Evaluation of reproductive function in patients after using different hemostatic techniques (fibrin glue and bipolar coagulation) during ovarian surgery

Benign ovarian neoplasms are most common disorders in women of reproductive age [1, 2]. Mature teratomas and cystadenomas are of great practical importance, since these morphological variants are often diagnosed in patients with unrealized reproductive function and require surgical treatment [1, 2]. Current surgical treatment strategies include focusing on organ-sparing approach aimed at not only removal of ovarian neoplasm, but also maximum preservation of healthy ovarian tissue [3, 4].

The issue of reproductive outcomes after ovarian surgeries remains relevant, since any surgical intervention can lead to the damage of healthy ovarian tissue, impaired microcirculation, ischemia and subsequent decrease in ovarian reserve [4]. The severity of these changes depends on tumor size and location, the volume of the removed tissue, enucleation, and, to a large extent, the method of achieving   hemostasis. Bipolar coagulation is a widely used, convenient and affordable technique. However, it is associated with thermal damage to the ovarian stroma and vascular bed [5, 6].

Gentle methods of surgical hemostasis сan be considered as the most promising ways to preserve reproductive potential. The use of fibrin glue provides reliable control of intraoperative hemorrhage without causing tissue damage by coagulation. Recent studies on the outcomes of ovarian surgeries show that hemostatic agents and sealants have potential benefits in preservation of anti-Müllerian hormone (AMH) levels and antral follicle count compared to electrosurgical modalities [3, 7–9].

The objective of the study was to evaluate reproductive function in patients after the use of different hemostatic techniques during ovary-sparing surgery.

Materials and methods

The study included 164 women of reproductive age (from 18 to 45 years) with the diagnosis of cystic ovarian neoplasms (cystadenomas and/or teratomas), who were admitted to the Gynecological Department of V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of Russia from 2022–2024. All patients have signed informed consent to participate in the study.

Based on the intraoperative technique for hemostasis, two groups were formed. Group 1 included the patients for whom fibrin glue was used after ovarian cystectomy (n=86). Group 2 included the patients for whom hemostasis was achieved using bipolar coagulation (n=78). All patients underwent laparoscopic ovarian-sparing surgery.

Laparoscopic procedure was performed using the standard method. After creating pneumoperitoneum, the laparoscope and trocars were introduced into the abdominal cavity. Depending on the size of the neoplasm and anatomical features, 3–4 trocars were used. The optical trocar was inserted in the umbilical area, and additional trocars were inserted in the iliac and suprapubic regions. The stages of surgery included tumor enucleation, achieving hemostasis, suturing for approximation of the ovarian edges and extraction of surgical material. A cut was made through the tunica albuginea in the area of minimal vascularization. Then the plane between the tumor capsule and ovarian tissue was identified and peeled away using atraumatic instruments. The resected mass was placed in a retrieval bag and removed through the trocar site.

After tumor enucleation hemostasis was performed using different hemostatic techniques – fibrin glue (n=86) and bipolar coagulation (n=78). In the fibrin glue group, the ovary was fixed with exposure of the cyst bed, after that a thin, uniform layer of glue was applied to the bleeding surface using an applicator. Polymerization occurred within 1–2 minutes and provided complete hemostasis without the need for additional applications. In the bipolar coagulation group, hemostasis was achieved by using pinpoint coagulation at power 36–40 W under intermittent irrigation of the surgical field. Short-bursts of coagulation were used in the bleeding area of ovarian tissue to limit the depth of thermal injury.

The surgical specimens were sent for histological examination which was performed using standard methods. Morphological features of mature ovarian teratomas and cystadenomas were analyzed.

Assessment of reproductive function included analysis of pregnancy planning after surgery, pregnancy rate within 12 months of follow-up, as well as the need for using assisted reproductive technologies (ART).

Statistical analysis

Statistical data processing was performed using nonparametric methods. The quantitative data were represented as the median and interquartile range. To assess the prognostic value of the surgical hemostasis method, ROC analysis was performed calculating sensitivity, specificity and the area under the curve (AUC) with 95% confidence interval (CI). Additionally, the odds ratio (OR) with 95% CI was assessed to determine the impact of hemostatic techniques on the probability of pregnancy.

AUC values were interpreted according to the conventional classification. AUC below 0.6 suggested that model had very poor predictive ability. The values between 0.6–0.7 indicated poor, between 0.7–0.8 good, between 0.8–0.9 very good, and ≥0.9 excellent predictive ability of the model. The differences were considered statistically significant at p<0.05.

Results

No complications occurred during the intraoperative phase of surgery. The duration of surgery was comparable between the groups. However, fibrin glue reduced the amount of blood loss and provided rapid achievement of complete surgical hemostasis. Additional methods to stop bleeding were not needed in the fibrin glue group. The effectiveness of application of different hemostatic techniques for blood loss reduction differed (Table). The use of fibrin glue significantly reduced intraoperative blood loss compared to bipolar coagulation (p=0.004), that indicated more effective bleeding control when using this technique. The duration of operative intervention did not differ between the groups and did not depend on the chosen hemostasis method (p=0.059). However, the time to achieve complete hemostasis was significantly shorter using fibrin glue – 60 [50; 80] seconds versus 90 [70; 110] seconds using bipolar coagulation (p=0.020).

After organ-sparing surgical treatment, the differences were found in the indicators of reproductive function (Fig.1). The rates of patients who were planning pregnancy after surgery were comparable – 60.5% (52/86) in group 1 and 56.4% (44/78) in group 2 (p=0.60). Pregnancy rate within 12 months of follow-up was significantly higher in group 1 –  86.5% (48/52) of patients became pregnant compared to 65.9% (29/44) of patients in group 2 (p=0.017). At the same time, spontaneous pregnancy occurred more often in group 1 – in 59.6% (31/52) of women compared to 38.6% (17/44) in group 2 (p=0.039).  There was no significant difference between the groups in the need for using ART – 32.7% (17/52) and 27.3% (12/44), respectively (p=0,56).  Pregnancy rate in patients with initial infertility was higher in group 1 – 81.8% (18/22) versus 55.6% (10/18) in group 2 (p=0.03) (Fig. 2).

It was found that the use of fibrin glue was associated with an increased likelihood of pregnancy (OR=6.21; 95% CI 1.88–20.51) compared to bipolar coagulation. Therefore, the data obtained in the study indicate that gentle hemostasis provides more favorable reproductive outcomes.

Discussion

The obtained results confirm the key role of hemostasis method in formation of postoperative reproductive prognosis. This is especially important for women of reproductive age who are planning for pregnancy. Bipolar coagulation can cause thermal damage to the ovarian stroma and follicular apparatus, local ischemia, and impaired microcirculation [5, 6, 10]. Fibrin glue provides hemostasis without additional disturbances in coagulation, that allows to preserve a large volume of functionally active tissue and better parameters of blood supply [3, 7–10].

It should be noted that a significant part of scientific literature encompasses the issues related to assessment of ovarian reserve in endometriomas, while benign ovarian tumors of other morphologies have been studied to a lesser extent [4, 5, 7, 8]. For this reason, the data in our study are of practical interest. These data demonstrate that in cases of mature teratomas and cystadenomas, hemostatic techniques can significantly impact postoperative ovarian reserve and reproductive function [11].

The clinical significance of the identified differences is the fact that individualized choice of surgical strategy has become possible. In patients with unrealized reproductive function, diminished ovarian reserve, or bilateral ovarian lesions, gentle hemostasis should be considered a priority during organ-sparing surgery.

Conclusion

In patients of reproductive age with mature ovarian teratomas and cystadenomas, the method of surgical hemostasis is of great importance for preservation of ovarian reserve. The use of fibrin glue significantly reduces intraoperative blood loss, provides rapid achievement of surgical hemostasis, and is associated with higher pregnancy rate in patients who are planning pregnancy after surgical treatment, that is crucial for preservation of reproductive potential in women after ovarian surgery.