 (0.2–0.25) 13 Suture group 8.47 ± 1.81 7.73 ± 1.44 0.11 (0.04–0.12) 15 Data are presented as mean ± standard deviation, median (interquartile ranges) or frequencies. Data are presented as medians (interquartile ranges) Fig. 2 Temporal dynamics of AFC in the three groups: Detailed adjusted P values for pairwise group comparisons are provided within each panel. The AFC decline rates for each subgroup at 6 months ( A , B , C ) postoperatively. Statistical analysis: Kruskal–Wallis test followed by post hoc Dunn's test with Bonferroni correction for multiple comparisons. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, * < 0.05, ns no significant). OCG Oxidized cellulose polymer group, BCG Bipolar coagulation group, STG Suture group Table 5 Ovarian reserve by assessment of PSV preoperatively and postoperative 6 months Group Basal PSV m/s 6 M-POST PSV m/s Decline ratio n All Oxidized cellulose polymer group 0.144 ± 0.028 0.137 ± 0.027 0.051 (0.043–0.062) 30 Bipolar coagulation group 0.135 ± 0.035 0.107 ± 0.028 0.21 (0.179–0.229) 30 Suture group 0.144 ± 0.041 0.134 ± 0.039 0.076 (0.055–0.083) 30 Endometriosis Oxidized cellulose polymer group 0.136 ± 0.024 0.129 ± 0.023 0.055 (0.042–0.062) 19 Bipolar coagulation group 0.125 ± 0.03 0.098 ± 0.023 0.211 (0.186–0.229) 17 Suture group 0.129 ± 0.036 0.119 ± 0.035 0.083 (0.074–0.086) 15 Non-endometriosis Oxidized cellulose polymer group 0.158 ± 0.03 0.15 ± 0.029 0.051 (0.048–0.06) 11 Bipolar coagulation group 0.148 ± 0.038 0.118 ± 0.032 0.197 (0.179–0.222) 13 Suture group 0.159 ± 0.041 0.149 ± 0.039 0.057 (0.051–0.076) 15 Data are presented as mean ± standard deviation, median (interquartile ranges), or frequencies. Data are presented as medians (interquartile ranges) Fig. 3 Temporal dynamics of PSV in the three groups: Detailed adjusted P values for pairwise group comparisons are provided within each panel. The PSV decline rates for each subgroup at 6 months ( A , B , C ) postoperatively. Statistical analysis: Kruskal–Wallis test followed by post hoc Dunn's test with Bonferroni correction for multiple comparisons. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, * < 0.05, ns no significant). OCG Oxidized cellulose polymer group, BCG Bipolar coagulation group, STG Suture group Ovarian reserve by assessment of AFC preoperatively and postoperative 6 months Data are presented as mean ± standard deviation, median (interquartile ranges) or frequencies. Data are presented as medians (interquartile ranges) Temporal dynamics of AFC in the three groups: Detailed adjusted P values for pairwise group comparisons are provided within each panel. The AFC decline rates for each subgroup at 6 months ( A , B , C ) postoperatively. Statistical analysis: Kruskal–Wallis test followed by post hoc Dunn's test with Bonferroni correction for multiple comparisons. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, * < 0.05, ns no significant). OCG Oxidized cellulose polymer group, BCG Bipolar coagulation group, STG Suture group Ovarian reserve by assessment of PSV preoperatively and postoperative 6 months Data are presented as mean ± standard deviation, median (interquartile ranges), or frequencies. Data are presented as medians (interquartile ranges) Temporal dynamics of PSV in the three groups: Detailed adjusted P values for pairwise group comparisons are provided within each panel. The PSV decline rates for each subgroup at 6 months ( A , B , C ) postoperatively. Statistical analysis: Kruskal–Wallis test followed by post hoc Dunn's test with Bonferroni correction for multiple comparisons. Significant results are marked with asterisks (*** p  < 0.001, ** p  < 0.01, * < 0.05, ns no significant). OCG Oxidized cellulose polymer group, BCG Bipolar coagulation group, STG Suture group No transfusions or major complications occurred. Adhesion rates did not differ significantly between groups ( P  = 0.443).

The ovary is a vital endocrine organ in females, with diminished ovarian reserve resulting from follicular depletion and declining oocyte quality [1 , 15] . Presently, no single diagnostic method accurately predicts ovarian reserve function, rendering a multimodal assessment approach integrating several indicators more reliable for evaluation [14 , 16 , 17] . Key parameters for ovarian reserve assessment encompass serum anti-Müllerian hormone (AMH) levels and transvaginal ultrasound measurements, including antral follicle count (AFC) and peak systolic velocity (PSV) of ovarian stromal blood flow [3 , 13 , 18 , 19] . Benign ovarian lesions are common gynecological conditions frequently associated with ovarian dysfunction, endocrine disturbances, and female infertility; therefore, ovarian reserve preservation during therapeutic interventions is critical for women of reproductive age. Laparoscopic surgery represents the preferred approach for benign ovarian tumors, with single-port laparoscopic ovarian cystectomy offering considerable advantages: minimal invasiveness, rapid recovery, low recurrence rates, reduced postoperative adhesions, and shorter hospitalization. Nevertheless, even this advanced technique may still induce ovarian tissue damage and impair postoperative ovarian function [4 , 7 , 8 , 20 , 21] . Consequently, surgical management necessitates not only maximal preservation of normal ovarian tissue but also meticulous attention to minimize injury during hemostasis procedures. The choice of hemostatic method represents a key determinant in maximizing ovarian reserve preservation [22] , as both bipolar coagulation and suturing techniques can potentially inflict additional damage to ovarian reserve [7 , 23 , 24] , and intracorporeal suturing in LESS necessitates a prolonged learning curve [25] , the application of diverse hemostatic agents during surgery has been increasingly reported in the recent literature. Prior studies predominantly compared hemostatic agents with bipolar coagulation [26] , three relevant randomized-controlled trials (RCTs) highlighted the beneficial effects of gelatin matrix combined with human thrombin (Floseal®; Baxter Healthcare Corporation, Fremont, CA, USA) on residual ovarian reserve following laparoscopic ovarian cystectomy [27 – 29] . In these studies, ovarian reserve was assessed by measuring the decline rate of serum AMH levels at 3 months postoperatively, ranging from 41.2 to 41.9% in patients treated with bipolar coagulation compared with only 15.4–16.1% in those receiving hemostatic agents. However, limited data exist regarding whether oxidized cellulose polymer demonstrates comparable hemostatic effectiveness relative to both bipolar coagulation and suturing techniques. Our study specifically assessed the effects of oxidized cellulose polymer as a hemostatic agent on ovarian reserve and hemostasis in patients undergoing LESS ovarian cystectomy. Our study demonstrates that oxidized cellulose polymer achieves hemostatic efficacy and safety comparable to both bipolar coagulation and suturing in LESS ovarian cystectomy, with no significant differences observed in time to hemostasis, intraoperative blood loss, or postoperative complication rates. The variations in hemoglobin decline among groups might be attributable to confounding factors, including preoperative intraperitoneal hemorrhage volume, intraoperative fluid administration, and individual differences in postoperative blood sampling timing. Crucially, oxidized cellulose polymer not only provides safe and effective hemostasis but also offers superior cost-effectiveness compared with more expensive alternatives, such as gelatin–thrombin combinations (e.g., Floseal®). These findings position oxidized cellulose polymer as both a clinically reliable and economically viable hemostatic option for LESS procedures, particularly valuable in resource-conscious healthcare settings. In terms of ovarian function preservation, our study revealed that oxidized cellulose polymer demonstrated significantly superior ovarian reserve protection compared to bipolar coagulation techniques, also showing advantages over suturing methods. Bipolar coagulation is frequently favored in LESS owing to its technical simplicity, it risks thermal injury potentially compromising vascular integrity in residual ovarian tissue, ultimately impairing ovarian reserve [26] . Suturing, while avoiding thermal damage, presents several limitations—over-tight ligation may compromise ovarian blood supply, the suturing process risks puncturing multiple follicles, and the suture material itself can trigger inflammatory reactions and tissue edema, thereby further impairing ovarian reserve function [30] . In contrast, oxidized cellulose polymer applied with compression hemostasis provides effective bleeding control without inflicting secondary trauma upon residual ovarian tissue, thereby optimally preserving ovarian reserve function. In our study at 6 months, oxidized cellulose polymer demonstrated superior preservation, AMH decline was smallest in three groups, although there was no statistically significant difference in the decline of AMH levels between the oxidized cellulose polymer group and the suture group ( P  = 0.749), the suture group still exhibited a greater reduction compared to the oxidized cellulose polymer group. (Δ–0.27 ng/mL vs. Δ–0.22 ng/mL). Our findings further demonstrate that ovarian pathology type, in addition to hemostatic method choice, significantly influences postoperative ovarian reserve outcomes. In patients with endometriosis, bipolar coagulation appears to exert prolonged detrimental effects on ovarian reserve, likely through direct thermal damage to primordial follicles [1 , 9] . Our data revealed that endometriosis patients undergoing coagulation maintained significantly lower AMH levels, AFC, and PSV compared with preoperative values throughout the 6-month follow-up period, without returning to baseline levels. Crucially, the oxidized cellulose polymer group consistently demonstrated superior ovarian reserve preservation compared with both coagulation and suturing in this population, confirming its clinical benefit for endometriosis cases. Endometriosis is a well-established risk factor for infertility, with its association with diminished ovarian reserve attributed to surgical interventions and the disease process itself [31 , 32] . This correlation stems partly from the unique pathology of endometriomas, where the ovarian cortex becomes invaginated to form the cyst wall. Notably, histological studies demonstrate aberrant follicular patterns in ovarian tissue adjacent to endometrioma walls, whereas the ovarian cortex surrounding other benign cysts typically retains normal follicular architecture [1] . The disease process itself may additionally impair ovarian function and vascular integrity, potentially amplifying the ovarian response to surgical trauma. These pathological distinctions explain our findings: endometriosis patients in the bipolar coagulation group exhibited more pronounced AMH decline, likely reflecting thermal damage to an already compromised ovarian reserve, while the suture group showed greater AMH reduction than the oxidized cellulose polymer group, possibly due to mechanical follicular injury during suturing. In contrast to the marked differences observed in endometriosis patients, those with benign ovarian cysts demonstrated that the oxidized cellulose polymer group maintained superior ovarian function preservation (as evidenced by AMH levels, AFC, and PSV) compared to the bipolar coagulation group, though the advantage over suturing did not reach statistical significance ( P  > 0.05). This attenuated effect may be attributed to the enrolled patients' younger age (mean 32.8 ± 5.6 years), robust baseline ovarian reserve (mean AMH 3.71 ± 1.27 ng/mL), and relatively short follow-up duration. Nevertheless, even within the 6-month observation period, all ovarian reserve parameters consistently favored oxidized cellulose polymer over suturing, with this difference becoming statistically significant in the endometriosis subgroup with diminished ovarian reserve ( P  = 0.006 for AMH, P  = 0.035 for AFC). These findings suggest that the non-traumatic nature of oxidized cellulose polymer may confer lasting protective benefits for ovarian function in benign cyst cases, particularly when considering the cumulative effect of repeated surgical interventions over a patient's reproductive lifespan. While our study confirmed the pronounced advantages of oxidized cellulose polymer in endometriosis patients, current clinical practice increasingly favors pharmacological management for smaller endometriotic cysts ( 8 cm)—which were intentionally excluded from our study protocol—warrants further investigation through multicenter trials with extended follow-up. Based on the current evidence, we propose that oxidized cellulose polymer may be particularly suitable for: (1) fertility-preserving surgery in young women with benign ovarian conditions (e.g., hemorrhagic corpus luteum cysts), where rapid hemostasis and minimal ovarian trauma are paramount; (2) cases requiring maximal ovarian tissue conservation, such as recurrent cystectomies or borderline tumor excisions. Several limitations warrant acknowledgement in this study. First, while incorporating AFC and PSV measurements, the absence of concurrent baseline follicle-stimulating hormone (FSH) level assessments may have hindered a fully comprehensive evaluation of ovarian reserve function. Second, our analysis was confined to short-term ovarian reserve outcomes; the long-term effects of oxidized cellulose polymer on ovarian preservation, particularly concerning potential subgroups that might derive greater benefit from specific hemostatic techniques, merit further investigation. Finally, postoperative pregnancy outcomes were not tracked in our cohort—a critical parameter for subsequent research to address, validating the clinical implications of our findings.

Compared with bipolar coagulation and suturing techniques, oxidized cellulose polymer demonstrates comparable hemostatic efficacy and safety while conferring superior ovarian reserve preservation in single-port laparoscopic ovarian cystectomy. Oxidized cellulose polymer effectively meets this clinical need, offering a valuable surgical option for young women prioritizing fertility preservation.

Benign ovarian lesions are common gynecological conditions, associated with ovarian pain, ovulatory dysfunction, endocrine abnormalities, and female infertility, largely attributable to their impact on ovarian structure and function [1 , 2] . Consequently, preserving ovarian reserve during the diagnosis and treatment of ovarian cysts is paramount for women of reproductive age [3] . Currently, laparoscopic cystectomy constitutes the standard surgical approach for these lesions [4] . Following cyst excision, bipolar coagulation or suturing is commonly employed to achieve hemostasis at the ovarian wound site. Single-port laparoscopic surgery (LESS) has gained increasing prominence in managing benign gynecological diseases. While bipolar coagulation is frequently utilized owing to its technical simplicity, the thermal injury it induces (reaching temperatures of 200–400 °C) can damage the follicular vascular network [5 – 9] . Similarly, suturing may provoke ischemic changes and inflammatory cascades as a result of mechanical compression [7] . Previous studies have explored the application of various hemostatic agents onto ovarian wounds, suggesting that these agents may offer superior preservation of ovarian reserve compared to bipolar coagulation [10 , 11] . However, these investigations relied primarily on anti-Müllerian hormone (AMH) as a marker for ovarian reserve assessment. This approach has limitations, as AMH levels may not accurately reflect localized ovarian damage due to potential compensatory effects from the unaffected contralateral ovary [1 , 12 – 14] . In this study, we evaluate oxidized cellulose polymer as a hemostatic agent and compare its efficacy and impact on ovarian reserve against bipolar coagulation and suturing. In addition to AMH, we also assessed antral follicle count (AFC) and peak systolic velocity (PSV) of ovarian stromal blood flow as complementary markers, thereby providing a more comprehensive evaluation of ovarian reserve function.