Minimally Invasive Myomectomy with Temporary Bilateral Uterine Artery Blockage at Anterior Cul-de-Sac.

Background and Objectives: Minimizing intraoperative bleeding is pivotal in myomectomy, and blockage of uterine arteries has been reported as an effective approach. We developed a novel technique to temporary occlude bilateral uterine arteries at the anterior cul-de-sac in minimally invasive myomectomy (MIS), including minilaparotomy, laparoscopic-assisted myomectomy, and laparoscopic myomectomy. This study aims to evaluate the intraoperative and postoperative outcomes of this technique in complicated myomectomy cases.

Twenty-seven patients underwent minimally invasive myomectomy by single minimally invasive surgeon using bilateral uterine arteries blockage. To match the complexity of myomectomy, 66 open cases performed by generalists were used for control.

There were no significant differences in fibroid size, number, or weight between MIS and open myomectomy groups. For intraoperative outcomes, the MIS group showed longer operative time (271.3 ± 72.9 vs 179.9 ± 78.8 minutes, P < .05), but fewer cases of intraoperative blood transfusion (3% vs 17%, P < .05) and fewer intraoperative complications (0% vs 3%, P < .005). For postoperative outcomes, the MIS group demonstrated shorter hospital stay (70% vs 29% for 0–1 day; 11% vs 42% for 2 days; 19% vs 29% for 3 or more days, P < .05) and fewer postoperative complications (3% vs 9%, P < .05).

Temporary blockage bilateral uterine arteries enable the safe performance of complicated myomectomy via minimally invasive surgery.

Bulldog, Minimally invasive surgery, Myomectomy, Uterine artery

Uterine leiomyoma, or fibroid, is the most common benign tumor in women. The estimated cumulative incidence reported is up to 70% in white women and approaches 80% in black women during the premenopausal years.1 About 15–30% of patients with uterine fibroids can develop severe symptoms such as heavy menstrual bleeding, bulk symptoms, pelvic pain, infertility, or adverse pregnancy outcomes.2 Symptomatic women do require management and the cost burden of this in the United States is reported to exceed $34 billion every year.3 Symptomatic fibroid is the primary indication for hysterectomy in the United States and accounts for more than 400,000 cases of this surgery annually.4 Alternative modalities frequently used for management include medication, radiofrequency ablation, uterine artery embolization, hysterectomy and myomectomy.5 For the purposes of preserving childbearing potential, myomectomy is a surgical option for management which has been adopted since 1931. The first experience of laparoscopic myomectomy was reported in 1979.6 However, laparoscopic myomectomy remains a complex procedure. In a recent cross-sectional study of 114,850 myomectomy cases, 330 (7%) were reported to be minimally invasive, whereas 106,520 (93%) were open. In addition, the study found African American, Hispanic, and women of other races were less likely to undergo minimally invasive myomectomy compared to Caucasian women.7 A different study from Canada reported that approximately 20% of myomectomies were performed laparoscopically at 2 of the 5 metropolitan area hospitals, suggesting a clustering of surgical skill at a few select institutes.8 The critical limiting factor to widespread utilization of minimally invasive myomectomy, especially via laparoscopy, undoubtably appears to be individualized surgeon skill. Even for a surgeon with advanced laparoscopic skills, the laparoscopic myomectomy is not possible or beneficial for all cases, especially if the patient presents with extremities on numbers, sizes, or locations. Considering the potential of excessive bleeding, prolonged surgical time, intraoperative complications and postoperative recovery from those extreme cases, the advantages of open surgery, such as palpation of fibroids with a surgeon’s hands, entire enucleation of fibroid and most importantly, the fast suturing should not be neglected. Laparoscopic-assisted myomectomy (LAM) was first introduced in 1994.9 Multiple groups reported successful adoption of this technique for challenging myomectomy.10–12 Another modality is the myomectomy through minilaparotomy (Mini-Lap).13,14 The intentional idea of Mini-Lap and LAM is to combine the advantages of open surgery with minimally invasive myomectomy (MIS). However, this outcome usually is not achievable unless the notorious potential of bleeding from myomectomy can be secured. Regardless of various approaches, minimizing the bleeding is paramount in performing myomectomy and assurance of uneventful recovery of the patients. There are mainly 2 strategies to control bleeding in myomectomy: medication versus mechanical. The medications commonly used in myomectomy are: vasopressin, GnRH agonist, GnRH antagonist, tranexamic acid (TAX), Prostaglandin and other medications, such as oxytocin, epinephrine, bupivacaine with epinephrine, vasopressin with misoprostol, ornipressin, and ascorbic acid.15 For mechanical techniques, the first one is the pericervical tourniquet. Multiple studies have demonstrated its efficacy in reducing blood loss and the rate of blood transfusion.15–17 The second approach is to block bilateral uterine arteries at their origin. The dissection and occlusion of the uterine arteries at different locations is well reported in both laparoscopic and robotic myomectomy.18–22 A recent systemic review and meta-analysis of 25 studies (5 randomized control trials and 20 observational studies) including 2,871 women undergoing surgical uterine artery blockade at the time of myomectomy found a statistically significant reduction in estimated blood loss, risk of blood transfusion, and decrease in postoperative hemoglobin compared to controls.21 These findings held for both laparoscopic and open approaches and the results remained consistent when randomized control trials and higher quality observational trials were analyzed separately.21 The 3 main routes to access the uterine artery at its origin are anterior, posterior, and medial approaches.18 Although the posterior approach is commonly cited in the literature, there is a paucity of studies reporting its success rate, especially for cases of large uterus no longer confined within the pelvis. Surgeons should be familiar with all 3 approaches, given the potential variation and distortion in anatomy secondary to location or size of fibroids. In this study, we report our experience of temporary blockage of bilateral uterine arteries at the anterior cul-de-sac (anterior approach). With this technique, we were able to perform complex cases with MIS approach, minimizing the intraoperative and postoperative complications.

Patient Populations Institutional Review Board approval was obtained and a retrospective chart review of MIS and open myomectomy was conducted. Totally 54 cases of MIS were performed from September 2022 to July 2024. If the uterine fibroid size is less than 5–6 cm, the number is less 3 and the type is more than type 3, only vasopressin was used for laparoscopy myomectomy. Otherwise, the bilateral uterine arteries blockage was attempted, either laparoscopic myomectomy or LAM or Mini-Lap was performed based on fibroid size, number, location, and indications. Overall, 17/54 cases were performed with vasopressin only and 37/54 cases were attempted with bilateral uterine artery blockage. Among those 37 cases, 27/37 cases were successful with bilateral uterine arteries blockage, 6/37 cases with unilateral artery blockage and 4/37 with no artery blockage. For the cases with 1 or no uterine artery blockage, LAM or Mini-Lap were performed in order to minimize intraoperative bleeding, even though the original plan might have been laparoscopic myomectomy. The study was focused on the outcomes of cases with 2 uterine arteries blockage. For the comparable complexity, 66 cases of open myomectomy performed by other generalists were used as the control. Uterine Artery Blockage at Anterior Cul-de-Sac (Anterior Approach) Patient position and trocar placement: Patients were placed in supine lithotomy position. An appropriately sized uterine manipulator, such as V-Care (ConMed, Largo, FL, USA), was placed. For laparoscopic myomectomy and LAM procedure, the first trocar was usually placed at Palmer’s point or umbilical site based on the size of the uterus, followed by other 5-mm trocars for laparoscopic myomectomy or LAM procedure. Another 12-mm trocar was placed 2 cm above the suprapubic bone (Figure 1). 20–30 degrees Trendelenburg position was then adopted. Laparoscopic uterine artery dissection at anterior cul-de-sac: Identification of landmarks: utero-vesical fold, lower uterine segment, round ligament, and umbilical artery. Delineation of utero-vesical fold and lower uterine segment with the guidance of V-Care. The peritoneal membrane between the utero-vesical fold and ipsilateral round ligament was dissected and opened. Further dissection was conducted layer by layer and millimeter by millimeter. If standing at the patient’s left side, the surgeon would use the left 5-mm trocar and the 12-mm suprapubic trocar to carry out the dissection. The first location to identify the uterine artery was lateral to the lower uterine segment and above the utero-vesical fold. Normally, the uterine artery will curve and ascend to uterine body at this spot. If the artery pulsation was revealed, careful dissection was continued. Once the artery was adequately exposed, a laparoscopic bulldog was inserted through the 12 mm trocar and applied to the artery (Figure 2). Because the uterine artery is commonly adjacent to multiple uterine veins at this location, it is very difficult to dissect the uterine artery circumferentially for ligation with suture or vessel clips like Hem-O-Loc clip (Teleflex, Morrisville, NC, US).18 Titanium clip (Peters Surgical, Plymouth, MS, US) can be used for temporary or permanent uterine clamp, but the tip of Titanium clip will occasionally perforate the surrounding vein and then cause significant bleeding. Bulldog vascular clamps are well used in vascular and transplant surgeries. The application and removal of bulldog clamps are easy and safe to handle, and less likely to cause trauma to vessels.19,20 If the uterine artery could not be found at lower uterine segment, further dissection towards pelvic side wall was warranted to identify the uterine artery at its origin. At this point, the umbilical artery was used for another landmark. Following the umbilical artery, superior vesical artery and uterine artery would be dissected. Attention should be paid not to confuse the superior vesical artery and uterine artery (Figure 2). The identification and blockage of uterine artery from the other side would be performed similarly. Open uterine artery dissection at anterior cul-de-sac: If the blockage of uterine artery via laparoscopy was not feasible, open uterine artery dissection at anterior cul-de-sac could be performed as well, following the same principle. A 4- to 5-cm Pfannenstiel incision was made and an auto-retractor, such as Alexis (Applied Medical, Rancho Santa Margarita, CA, US), was used for exposure. The incision could be extended if more exposure was needed. Myomectomy For laparoscopic myomectomy, vasopressin (20 U in 200 ml normal saline) was injected under the pseudocapsule and then adequate incision was made. The procedure of myomectomy was well described in other literatures.12 Finally, all specimens were placed into an Endobag (Ethicon, USA). The suprapubic 12-mm incision was extended to about 2 cm. The Endobag was pulled towards the incision and the contained morcellation was carried out. For LAM procedure, the suprapubic 12-mm incision was extended to about 3 cm after blockage the bilateral uterine arteries laparoscopically. An Alexis retractor was placed and this retraction increased the incision to about 4 cm. Vasopressin (20 U in 200 ml normal saline) was injected under the pseudocapsule. The closest fibroid was grasped and pulled towards the incision and the removal of each fibroid was performed as previously described.9 The myomectomy part of Mini-Lap is very similar to the LAM procedure, except the incision of mini-Lap is relatively larger. Statistical Analysis The Student’s t test was used for the analysis of continuous variables. For analyzing discrete variables, χ2 test or Fisher’s exact test was used. A P value < .05 was considered to be statistically significant. All analyses were performed by using the statistical software SPSS v15.0 for Windows (SPSS Inc., Chicago, IL).

Patient Population and Characteristics All patients were African American or Hispanic. There was no difference between 2 groups regarding the ethnic distribution (African American 53% vs 70%, Hispanic 47% vs 30%, P = .12). There was no difference of average age in 2 groups (37.2 ± 5.4 vs 39.5 ± 6.9, P = .09). Patients in both groups are obese but there is no significant difference (body mass index [BMI]: 31.3 ± 5.6 vs 30.6 ± 5.5, P = .54). The indication of surgery, however was more heterogenous in open myomectomy group rather than MIS group, including abnormal uterine bleeding (AUB) (78%), bulk symptoms (21%), infertility (15%), pain (18%). The indication of MIS group is mainly AUB (100%), bulk symptoms (3%) and pain (18%). For fibroid characteristics, there was no significant difference between the 2 groups in term of size, numbers, and weight. The average largest fibroid size was 9.0 ± 3.2 and 9.9 ± 6.0 cm for open myomectomy group and MIS group, respectively. In open myomectomy group, the fibroid numbers are: 17 cases (25%) with 1–3 fibroids, 8 cases (12%) with 3–5 fibroids, and 41 cases (63%) with more than 5 fibroids. In MIS group, the fibroid numbers are: 8 cases (30%) with 1–3 fibroids, 3 cases with 3–5 fibroids (11%), and 16 cases (59%) with more than 5 fibroids. The specimen weight in 2 groups is 520.1 ± 454.0 versus 806.5 ± 1,202.2 g for open myomectomy group and MIS group, respectively. The pathology in 2 groups are fibroids 66/66 and 27/27 case (100%) with co-occurence of adenomyosis and endometriosis 2/66 (3%) and 3/27 (11%), respectively (Table 1). Table 1. | Open Myomectomy (66) | MIS (27) | P Value | | |---|---|---|---| | Age | 37.2 ± 5.4 | 39.5 ± 6.9 | .09 | | Ethic race | .12 | || | African American | 35 (53%) | 19 (70%) | | | Hispanic | 31 (47%) | 8 (30%) | | | BMI | 31.3 ± 5.6 | 30.6 ± 5.5 | .54 | | Indications | ||| | AUB | 52 (78%) | 27 (100%) | <.05 | | Bulk symptoms | 14 (21%) | 1 (3%) | <.05 | | Infertility | 10 (15%) | - | <.05 | | Pain | 12 (18%) | 5 (18%) | .13 | | Fibroid numbers | ||| | 1–3 | 17 (25%) | 8 (30%) | .24 | | 3–5 | 8 (12%) | 3 (11%) | .48 | | ≥5 | 41 (63%) | 16 (59%) | .14 | | Fibroid size (cm) | 9.0 ± 3.2 | 9.9 ± 6.0 | .40 | | Specimen weight (g) | 520.1 ± 454.0 | 806.5 ± 1202.2 | .11 | | Pathology | ||| | Fibroid | 66 (110%) | 27 (100%) | .48 | | Adenomyosis | 2 (3%) | 3 (11%) | .13 | | Endometriosis | 2 (3%) | 3 (11%) | .23 | Intraoperative Outcomes In open myomectomy group, pericervical tourniquet and vasopressin were used in 12/66 cases. Tourniquet only was used in 15/66 cases. Vasopressin only was used in 22/66 cases and 17/66 cases were completed without any intervention (Table 4). Seven out of 66 (10%) patients underwent vertical incision and 59/66 (90%) patients underwent transverse incision. The data of 27 MIS cases with bilateral uterine artery blockage were analyzed in this study. Among all 27 cases, 9 cases were completed with laparoscopy, 10 cases were performed with LAM and 8 cases were performed with Mini-Lap (Table 2). Table 2. | Open Myomectomy (66) | MIS (27) | P Value | | |---|---|---|---| | Operative time (minutes) | 179.9 ± 78.8 | 271.3 ± 72.9 | <.05 | | EBL (cc) | 325.7 ± 380.3 | 368.1 ± 480.4 | .66 | | Blood transfusion (%) | 11 (17%) | 1 (3%) | <.05 | | Preoperative Hb (g/dL) | 12.0 ± 1.7 | 11.3 ± 3.0 | .58 | | Postoperative Hb (g/dL) | 10.0 ± 2.0 | 8.8 ± 2.1) | .35 | | Hb change (g/dL) | 1.9 ± 1.1) | 2.2 ± 1.4 | .32 | | Incision | ||| | Transverse | 59 (90%) | || | Vertical | 7 (10%) | || | Laparoscopy | 9 (33%) | || | LAM | 10 (37%) | || | Minilaparotomy | 8 (30%) | || | Intra-OP complications* | 2 (3%) | 0 | Compared to open myomectomy, the operative time of MIS myomectomy is significant longer: 179.9 ± 78.8 versus 271.3 ± 72.9 minutes, P < .05. All surgeries were performed by a single, high volume MIS surgeon, with significant experience in laparoscopic myomectomy. MIS, especially laparoscopic myomectomy, usually takes longer surgical time than open myomectomy9,13. There was no record of time on uterine artery blockage in our study, but the estimated time for this procedure was about 25–30 minutes on average, which would be another factor to contribute longer surgical time of MIS. There is less intraoperative blood transfusion and less occurrence of intraoperative complications. There were 11/66 (17%) cases of blood transfusion in open myomectomy but only 1/27 (3%) case of blood transfusion in MIS group (Table 2). Among the 11 open myomectomy cases with blood transfusion, 1 patient received blood transfusion out of 15 who had a tourniquet applied, and none of the 12 patients who received both a tourniquet and vasopressin required a blood transfusion, suggesting that the combination of these 2 interventions may effectively reduce the need for transfusion in open myomectomy procedures. However, there were 4/22 cases of blood transfusion with vasopressin only and 6/17 cases of transfusion if there was no intervention. Therefore, there was significant difference of intraoperative blood transfusion between mechanical and nonmechanical intervention even for open myomectomy (P < .05) (Table 4). There were 2/66 (3%) cases with significant intraoperative complications in open myomectomy group. One complication was ovarian injury with subsequent oophorectomy on a patient with about 34-week size uterus and extensive adhesions. A vertical incision was made and general surgery consult was called for lysis of adhesion. Vasopressin only was used for myomectomy and 4 U packed red blood cells (PRBC) and 2 U albumin were transfused with estimated blood loss of 2800 cc. Left salpingo-oophorectomy was performed due to infundibulopelvic ligament laceration and bleeding. The patient also received another 2 U PRBC on postoperative day 2. Another complication was rectal injury due to the severe adhesions between fibroid and rectum. Rectal laceration occurred during manipulation. The general surgery consult was called and primary repair was performed. There was no intraoperative complication in MIS group (Table 2). There was no significant difference between 2 groups regarding preoperative Hb level, postoperative hemoglobin (Hb) level and decreasing of Hb after surgery (Table 2). Postoperative Outcomes Compared to open myomectomy group, the hospital stay of MIS group was significantly shorter 0–1 day: 19/66 (29%) versus 19/27 (70%), P < .05; 2 days: 28/66 (42%) versus 3/27 (11%), P < .05; ≥ 3 days: 19/66 (29%) versus 5/27 (19%), P < .05. The postoperative complications in open myomectomy group were also significant compared to MIS group: 6/66 (9%) versus 1/27 (3%), P < .05. The complications in open myomectomy group are: 1 case of sepsis with admission to ICU, 2 cases of postoperative fever, 2 cases of wound infection and 1 case of bleeding with exploratory laparotomy. The exploratory laparotomy happened to a patient with about 30-week size uterus and postoperative bleeding on postoperative day 1. The vertical incision was made and cervical tourniquet was used for hemostasis. The intraoperative estimated blood loss was about 200 cc but there was postoperative internal bleeding. The patient unfortunately developed prolonged ileus and then pelvic abscess, which were treated accordingly. The complication in MIS group was 1 case of endometritis, which required antibiotic treatment and prolonged hospital stay for 5 days. There was no difference of postoperative blood transfusion: 10/66 (15%) versus 6/27 (22%), P = .08. However, the preoperative hemoglobin of 4/6 cases in MIS group were 8.0–10.5 g/dL. There was no readmission in 2 groups (Table 3). Table 3. | Open Myomectomy (66) | MIS (27) | P Value | | |---|---|---|---| | Hospital stay (days) | ||| | 0–1 | 19 (29%) | 19 (70%) | <.05 | | 2 | 28 (42%) | 3 (11%) | <.05 | | ≥3 | 19 (29%) | 5 (19%) | <.05 | | Blood transfusion | 10 (15%) | 6 (22%) | .08 | | Postoperative Complications* | 6 (9%) | 1 (3%) | <.05 | | Readmission | 0 | 0 | Table 4. | Tourniquet | Tourniquet + Vasopressin | Vasopressin | None | Total | | |---|---|---|---|---|---| | Hemostat | 15 | 12 | 22 | 17 | 66 | | Intraoperative transfusion | 1 | 0 | 4 | 6 | 11 | | Postoperative transfusion | 2 | 1 | 4 | 3 | 10 | | Tourniquet/tourniquet + vasopressin n = 27 | Vasopressin/none n = 39 | P-value | ||| |---|---|---|---|---|---| | Intraoperative transfusion | 1 | 10 | <.05 | || | Postoperative transfusion | 3 | 7 | .45 |

It has been proven to be true with extensive evidence over the past 20 years, that all surgeries should be carried out by minimally invasive approach, if possible, for the best interests of patients. Compared to open myomectomy, MIS enables faster recovery for patients. One recent study found that abdomina myomectomy was associated with a close to 2-week longer time to return to work compared to laparoscopic myomectomy.23 However, the critical question is how we can extend the scope of MIS to more complex cases, such as the patients with numerous and large fibroids. It is a unanimous consensus that there are 2 main obstacles in performing laparoscopic myomectomy.5,24 One is laparoscopic suturing and another one is bleeding control. While the utilization of alternative approaches, such as robotic platform, LAM and Mini-Lap procedure, is to overcome the challenge of laparoscopic suturing, the tools for bleeding control are still limited and there is no conclusive solution. Without confirmative bleeding control, the alternative approaches of myomectomy for complex cases are still associated with high chance of excessive intraoperative bleeding. Intramyometrial injection of vasopressin has been used routinely in myomectomy to reduce blood loss, though it has never been approved by the United States Food and Drug Administration for this indication. A high concentration of vasopressin in the bloodstream can, however, produce adverse side effects such as bradycardia, pulmonary edema, myocardial ischemia, myocardial infarction, and cardiac arrest even in healthy patients.25 The minimum concentration of vasopressin with therapeutic effect has been reported to be 0.05 U/mL and its half-life only 10–35 minutes.26 In light of this, it is unrealistic to rely solely on vasopressin to complete laparoscopic or robotic myomectomy to tackle with complex fibroids. In our study, the rate of intraoperative blood transfusion for cases with vasopressin or no intervention in open myomectomy group was 10/39 while the transfusion rate with tourniquet was 1/27 (P < .05). Compared to the MIS group, the operative time of open surgery was much quicker and therefore the open myometrium wound was closed in a much shorter period of time, but bleeding was still dramatically high with only medical intervention or no intervention. In the MIS group, the intraoperative blood transfusion was 1/27 and postoperative transfusion was 6/27. The rate of postoperative transfusion rate was relatively high because the preoperative hemoglobin level in 4 cases was as low as 8.0–10.5 g/dL. From those data, we speculate that mechanical blockage of uterine arteries either by tourniquet or bulldog clamps is critical to perform complex myomectomy safely. The application of tourniquet generally needs the exteriorization of uterus, so it more often was used in open myomectomy. Therefore, vertical incision is warranted if the uterus is extremely large. The technique of tourniquet application in MIS is challenging and the only available experience was reported by 1 group.11,27 The surgeons achieved transient uterine artery blockade using the tourniquet in 62.8% of cases and permanent uterine artery ligation in 12.3%.27 Our approach of dissection and blockage of uterine arteries at anterior cul-de-sac does not need very large incision. A transverse Mini-Lap incision is normally enough even if laparoscopic procedure is not feasible. Therefore, a large transverse or vertical incision was avoided even if the uterus sample is extremely big. We have to admit that our technique is not easier than tourniquet application but our successful rate for bilateral uterine arteries was also about 73%. With our technique, we were able to perform a LAM procedure on a patient with about 35-weeks size uterus and the weight of specimen was 3,100 g. We also performed Mini-Lap on another patient with 40-week size uterus and the weight of specimen was 5,432 g. However, we should acknowledge that all our patients are either African American or Hispanic, our experience cannot be generalized to all ethnic groups without further investigation. Compared to the dissection and blockage of uterine arteries from posterior approach, the dissection of uterine arteries at anterior cul-de-sac is more challenging.18 Uterine veins can be extremely dilated and bulge in cases of large uterine fibroids. The single uterine artery can be completely covered by those veins at the lower uterine segment. If the dissection of uterine artery at lower uterine segment is not possible, we will try to dissect more lateral to the pelvic side wall to identify the uterine artery close to umbilical artery. If the dissection of uterine arteries is deemed to be not possible laparoscopically, we will convert the case to Mini-Lap to dissect bilateral uterine arteries under open style. There is a learning curve of this technique based on a surgeon’s skill. It took the surgeon about 10–15 cases to feel comfortable but still more experience is needed. Challenging as it is, our technique presents 2 advantages. First, the access to uterine arteries from medial or posterior approaches is almost impossible when the fibroid uterus is large and out of pelvic cavity. However, it is the cases with large uterus that really are benefit from uterine artery blockage. If the fibroids are small in size or number, the intervention of vasopressin only will be enough for performing laparoscopic myomectomy. In our study, 17/54 cases were performed laparoscopically without attempting uterine artery blockage. Second, the suprapubic 12-mm incision is for uterine artery dissection and insertion of laparoscopic bulldog clamps. It can also be used for specimen removal for laparoscopic myomectomy, or can be extended for LAM or Mini-Lap procedure. We emphasize the importance of MIS due to its low intraoperative and postoperative complications, which are clearly demonstrated in our study. A large study of 66,012 women undergoing myomectomy reported that 5,265 (8.0%) had at least 1 complication, and the minimally invasive approach was associated with a decreased risk of complications compared to open myomectomy (odds ratio [OR]: 0.29; 95% confidence interval [CI], 0.25–0.33; P < .001).28 We agree that MIS takes much longer surgical time but this price is paid back by tremendous benefits to our patients. In conclusion, blocking uterine arteries from anterior cul-de-sac can significantly minimize the potential of hemorrhage during myomectomy, enabling the possibility of MIS for challenging cases with fewer complications. Footnotes Conflict of interests: none. Funding sources: none. Disclosure: none. Contributor Information Pengfei Wang, Department of Obstetrics and Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY. (Dr. Wang, Seeraj, and Mehdizadeh); Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh). Lucia Di Francesco, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh). Valmiki Seeraj, Department of Obstetrics and Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY. (Dr. Wang, Seeraj, and Mehdizadeh); Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh). Swati Kumari, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh). Salma Moustafa, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh). Liaisan Uzianbaeva, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh). Alireza Mehdizadeh, Department of Obstetrics and Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY. (Dr. Wang, Seeraj, and Mehdizadeh); Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Wang, Di Francesco, Seeraj, Kumari, Moustafa, Uzianbaeva, and Mehdizadeh).

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