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