Old- versus New-School: Laparoscopy versus Laparotomy in Complex and Multiple Myomectomies

Old- versus New-School: Laparoscopy versus Laparotomy in Complex and Multiple Myomectomies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Old- versus New-School: Laparoscopy versus Laparotomy in Complex and Multiple Myomectomies Panayiotis Tanos, Robin Hupet, Ambre Balestra, Evy Gillet, Deliar Yazdanian, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6314972/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Complex myomectomies involving large myomas more than 10cm and multiple myomas are considered challenging in laparoscopic surgery. The aim of this original study is to compare the fertility outcomes and complications of laparotomy versus laparoscopy in complex myomectomies. Methods Retrospective study approved by the Brugmann University Hospital’s ethics committee (CE2023/79). Complex myomectomies were defined as single fibroids larger than 10cm and multiple fibroids. Ninety-four patients (mean-age-35-years) included. The laparoscopic and laparotomic myomectomy groups consisted of 54 and 40 patients respectively. Normality of data was assessed by Q-Q plot, when normality was not ascertained comparisons were carried out using the Mann-Whitney tests for unpaired comparisons, or Wilcoxon otherwise. When normality was reached t-tests for paired or unpaired comparisons were preferred. Results The peri-operative blood loss is significantly higher when the surgical approach used was laparotomy (700 vs 500 mL, p = 0.031), associated with a greater drop in hemoglobin (2.3 vs 2.1, p = 0.081) and a higher transfusion rate (0.13% vs 0.06%, p = 0.486). Median surgery time was shorter (180 min. vs 240 min., p = 0.0002) and hospital stay longer (3 days vs. 2 days, p < 0.0001) in the laparotomy group. The laparotomy conversion rate was 3,2%. In multiple linear regression analysis, blood loss appears to be significantly influenced by the number of fibroids and the fibroids’ weight. Hospital stay appears to be significantly influenced by the patients age, the fibroids’ weight, and the surgery time. Thirty-two percent of patients achieved pregnancy post-surgery, with no statistically significant differences between the two groups in terms of pregnancy success rates (p = 0.5304). Conclusion These results show that even in complex myomectomies, laparoscopic approach could still be the first line of treatment. Laparoscopic myomectomy does not signify higher risks or complications and has significantly lower risk of bleeding and hospitalisation time without compromising fertility outcomes. Fibroids laparoscopy laparotomy complications myomectomy 1. Introduction Uterine fibroids (UFs), or otherwise called leiomyomas or myomas, are hormonally responsive benign neoplasms originating from the smooth muscle cells of the uterine wall [ 1 , 2 ]. Incidence and prevalence of UFs range from around 4.5–77% in women of reproductive age and represent a significant burden in women’s health (menorrhagia, dysmenorrhea, and pelvic discomfort or pain) contributing to 30% of hysterectomies [ 3 ]. Furthermore, UFs are the cause of bleeding in almost half of the women admitted to the hospital for heavy bleeding or anaemia [ 3 ]. The decision for myomectomy necessitates a thorough evaluation of the patient's reproductive goals, the location, number, and characteristics of the fibroids, as well as their symptomatic presentation [ 4 ]. Medical management of UFs includes analgesia, hormonal therapy such as levonorgestrel-intra uterine device, and gonadotrophin-releasing hormone (GnRH) agonists which have been shown to temporarily shrink fibroids by suppressing hormonal production. Despite their good results they are usually used for short periods of time [ 2 , 4 ]. Surgical myomectomy remains the treatment of choice for women with multiple myomas, big myomas of more than 5cm and symptomatic patients [ 5 , 6 ]. Despite longer operating times, laparoscopic procedures generally show superior outcomes, and reduced complications compared with laparotomy. Complications can be reduced by adequate training and experience of the operating surgeon [ 6 ]. Until now there is very little evidence comparing surgical treatments of fibroids. Even more rare is the evidence on complex myomectomies defined as multiple myomectomies (more than 1 UF) and single myomectomies of fibroid measuring at least 10 cm. The aim of this original retrospective study is to compare laparotomic to laparoscopic myomectomy in patients operated for complex myomectomies. 2. Methods 2.1. Ethics approval and consent to participate The study protocol was reviewed and approved by the Ethics Committee of Brugmann University Hospital, Brussels, Belgium (approval No. CE2023/79). All procedures were performed in accordance with the Declaration of Helsinki and relevant Belgian regulations. Because the study analysed retrospectively collected, de‑identified data, the committee waived the requirement for written informed consent from the participants. 2.2. Inclusion and Exclusion criteria The extensive database of the department of gynecology has been studied to extract the cases of myomectomy between January 2011 and December 2023. Myomectomies realized after uterine artery embolization or by hysteroscopy have been excluded from the study. Single fibroid myomectomies with a diameter of less than 10 cm were also excluded from the study. Ninety-four (94) cases were included in this series and several parameters were studied. Primary some patients’ characteristics such as their age or origin. After, some surgical characteristics (type, blood loss, surgery time, hospital stay, complications). Finally, the fibroids’ characteristics like number, weight and maximal diameter of the dominant fibroid. The population was split according to the surgery approach used: 1) Myomectomy by laparoscopy group: 54 cases between 2017 and 2023, 2) Myomectomy by laparotomy group: 40 cases between 2012 and 2023. Additionally, the population was split according to complexity of myomectomy 1) Multiple myomas (>1 fibroma), 2) single myomas >10cm. The operative blood loss, surgery duration, hospital length of stay and drop of hemoglobin were compared. 2.3. Statistics All tests were performed using GraphPad Software (Prism 10.2.2, 2024). Normality of data was assessed by Q-Q plot, when normality was not ascertained comparisons were carried out using the Mann-Whitney tests for unpaired comparisons, Wilcoxon otherwise. When normality was reached t-tests for paired or unpaired comparisons were preferred. All data are presented as percentage when categorical and median when normality was not met or presented as mean ± standard deviation (SD) when continuous and normally distributed. To analyze the link between blood loss or hospital stay and several independent variables (surgical approach, age, number of myomas and myomas’ weight) a multiple regression line by means of the least squares method has been performed. A threshold of p < 0.05 was considered statistically significant. 2.4. Outcomes The primary outcome will look at the difference in operating time and time of hospital stay in laparotomic and laparoscopic complex myomectomies. The secondary outcome will identify changes in hemoglobin, need of blood transfusion and complications rate in laparotomic and laparoscopic complex myomectomies. 3. Results 3.1. Patient demographics Ninety-four (94) multiple myomectomies or single myomectomies of myoma measuring more than 10cm, laparoscopy or laparotomy without pre-operative uterine artery embolization, were performed at the Brugmann University Hospital between January 2011 and December 2023. The laparoscopic myomectomy group consisted of 54 patients and the laparotomic myomectomy of 40 patients. Concerning the population’s characteristics, the mean age was 35 years in both groups. The median number of fibroids was higher in the laparoscopy group, but the difference was not significant (3 vs 4, p=0.737). Concerning the median maximum diameter of the dominant fibroid according to pre-operative imaging, the difference was significantly higher in the laparotomy group (98 vs 80 mm, p=0.048). Finally, the fibroids’ median weight was also higher in the laparotomy group, but the difference was not statistically significant (366 g vs 250.5 g, p=0.068) (Table 1) . 3.2. Post-operative outcomes The median peri-operative blood loss is significantly higher when the surgical approach used was laparotomy (700 vs 500 mL, p=0.031), associated with a greater drop in Hb (2.3 vs 2.1, p=0.081) and a higher transfusion rate (0.13% vs 0.06%, p=0.486) but without reaching statistical significance. However, when hemoglobin variations are studied in terms of postoperative residual percentage compared with baseline hemoglobin, the rate is significantly lower in the laparotomy group (78% vs 84%, p=0.0213) (Table 2) . Median surgery time was shorter (180 min. vs 240 min., p=0.0002) and hospital stay longer (3 days vs. 2 days, p<0.0001) in the laparotomy group, the result being statistically significant in both cases (Table 2) . In this study, the laparotomy conversion rate was 3,2%. A multiple linear regression was done to analyze variables’ (age, surgery approach, number of fibroids, fibroids’ weight and surgery time) which influence on blood loss and hospital stay when they were held as constant independent variables. Blood loss appears to be significantly influenced by the number of fibroids and the fibroids’ weight. Hospital stay appears to be significantly influenced by the patients age, the fibroids’ weight and the surgery time (Table 3) . Post-operative outcomes in the multiple myomectomy group The median peri-operative blood loss is higher when the surgical approach used was laparotomy (850 vs 500 mL, p=0.0029), associated with a greater drop in Hb (2,032 vs 2,845, p=0.0244). Median surgery time was shorter (165 min. vs 240 min., p=0.0005) and hospital stay longer (4 days vs. 2 days, p10 cm myomectomy group The peri-operative blood loss is higher when the surgical approach used was laparotomy (500 vs 683,8 mL, p=0.6438), associated with a substantially similar drop in Hb in both groups though (2.625 vs 2.685, p=0.9380). Median surgery time remains shorter (180 min. vs 195 min., p=0,4841) and hospital stay longer (3 days vs. 2 days, p=0,3113) in the laparotomy group. Taking into consideration the small sample size, none of the results reached statistical significance (Table 5) . Fertility outcomes Our findings demonstrate that post-operative fertility outcomes are not inferior in patients undergoing laparoscopy compared to laparotomy for complex myomectomies. Specifically, 32% of patients achieved pregnancy post-surgery, with no statistically significant differences between the two groups in terms of pregnancy success rates (p=0.5304). Despite the longer operation time in the laparoscopy group, it did not negatively impact the fertility outcomes ( Table 6) . Discussion 5.1. Main Findings Laparoscopic or laparotomic myomectomy is the treatment of choice for symptomatic patients with uterine fibroids wishing to preserve their fertility. Surgical management is preferred in the removal of subserosal and intramural fibroids (types 4–7 in FIGO classification) [7]. The well-established advantages offered by the laparoscopic approach include shorter recovery time, decreased morbidity, and less adhesion formation, with the latter being challenging to assess [8]. Complex myomectomies have been associated with an increased surgical complication rate. They have been defined to be involved with fibroids greater than 5 cm in diameter, or those with the presence of more than 2 fibroids or type 4 fibroids (in FIGO classification) [9]. Due to the evolution of laparoscopic surgical training and education, surgeons are becoming more familiar and comfortable with laparoscopic myomectomies [6]. However, when it comes to complex myomectomies, literature and less experienced endoscopic surgeons still lack confidence in their management through laparoscopic myomectomy. Additionally, previous studies and national guidelines (National Institute of Health and Care Excellence, United Kingdom), define fibroids with diameter of more than 10cm as the limit of laparoscopic myomectomy [10, 11]. This study provides evidence on the benefits of laparoscopic over laparotomic surgery in complex myomectomies including those with fibroids larger than 10cm agreeing with a comparable, smaller scale (lower myomas complexity) study by Rossetti et al. 2007 [12]. Recurrence and Conversion Rate Fibroids recurrence rate is similar in open or laparoscopic myomectomies [9, 10 ]. Risk of recurrence after laparoscopic myomectomy increases over time. Shiota et al. 2012 define additional attention for recurrence being required in patients with uterine myomas of diameter ≥10 cm, multiple myomas and age 35 years or older [13]. Dubuisson JB et al. 2001 show 11.3% of their patient cohort being converted from laparoscopic to open myomectomy. They define the risk based on size more than 50 mm in ultrasound, intramural type fibroids, anterior location, and pre-operative use of gonadotrophin-releasing hormone agonists [14]. Their predictive model does not expand to complex myomectomies. Our study shows a smaller conversion rate (3,2%) even in myomas with mean diameter size of more than 50mm. Further predictive models could provide decrease in operating time and complications by choosing laparotomy over laparoscopy in the patients with the highest risk of conversion [15]. Additionally, Leung et al. 2018 created a grading tool for objective evaluation of such complex procedures. GESEA has focused on systematic training and education of young endoscopists in laparoscopic skills [16, 17]. The importance of training and objective evaluation in modern laparoscopic surgery is imperative. Surgical Complications The most recent meta-analysis by Giannini et al. 2024, reports no statistically significant difference in intra-operative and post-operative complication rates (Clavein-Dindo classification), in pregnancy rate and obstetrical outcomes (uterine rupture, type of delivery, number of abortions) between laparoscopic versus laparotomic myomectomy. Only one study included, reports short- and long-term post-operative complications. Our study shows minimal complications in both groups. One patient who initially underwent laparoscopy developed a paralytic ileus after conversion to laparotomy. The condition necessitated reoperation under general anesthesia to resolve the issue (grade IIIb regarding the Clavein-Dindo classification). Two cases of acute intestinal breach occurred, both during laparotomy procedures. These breaches were promptly identified and repaired during the same surgical session, avoiding the need for additional surgeries or prolonged post-operative interventions (grade IIIb regarding the Clavein-Dindo classification). Despite these non-significant findings, laparoscopic myomectomy shows multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need when compared to abdominal myomectomy [18]. Vargas et al. 2019, showed that operating time can be predictive of incidence of complications for both laparoscopic and laparotomic myomectomies. However, despite longer operating times, laparoscopic procedures generally had superior 30-day outcomes up to 270 minutes where the odds of a composite complication variable increased compared with laparotomy <90 minutes. Simultaneously, despite shorter operating times, morbidity was greater in laparotomic cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%) [19]. Our study only observed complications in 4% (4/94) of cases. From these patients the 75% (3/4) received laparotomy and only one patient (1/3 converted cases) received laparoscopy which was transformed to laparotomy. Fertility Odejinmi et al. 2015 point out that in perimenopausal women, the decision to perform myomectomy can be controversial. Laparoscopic hysterectomy can have potential advantages to laparoscopic myomectomy in the management of uterine fibroids, due to reduced operation length, blood loss and hospital stay but with increased risk of urinary tract injury. However, this depends on operator experience and case complexity [20]. Our patient cohort had the wish to preserve their fertility and or uterus. The observed fertility outcomes in our study are likely influenced by factors such as reduced adhesion formation and faster recovery times associated with laparoscopic surgery. This aligns with evidence suggesting that minimally invasive procedures promote better uterine healing and minimize complications like intrauterine adhesions, which can impair fertility. Further research should aim to following-up these patients for long term complications and fertility outcomes. 5.2. Strengths and Limitations This study appears to be unique in the literature making it hard to compare its results. However, this study is confined by its retrospective nature and associated limitations. The study avoided selection bias by including all available data over a 12-year period. Both laparotomies and laparoscopies were not performed by a single surgeon introducing discrepancy due to operating techniques. However, surgical steps, equipment and treatment protocols remain under the same department. 5.3. Conclusion Complex myomectomies are usually performed by laparotomy due to lack of advanced endoscopic skills experience and fear of major peri-surgical complications. Our results show that even in complex myomectomies (single myomas more than 10cm or multiple myomas), laparoscopic approach could still be the first line of treatment even for women wishing to preserve their fertility. Laparoscopic myomectomy does not signify higher risks or complications and has significantly lower risk of bleeding and hospitalisation time. Declarations Author contribution: Conceptualisation (PT, RH, AB, SK, MN), Methodology (PT, RH, AB, EG, DY, FD, EF, SE, GS), Data Curation (PT, RH, AB, SD), Writing Original Draft (PT, RH, AB), Writing Review (PT, RH, AB, SK, EG), Supervision (MN, SK) Funding statement: No funding has been received by any of the authors for this study. Dr Panayiotis Tanos, Dr Robin Hupet, Dr Ambre Balestra, Dr Evy Gillet, Dr Deliar Yazdanian, Dr Elie Finianos, Dr Sara Engels, Dr Francesca Donders, Dr Georges Salem Wehbe, Dr Michelle Nisolle and Dr Stavros Karampelas have no conflicts of interest or financial ties to disclose. Acknowledgement: N/A Ethical statement: Approved by the Ethics Committee of Brugmann University Hospital, Brussels, Belgium (CE2023/79). Consent to Publish declaration: Not applicable: the manuscript contains no individual clinical images or personal data that would identify participants. Consent to Participate declaration: Requirement for written informed consent was waived by the same committee owing to the retrospective, anonymised design. Clinical trial number: not applicable. References Tanos V, Laidlaw J, Tanos P, Papadopoulou A. New insights into the neural network of the nongravid uterus. 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Best Pract Res Clin Obstet Gynaecol. 2018;46:12–30. doi: 10.1016/j.bpobgyn.2017.10.004 . Epub 2017 Oct 16. Erratum in: Best Pract Res Clin Obstet Gynaecol. 2018;: PMID: 29126743. Munro M. G., Critchley H. O. D., Fraser I. S. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? American Journal of Obstetrics and Gynecology. 2012;207(4):259–265. doi: 10.1016/j.ajog.2012.01.046 . Luciano D. E., Roy G., Luciano A. A. Adhesion reformation after laparoscopic adhesiolysis: where, what type, and in whom they are most likely to recur. Journal of Minimally Invasive Gynecology. 2008;15(1):44–48. doi: 10.1016/j.jmig.2007.09.012 . Jin C., Hu Y., Chen X.-C., et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2009;145(1):14–21. doi: 10.1016/j.ejogrb.2009.03.009 . 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GESEA4EU Giannini A, Cuccu I, D'Auge TG, De Angelis E, Laganà AS, Chiantera V, Caserta D, Vitale SG, Muzii L, D'Oria O, Perniola G, Bogani G, Di Donato V. The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon. Eur J Obstet Gynecol Reprod Biol. 2024;297:50–58. doi: 10.1016/j.ejogrb.2024.03.045. Epub ahead of print. PMID: 38581885. Vargas V. M, Larson, K. D., Sparks A. et al. Association of operative time with outcomes in minimally invasive and abdominal, Volume 111, Issue 6, P1252-1258.E1, April 12, 2019, https://doi.org/10.1016/j.fertnstert.2019.02.020 Odejinmi, F., Maclaran, K. & Agarwal, N. Laparoscopic treatment of uterine fibroids: a comparison of peri-operative outcomes in laparoscopic hysterectomy and myomectomy.Arch Gynecol Obstet 291, 579–584 (2015). https://doi.org/10.1007/s00404-014-3434-y Tables Table 1. Patient demographics Patients Demographics Laparoscopy (n = 54) Laparotomy (n = 40) P-value Age (Years [SD]) 35 [5.2] 35 [5.0] 0.4775 (t-test) Number of Fibroids [IQR] 4 [40] 3 [55] 0.7370 (Mann-Whitney) Diameter of Largest Fibroids (mm [IQR]) 80 [208] 98 [207] 0.0482 (*)(Mann-Whitney) Fibroid weight (g [IQR]) 250.5 [973] 366 [2112] 0.0680 (Mann-Whitney) Table 2. Post-operative outcomes in laparoscopy and laparotomy in complex myomectomies Post-operative Outcomes Laparoscopy (n = 54) Laparotomy (n = 40) P-value Blood loss (mL [IQR]) 500 (2680) 700 (4980) 0,0315 (*) (Mann-Whitney) Drop in Hemoglobin (g/dL [IQR]) Post-operative Hemoglobin level (%[SD]) 2,1 (4,3) 84 (11) 2,3 (6,7) 78 (12) 0,0818 (Mann-Whitney) 0,0213 (*) (t-test) Blood Transfusion (%[SD]) 0,065 (0,25) 0,13 (0,33) 0,4866 (t-test) Surgery time (Minutes [IQR]) 240 (420) 180 (270) 0,0002 (***) (Mann-Whitney) Hospital stay (Days [IQR]) 2,0 (30) 3,0 (11) <0,0001 (***) (Mann-Whitney) Table 3. Factors influencing blood loss and hospital stay in complex multiple myomectomies (Multiple linear regression). Dependent variables Independent variables B [SD] P-value R 2 Dof Blood Loss Holding other variables constant Age Surgery approach Number of Fibroids Fibroids weight Surgery Time -503 [519.4] 9.354 [14.32] -175.9 [155.5] 18.23 [7.016] 1.237 [0.1977] 1.797 [0.9644] 0.3359 0.6532 0.2628 0.0117 <0.0001 0.0674 0.57 60 Hospital stay Holding other variables constant Age Surgery approach Number of Fibroids Fibroids weight Surgery Time 29 [9.4] -0.78 [0.26] 4.2 [5.7] 0.61 [0.49] -0.032 [0.0079] -0.15 [0.039] 0.0030 0.0049 0.4716 0.2180 0.0002 0.0003 0.71 50 Table 4. Post-operative outcomes in multiple myomectomy group Post-operative Outcomes Laparoscopy n = 48 Laparotomy n = 26 P-value Blood loss (mL [IQR]) 500 (2680) 850 (4980) 0,0029 (**) (Mann-Whitney) Drop in Hemoglobin (g/dL [SD]) 2,032 (1,023) 2,845 (1,781) 0,0244 (*) (t-test) Surgery time (Minutes [IQR]) 240 (420) 165 (255) 0,0005 (***) (Mann-Whitney) Hospital stay (Days [IQR]) 2 (30) 4 (11) 10 cm myomectomy group Post-operative Outcomes Laparoscopy (n = 6) Laparotomy (n = 14) P-value Blood loss (mL [SD]) 500 (264,6) 683,8 (842,3) 0,6438 (t-test) Drop in Hemoglobin (g/dL [SD]) 2,625 (0,3948) 2,685 (1,462) 0,9380 (t-test) Surgery time (Minutes [IQR]) 195 (150) 180 (180) 0,4841 (Mann-Whitney) Hospital stay (Days [IQR]) 2 (1) 3 (4) 0,3113 (Mann-Whitney) Table 6. Obstetrical data – Multiple myomectomy Age (years [SD]) Pre-operative gestation (mean [SD]) Patients with post-operative pregnancy (% (n)) Patients with post-operative lived pregnancy (% (n)) Ectopic pregnancies (% (n)) Laparoscopy (n=54) Laparotomy (n=40) P-value 35 [5.2] 0.7 [1.8] 16.6 (9) 14.8 (8) 1.8 (1) 35 [5.0] 1 [2.3] 15 (6) 15 (6) 0 (0) 0.4775 0.0380 0.5304 0.9852 0.4014 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6314972","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":453456412,"identity":"32115dd0-3b7f-42ee-8c65-5aa25b34ec06","order_by":0,"name":"Panayiotis Tanos","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Panayiotis","middleName":"","lastName":"Tanos","suffix":""},{"id":453456414,"identity":"45d46092-536b-45f9-b81c-c0e8ad2e3550","order_by":1,"name":"Robin Hupet","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACAyidwMbAfABIS8gQp+UAWAtbAkgLD/FaGBh4wGzCWswlcg8+/rjHJo9Puufzqxs1FjwM7IePbsCnxXJGXrLBgWdpxWwyZ7dZ5xwDOownLe0GXofdyDGTOHDgcGKbRO424xw2oBYJHjNCWsx/QLTkPDPO+UecFjMGqBbmx7ltxGg58y5Z4swBoF8k0syYc/skeNgI+uV47sEPFQds8uRnJD/+nPOtTo6f/fAxvFqQI4JNAkziV46qhfkDYdWjYBSMglEwEgEAlMNKF2MafhcAAAAASUVORK5CYII=","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":true,"prefix":"","firstName":"Robin","middleName":"","lastName":"Hupet","suffix":""},{"id":453456415,"identity":"2c3ff93a-9bf8-4828-a0e2-ea8d744dd1ec","order_by":2,"name":"Ambre Balestra","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Ambre","middleName":"","lastName":"Balestra","suffix":""},{"id":453456416,"identity":"0891d9e0-bfb8-46d9-a856-4baf07883c6f","order_by":3,"name":"Evy Gillet","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Evy","middleName":"","lastName":"Gillet","suffix":""},{"id":453456417,"identity":"09336030-919a-40da-bd64-853abf97867d","order_by":4,"name":"Deliar Yazdanian","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Deliar","middleName":"","lastName":"Yazdanian","suffix":""},{"id":453456418,"identity":"617fee58-1852-4d3f-b4bd-08391e692673","order_by":5,"name":"Elie Finianos","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Elie","middleName":"","lastName":"Finianos","suffix":""},{"id":453456419,"identity":"b929c106-83e2-44a5-8512-ab788c8d79ba","order_by":6,"name":"Sara Engels","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Engels","suffix":""},{"id":453456420,"identity":"7408e24c-a664-4152-a7ec-64f6ae248472","order_by":7,"name":"Francesca Donders","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Francesca","middleName":"","lastName":"Donders","suffix":""},{"id":453456421,"identity":"900fac6b-f318-423f-aec0-c918562c52df","order_by":8,"name":"Georges Salem Wehbe","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Georges","middleName":"Salem","lastName":"Wehbe","suffix":""},{"id":453456422,"identity":"c779023c-c18c-4489-ab1f-2e5d72b2af0e","order_by":9,"name":"Michelle Nisolle","email":"","orcid":"","institution":"Centre Hospitalier Regional de la Citadelle","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Nisolle","suffix":""},{"id":453456423,"identity":"fee209f2-9b43-4920-8e1c-87f3c657105b","order_by":10,"name":"Stavros Karampelas","email":"","orcid":"","institution":"Centre Hospitalier Universitaire Brugmann","correspondingAuthor":false,"prefix":"","firstName":"Stavros","middleName":"","lastName":"Karampelas","suffix":""}],"badges":[],"createdAt":"2025-03-26 19:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6314972/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6314972/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82247905,"identity":"a66f7b87-52a4-4024-81dc-6b0e6e59b82a","added_by":"auto","created_at":"2025-05-08 09:27:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":892741,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6314972/v1/4bbd903b-d9b1-47ee-986c-99bf2f49ff2f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Old- versus New-School: Laparoscopy versus Laparotomy in Complex and Multiple Myomectomies","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eUterine fibroids (UFs), or otherwise called leiomyomas or myomas, are hormonally responsive benign neoplasms originating from the smooth muscle cells of the uterine wall [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Incidence and prevalence of UFs range from around 4.5\u0026ndash;77% in women of reproductive age and represent a significant burden in women\u0026rsquo;s health (menorrhagia, dysmenorrhea, and pelvic discomfort or pain) contributing to 30% of hysterectomies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, UFs are the cause of bleeding in almost half of the women admitted to the hospital for heavy bleeding or anaemia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe decision for myomectomy necessitates a thorough evaluation of the patient's reproductive goals, the location, number, and characteristics of the fibroids, as well as their symptomatic presentation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMedical management of UFs includes analgesia, hormonal therapy such as levonorgestrel-intra uterine device, and gonadotrophin-releasing hormone (GnRH) agonists which have been shown to temporarily shrink fibroids by suppressing hormonal production. Despite their good results they are usually used for short periods of time [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical myomectomy remains the treatment of choice for women with multiple myomas, big myomas of more than 5cm and symptomatic patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite longer operating times, laparoscopic procedures generally show superior outcomes, and reduced complications compared with laparotomy. Complications can be reduced by adequate training and experience of the operating surgeon [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUntil now there is very little evidence comparing surgical treatments of fibroids. Even more rare is the evidence on complex myomectomies defined as multiple myomectomies (more than 1 UF) and single myomectomies of fibroid measuring at least 10 cm. The aim of this original retrospective study is to compare laparotomic to laparoscopic myomectomy in patients operated for complex myomectomies.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1. Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Ethics Committee of Brugmann University Hospital, Brussels, Belgium (approval No. CE2023/79). All procedures were performed in accordance with the Declaration of Helsinki and relevant Belgian regulations. Because the study analysed retrospectively collected, de‑identified data, the committee waived the requirement for written informed consent from the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Inclusion and Exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe extensive database of the department of gynecology has been studied to extract the cases of myomectomy between January 2011 and December 2023. Myomectomies realized after uterine artery embolization or by hysteroscopy have been excluded from the study. Single fibroid myomectomies with a diameter of less than 10 cm were also excluded from the study.\u003c/p\u003e\n\u003cp\u003eNinety-four (94) cases were included in this series and several parameters were studied. Primary some patients’ characteristics such as their age or origin. After, some surgical characteristics (type, blood loss, surgery time, hospital stay, complications). Finally, the fibroids’ characteristics like number, weight and maximal diameter of the dominant fibroid. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe population was split according to the surgery approach used: 1) Myomectomy by laparoscopy group: 54 cases between 2017 and 2023, 2) Myomectomy by laparotomy group: 40 cases between 2012 and 2023. Additionally, the population was split according to complexity of myomectomy 1) Multiple myomas (\u0026gt;1 fibroma), 2) single myomas \u0026gt;10cm. The operative blood loss, surgery duration, hospital length of stay and drop of hemoglobin were compared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Statistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll tests were performed using GraphPad Software (Prism 10.2.2, 2024). Normality of data was assessed by Q-Q plot, when normality was not ascertained comparisons were carried out using the Mann-Whitney tests for unpaired comparisons, Wilcoxon otherwise. When normality was reached t-tests for paired or unpaired comparisons were preferred. All data are presented as percentage when categorical and median when normality was not met or presented as mean ± standard deviation (SD) when continuous and normally distributed. To analyze the link between blood loss or hospital stay and several independent variables (surgical approach, age, number of myomas and myomas’ weight) a multiple regression line by means of the least squares method has been performed. A threshold of p \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome will look at the difference in operating time and time of hospital stay in laparotomic and laparoscopic complex myomectomies. The secondary outcome will identify changes in hemoglobin, need of blood transfusion and complications rate in laparotomic and laparoscopic complex myomectomies.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results ","content":"\u003cp\u003e\u003cstrong\u003e3.1. Patient demographics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNinety-four (94) multiple myomectomies or single myomectomies of myoma measuring more than 10cm, laparoscopy or laparotomy without pre-operative uterine artery embolization, were performed at the Brugmann University Hospital between January 2011 and December 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe laparoscopic myomectomy group consisted of 54 patients and the laparotomic myomectomy of 40 patients. Concerning the population\u0026rsquo;s characteristics, the mean age was 35 years in both groups. The median number of fibroids was higher in the laparoscopy group, but the difference was not significant (3 vs 4, p=0.737). Concerning the median maximum diameter of the dominant fibroid according to pre-operative imaging, the difference was significantly higher in the laparotomy group (98 vs 80 mm, p=0.048). Finally, the fibroids\u0026rsquo; median weight was also higher in the laparotomy group, but the difference was not statistically significant (366 g vs 250.5 g, p=0.068)\u0026nbsp;\u003cstrong\u003e(Table 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Post-operative outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median peri-operative blood loss is significantly higher when the surgical approach used was laparotomy\u0026nbsp;(700 vs 500 mL, p=0.031),\u0026nbsp;associated with a greater drop in Hb (2.3 vs 2.1, p=0.081) and a higher transfusion rate (0.13% vs 0.06%, p=0.486) but without reaching statistical significance. However, when hemoglobin variations are studied in terms of postoperative residual percentage compared with baseline hemoglobin, the rate is significantly lower in the laparotomy group (78% vs 84%, p=0.0213) \u003cstrong\u003e(Table 2)\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMedian surgery time\u0026nbsp;was shorter (180 min. vs 240 min., p=0.0002) and hospital stay longer (3 days vs. 2 days, p\u0026lt;0.0001) in the laparotomy group, the result being statistically significant in both cases \u003cstrong\u003e(Table 2)\u003c/strong\u003e. In this study, the laparotomy conversion rate was 3,2%.\u003c/p\u003e\n\u003cp\u003eA multiple linear regression was done to analyze variables\u0026rsquo; (age,\u0026nbsp;surgery approach, number of fibroids, fibroids\u0026rsquo; weight and surgery time) which influence on blood loss and hospital stay when they were held as constant independent variables. Blood loss appears to be significantly influenced by the number of fibroids and the fibroids\u0026rsquo; weight. Hospital stay appears to be significantly influenced by the patients age, the fibroids\u0026rsquo; weight and the surgery time \u003cstrong\u003e(Table 3)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-operative outcomes in the multiple myomectomy group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe median peri-operative blood loss is higher when the surgical approach used was laparotomy (850 vs 500 mL, p=0.0029), associated with a greater drop in Hb (2,032 vs 2,845, p=0.0244).\u0026nbsp;Median surgery time was shorter (165 min. vs 240 min., p=0.0005) and hospital stay longer (4 days vs. 2 days, p\u0026lt;0.0001) in the laparotomy group, all the results being statistically significant\u0026nbsp;\u003cstrong\u003e(Table 4)\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-operative outcomes in unique \u0026gt;10 cm myomectomy group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe peri-operative blood loss is higher when the surgical approach used was laparotomy (500 vs 683,8 mL, p=0.6438), associated with a substantially similar drop in Hb in both groups though (2.625 vs 2.685, p=0.9380).\u0026nbsp;Median surgery time\u0026nbsp;remains shorter (180 min. vs 195 min., p=0,4841) and hospital stay longer (3 days vs. 2 days, p=0,3113) in the laparotomy group. Taking into consideration the\u0026nbsp;small sample size,\u0026nbsp;none of the results reached statistical significance \u003cstrong\u003e(Table 5)\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFertility outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings demonstrate that post-operative fertility outcomes are not inferior in patients undergoing laparoscopy compared to laparotomy for complex myomectomies. Specifically, 32% of patients achieved pregnancy post-surgery, with no statistically significant differences between the two groups in terms of pregnancy success rates (p=0.5304). Despite the longer operation time in the laparoscopy group, it did not negatively impact the fertility outcomes (\u003cstrong\u003eTable 6)\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003e\u003cstrong\u003e5.1. Main Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLaparoscopic or laparotomic myomectomy is the treatment of choice for symptomatic patients with uterine fibroids wishing to preserve their fertility. Surgical management is preferred in the removal of subserosal and intramural fibroids (types 4–7 in FIGO classification) [7]. The well-established advantages offered by the laparoscopic approach include shorter recovery time, decreased morbidity, and less adhesion formation, with the latter being challenging to assess [8]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComplex myomectomies have been associated with an increased surgical complication rate. They have been defined to be involved with fibroids greater than 5 cm in diameter, or those with the presence of more than 2 fibroids or type 4 fibroids (in FIGO classification) [9]. Due to the evolution of laparoscopic surgical training and education, surgeons are becoming more familiar and comfortable with laparoscopic myomectomies [6]. However, when it comes to complex myomectomies, literature and less experienced endoscopic surgeons still lack confidence in their management through laparoscopic myomectomy. Additionally, previous studies and national guidelines (National Institute of Health and Care Excellence, United Kingdom), define fibroids with diameter of more than 10cm as the limit of laparoscopic myomectomy [10, 11]. This study provides evidence on the benefits of laparoscopic over laparotomic surgery in complex myomectomies including those with fibroids larger than 10cm agreeing with a comparable, smaller scale (lower myomas complexity) study by Rossetti et al. 2007 [12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecurrence and Conversion Rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFibroids recurrence rate is similar in open or laparoscopic myomectomies [9,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5030427/#B7\"\u003e10\u003c/a\u003e].\u0026nbsp;Risk of recurrence after laparoscopic myomectomy increases over time. Shiota et al. 2012 define additional attention for recurrence being required in patients with uterine myomas of diameter ≥10\u0026nbsp;cm, multiple myomas and age 35 years or older [13].\u003c/p\u003e\n\u003cp\u003eDubuisson JB et al. 2001 show 11.3% of their patient cohort being converted from laparoscopic to open myomectomy. They define the risk based on size more than 50 mm in ultrasound, intramural type fibroids, anterior location, and pre-operative use of gonadotrophin-releasing hormone agonists [14]. Their predictive model does not expand to complex myomectomies. Our study shows a smaller conversion rate (3,2%) even in myomas with mean diameter size of more than 50mm. Further predictive models could provide decrease in operating time and complications by choosing laparotomy over laparoscopy in the patients with the highest risk of conversion [15]. Additionally, Leung et al. 2018 created a grading tool for objective evaluation of such complex procedures. GESEA has focused on systematic training and education of young endoscopists in laparoscopic skills [16, 17]. The importance of training and objective evaluation in modern laparoscopic surgery is imperative.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most recent meta-analysis by Giannini et al. 2024, reports no statistically significant difference in intra-operative and post-operative complication rates (Clavein-Dindo classification), in pregnancy rate and obstetrical outcomes (uterine rupture, type of delivery, number of abortions) between laparoscopic versus laparotomic myomectomy. Only one study included, reports short- and long-term post-operative complications. Our study shows minimal complications in both groups. One patient who initially underwent laparoscopy developed a paralytic ileus after conversion to laparotomy. The condition necessitated reoperation under general anesthesia to resolve the issue (grade IIIb regarding the Clavein-Dindo classification). Two cases of acute intestinal breach occurred, both during laparotomy procedures. These breaches were promptly identified and repaired during the same surgical session, avoiding the need for additional surgeries or prolonged post-operative interventions (grade IIIb regarding the Clavein-Dindo classification). Despite these non-significant findings, laparoscopic myomectomy shows multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need when compared to abdominal myomectomy [18].\u003c/p\u003e\n\u003cp\u003eVargas et al. 2019, showed that operating time can be predictive of incidence of complications for both laparoscopic and laparotomic myomectomies. However, despite longer operating times, laparoscopic procedures generally had superior 30-day outcomes up to 270\u0026nbsp;minutes where the odds of a composite complication variable increased compared with laparotomy \u0026lt;90\u0026nbsp;minutes. Simultaneously, despite shorter operating times, morbidity was greater in laparotomic cases (16% vs. 5.7%), with the highest rates in converted cases (20.5%) [19]. Our study only observed complications in 4% (4/94) of cases. From these patients the 75% (3/4) received laparotomy and only one patient (1/3 converted cases) received laparoscopy which was transformed to laparotomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFertility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOdejinmi et al. 2015 point out that in perimenopausal women, the decision to perform myomectomy can be controversial. Laparoscopic hysterectomy can have potential advantages to laparoscopic myomectomy in the management of uterine fibroids, due to reduced operation length, blood loss and hospital stay but with increased risk of urinary tract injury. However, this depends on operator experience and case complexity [20]. Our patient cohort had the wish to preserve their fertility and or uterus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe observed fertility outcomes in our study are likely influenced by factors such as reduced adhesion formation and faster recovery times associated with laparoscopic surgery. This aligns with evidence suggesting that minimally invasive procedures promote better uterine healing and minimize complications like intrauterine adhesions, which can impair fertility. Further research should aim to following-up these patients for long term complications and fertility outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.2. Strengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study appears to be unique in the literature making it hard to compare its results.\u0026nbsp;However, this study is confined by its retrospective nature and associated limitations. The study avoided selection bias by including all available data over a 12-year period. Both laparotomies and laparoscopies were not performed by a single surgeon introducing discrepancy due to operating techniques. However, surgical steps, equipment and treatment protocols remain under the same department.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.3. Conclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplex myomectomies are usually performed by laparotomy due to lack of advanced endoscopic skills experience and fear of major peri-surgical complications. \u0026nbsp;Our results show that even in complex myomectomies (single myomas more than 10cm or multiple myomas), laparoscopic approach could still be the first line of treatment even for women wishing to preserve their fertility. Laparoscopic myomectomy does not signify higher risks or complications and has significantly lower risk of bleeding and hospitalisation time.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor contribution: Conceptualisation (PT, RH, AB, SK, MN), Methodology (PT, RH, AB, EG, DY, FD, EF, SE, GS), Data Curation (PT, RH, AB, SD), Writing Original Draft (PT, RH, AB), Writing Review (PT, RH, AB, SK, EG), Supervision (MN, SK)\u003c/p\u003e\n\u003cp\u003eFunding statement: No funding has been received by any of the authors for this study.\u003c/p\u003e\n\u003cp\u003eDr Panayiotis Tanos, Dr Robin Hupet, Dr Ambre Balestra, Dr Evy Gillet, Dr Deliar Yazdanian, Dr Elie Finianos, Dr Sara Engels, Dr Francesca Donders, Dr Georges Salem Wehbe, Dr Michelle Nisolle and Dr Stavros Karampelas have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003eAcknowledgement: N/A\u003c/p\u003e\n\u003cp\u003eEthical statement: Approved by the Ethics Committee of Brugmann University Hospital, Brussels, Belgium (CE2023/79).\u003c/p\u003e\n\u003cp\u003eConsent to Publish declaration: Not applicable: the manuscript contains no individual clinical images or personal data that would identify participants.\u003c/p\u003e\n\u003cp\u003eConsent to Participate declaration: Requirement for written informed consent was waived by the same committee owing to the retrospective, anonymised design.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTanos V, Laidlaw J, Tanos P, Papadopoulou A. New insights into the neural network of the nongravid uterus. Adv Clin Exp Med. 2022;31(10):1153\u0026ndash;1162. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17219/acem/149913\u003c/span\u003e\u003cspan address=\"10.17219/acem/149913\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanos V, Lingwood L, Balami S, Junctional Zone Endometrium Morphological Characteristics and Functionality: Review of the Literature, Gynecol Obstet Invest (2020) 85 (2): 107\u0026ndash;117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000505650\u003c/span\u003e\u003cspan address=\"10.1159/000505650\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallach EE, Vlahos NF. 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PMID: 29234680; PMCID: PMC5694987.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanos V, Berry KE. Benign and malignant pathology of the uterus. Best Pract Res Clin Obstet Gynaecol. 2018;46:12\u0026ndash;30. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bpobgyn.2017.10.004\u003c/span\u003e\u003cspan address=\"10.1016/j.bpobgyn.2017.10.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2017 Oct 16. Erratum in: Best Pract Res Clin Obstet Gynaecol. 2018;: PMID: 29126743.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunro M. G., Critchley H. O. D., Fraser I. S. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? 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PMID: 17651554; PMCID: PMC3015797.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitsuru Shiota, Yasushi Kotani, Masahiko Umemoto, Takako Tobiume, Hiroshi Hoshiai, Recurrence of uterine myoma after laparoscopic myomectomy: What are the risk factors?, Gynecology and Minimally Invasive Therapy, Volume 1, Issue 1, 2012, Pages 34\u0026ndash;36, ISSN 2213\u0026ndash;3070, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.gmit.2012.08.003\u003c/span\u003e\u003cspan address=\"10.1016/j.gmit.2012.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJean-Bernard Dubuisson, Arnaud Fauconnier, Virginie Fourchotte, Katayoun Babaki-Fard, Jo\u0026euml;l Coste, Charles Chapron, Laparoscopic myomectomy: predicting the risk of conversion to an open procedure, Human Reproduction, Volume 16, Issue 8, August 2001, Pages 1726\u0026ndash;1731, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/humrep/16.8.1726\u003c/span\u003e\u003cspan address=\"10.1093/humrep/16.8.1726\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanos P, Ablett AD, Carter B, Ceelen W, Pearce L, Stechman M, McCarthy K, Hewitt J, Myint PK. 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PMID: 30439651.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGESEA4EU\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiannini A, Cuccu I, D'Auge TG, De Angelis E, Lagan\u0026agrave; AS, Chiantera V, Caserta D, Vitale SG, Muzii L, D'Oria O, Perniola G, Bogani G, Di Donato V. The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon. Eur J Obstet Gynecol Reprod Biol. 2024;297:50\u0026ndash;58. doi: 10.1016/j.ejogrb.2024.03.045. Epub ahead of print. PMID: 38581885.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVargas V. M, Larson, K. D., Sparks A. et al. Association of operative time with outcomes in minimally invasive and abdominal, Volume 111, Issue 6, P1252-1258.E1, April 12, 2019, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fertnstert.2019.02.020\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2019.02.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOdejinmi, F., Maclaran, K. \u0026amp; Agarwal, N. Laparoscopic treatment of uterine fibroids: a comparison of peri-operative outcomes in laparoscopic hysterectomy and myomectomy.Arch Gynecol Obstet 291, 579\u0026ndash;584 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00404-014-3434-y\u003c/span\u003e\u003cspan address=\"10.1007/s00404-014-3434-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Patient demographics\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePatients Demographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eLaparoscopy (n = 54)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eLaparotomy (n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eAge (Years [SD])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e35 [5.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e35 [5.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.4775 (t-test)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNumber of Fibroids [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e4 [40]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 [55]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.7370 (Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDiameter of Largest Fibroids (mm [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e80\u0026nbsp;[208]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e98 [207]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0482\u003c/strong\u003e (*)(Mann-Whitney)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eFibroid weight (g [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e250.5 [973]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e366 [2112]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.0680 (Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Post-operative outcomes in laparoscopy and laparotomy in complex myomectomies\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003ePost-operative Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eLaparoscopy\u003cbr\u003e\u0026nbsp;(n = 54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLaparotomy\u003cbr\u003e\u0026nbsp;(n = 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eBlood loss (mL [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e500 (2680)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e700 (4980)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,0315\u003c/strong\u003e \u003cstrong\u003e(*)\u003c/strong\u003e(Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eDrop in Hemoglobin (g/dL [IQR])\u003c/p\u003e\n \u003cp\u003ePost-operative Hemoglobin level (%[SD])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2,1 (4,3)\u003c/p\u003e\n \u003cp\u003e84 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2,3 (6,7)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e78 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e0,0818 (Mann-Whitney)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0,0213 (*)\u003c/strong\u003e (t-test)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eBlood Transfusion (%[SD])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0,065 (0,25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0,13 (0,33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e0,4866 (t-test)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSurgery time (Minutes [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e240 (420)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e180 (270)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,0002 (***)\u003c/strong\u003e(Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eHospital stay (Days [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2,0 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3,0 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,0001 (***)\u003c/strong\u003e(Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Factors influencing blood loss and hospital stay in complex multiple myomectomies (Multiple linear regression).\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eDependent variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eIndependent variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eB [SD]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003eDof\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eBlood Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eHolding other variables constant\u003c/p\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSurgery approach\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNumber of Fibroids\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFibroids weight\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSurgery Time\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-503 [519.4]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.354 [14.32]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-175.9 [155.5]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18.23 [7.016]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.237 [0.1977]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.797 [0.9644]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.3359\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.6532\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.2628\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.0117\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0674\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eHospital stay\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eHolding other variables constant\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSurgery approach\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNumber of Fibroids\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFibroids weight\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSurgery Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e29 [9.4]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.78 [0.26]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.2 [5.7]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.61 [0.49]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.032 [0.0079]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.15 [0.039]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0030\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.0049\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.4716\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.2180\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.0002\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.0003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Post-operative outcomes in multiple myomectomy group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-operative Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLaparoscopy\u003cbr\u003e\u0026nbsp;n = 48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLaparotomy\u003cbr\u003e\u0026nbsp;n = 26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eBlood loss (mL [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e500 (2680)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e850 (4980)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,0029\u003c/strong\u003e \u003cstrong\u003e(**)\u003c/strong\u003e(Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eDrop in Hemoglobin (g/dL [SD])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2,032 (1,023)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2,845 (1,781)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,0244 (*)\u003c/strong\u003e(t-test)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eSurgery time (Minutes [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e240 (420)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e165 (255)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,0005 (***)\u003c/strong\u003e(Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eHospital stay (Days [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,0001 (***)\u003c/strong\u003e(Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Post-operative outcomes in unique \u0026gt; 10 cm myomectomy group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-operative Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLaparoscopy\u003cbr\u003e\u0026nbsp;(n = 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eLaparotomy\u003cbr\u003e\u0026nbsp;(n = 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eBlood loss (mL [SD])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e500 (264,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e683,8 (842,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0,6438 (t-test)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eDrop in Hemoglobin (g/dL [SD])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2,625 (0,3948)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2,685 (1,462)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0,9380 (t-test)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eSurgery time (Minutes [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e195 (150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e180 (180)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0,4841 (Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eHospital stay (Days [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 195px;\"\u003e\n \u003cp\u003e0,3113 (Mann-Whitney)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Obstetrical data \u0026ndash; Multiple myomectomy\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\" style=\"margin-right: calc(-1%); width: 101%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 61.4531%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAge (years [SD])\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePre-operative gestation (mean [SD])\u003c/p\u003e\n \u003cp\u003ePatients with post-operative pregnancy (% (n))\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePatients with post-operative lived pregnancy (% (n))\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEctopic pregnancies (% (n))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.2126%;\"\u003e\n \u003cp\u003eLaparoscopy (n=54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9484%;\"\u003e\n \u003cp\u003eLaparotomy (n=40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3183%;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.2126%;\"\u003e\n \u003cp\u003e35 [5.2]\u003c/p\u003e\n \u003cp\u003e0.7 [1.8]\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16.6 (9)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14.8 (8)\u003c/p\u003e\n \u003cp\u003e1.8 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9484%;\"\u003e\n \u003cp\u003e35 [5.0]\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 [2.3]\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (6)\u003c/p\u003e\n \u003cp\u003e15 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3183%;\"\u003e\n \u003cp\u003e0.4775 \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0380\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.5304\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.9852\u003c/p\u003e\n \u003cp\u003e0.4014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fibroids, laparoscopy, laparotomy, complications, myomectomy","lastPublishedDoi":"10.21203/rs.3.rs-6314972/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6314972/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eComplex myomectomies involving large myomas more than 10cm and multiple myomas are considered challenging in laparoscopic surgery. The aim of this original study is to compare the fertility outcomes and complications of laparotomy versus laparoscopy in complex myomectomies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Retrospective study approved by the Brugmann University Hospital\u0026rsquo;s ethics committee (CE2023/79). Complex myomectomies were defined as single fibroids larger than 10cm and multiple fibroids. Ninety-four patients (mean-age-35-years) included. The laparoscopic and laparotomic myomectomy groups consisted of 54 and 40 patients respectively. Normality of data was assessed by Q-Q plot, when normality was not ascertained comparisons were carried out using the Mann-Whitney tests for unpaired comparisons, or Wilcoxon otherwise. When normality was reached t-tests for paired or unpaired comparisons were preferred.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe peri-operative blood loss is significantly higher when the surgical approach used was laparotomy (700 vs 500 mL, p\u0026thinsp;=\u0026thinsp;0.031), associated with a greater drop in hemoglobin (2.3 vs 2.1, p\u0026thinsp;=\u0026thinsp;0.081) and a higher transfusion rate (0.13% vs 0.06%, p\u0026thinsp;=\u0026thinsp;0.486). Median surgery time was shorter (180 min. vs 240 min., p\u0026thinsp;=\u0026thinsp;0.0002) and hospital stay longer (3 days vs. 2 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) in the laparotomy group. The laparotomy conversion rate was 3,2%. In multiple linear regression analysis, blood loss appears to be significantly influenced by the number of fibroids and the fibroids\u0026rsquo; weight. Hospital stay appears to be significantly influenced by the patients age, the fibroids\u0026rsquo; weight, and the surgery time. Thirty-two percent of patients achieved pregnancy post-surgery, with no statistically significant differences between the two groups in terms of pregnancy success rates (p\u0026thinsp;=\u0026thinsp;0.5304).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese results show that even in complex myomectomies, laparoscopic approach could still be the first line of treatment. Laparoscopic myomectomy does not signify higher risks or complications and has significantly lower risk of bleeding and hospitalisation time without compromising fertility outcomes.\u003c/p\u003e","manuscriptTitle":"Old- versus New-School: Laparoscopy versus Laparotomy in Complex and Multiple Myomectomies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 09:11:38","doi":"10.21203/rs.3.rs-6314972/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-09T04:32:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-07T21:18:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291493981713151374556563590520048592205","date":"2025-05-07T20:54:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-07T12:41:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339071777916744477041359193538332917742","date":"2025-05-07T12:16:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-06T14:08:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120108461229802408801136311726305556686","date":"2025-05-05T12:15:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T12:02:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T07:28:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-04T18:44:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-05-04T18:42:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"18db13b8-66ad-452c-bae8-1b96bec4d4dc","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-21T12:23:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 09:11:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6314972","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6314972","identity":"rs-6314972","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}