Introduction
Benign ovarian cysts are common gynecological problems in approximately 7 % of women during procreative age1. Laparoscopic ovarian cystectomy, rather than oophorectomy, has been considered the surgical treatment of benign ovarian cysts in patients who desire further fertility. Surgeons perform excision of ovarian cysts by stripping the cyst wall, and the subsequent bleeding may be controlled using electrocoagulation, a hemostatic agent, or suturing2. The ovarian reserve may be affected by mechanical injury or thermal damage during laparoscopic cystectomy. Mechanical injury is often caused by the removal of healthy ovarian tissue close to the lesion 3. Furthermore, hemostasis achieved with electrical energy increases the risk of thermal damage to the surrounding ovarian tissue 4.
Treating benign ovarian cysts has become an issue for patients desiring fertility. Previous studies had reported reduced ovarian reserve after laparoscopic cystectomy 5, 6. Varied types of hemostatic agents have been developed and introduced in surgical intervention to avoid using bipolar coagulation and reduce thermal damage 7. The hemostatic matrix commonly used is comprised of a gelatin-based matrix and a human-derived thrombin component. When the gelatin granules contact the bleeding site, they swell to tamponade the bleeding. Then, they interact with thrombin and induce clot formation, achieving rapid hemostasis. Studies have been conducted to compare the preservation of ovarian reserve in laparoscopic cystectomy when using nonthermal hemostatic methods versus bipolar coagulation.
Previous studies employed the ovarian reserve to define the functional potential of the ovary and reflect the number and quality of oocytes remaining in the ovary. Several measurements, such as anti-Müllerian hormone (AMH), antral follicle count (AFC), and basal follicle-stimulating hormone (FSH) level, are used to evaluate ovarian reserve 8-10. Among these ovarian reserve markers, AMH and AFC are the most accurate ones for representing the functional potential of the ovary11, 12.
A meta-analysis in 2018, including three randomized controlled trials (RCTs), showed a significant adverse effect of bipolar electrocoagulation on postoperative ovarian reserve three months after laparoscopic surgery for endometrioma compared to nonthermal hemostatic methods 13. In another meta-analysis conducted in 2022, RCTs comparing at least two hemostatic approaches in laparoscopic excision of endometrioma were included. It concluded that suturing is an effective hemostatic method for maintaining a higher ovarian reserve14. Naturally, endometrioma is close to the ovarian cortex, where the primordial follicles reside. Consequently, inadvertent damage of the cortex during surgical intervention can result in a more significant loss of follicles. By contrast, other benign ovarian cysts are not located beside the ovarian cortex15. Since the detrimental effect of mechanical or thermal injury on other benign ovarian cysts is unclear, we performed a systematic review and meta-analysis to analyze the impact of nonthermal hemostatic methods on ovarian reserve during laparoscopic cystectomy compared to electrocoagulation. We undertook a comprehensive analysis of follow-up data at postoperative 3, 6, and 12 months, providing insights into both short-term and long-term effects of thermal injury induced by electrocoagulation. In contrast to prior meta-analyses, we also conducted separate subgroup analyses on the data for endometriomas and other benign ovarian cysts.
Materials and methods