RESUMO
OBJECTIVE: To compare the effect of hemostatic techniques (bipolar energy versus hemostatic sealants versus suture) on the ovarian reserve of patients submitted to laparoscopic cystectomy for the surgical excision of unilateral endometrioma. METHODS: A randomized controlled trial conducted in a teaching hospital included 84 patients with unilateral endometrioma. The patients underwent laparoscopic stripping for excision of the unilateral endometrioma between March 2018 and February 2020. Three different hemostatic techniques-bipolar energy (Group 1), hemostatic sealants (Group 2), and suture (Group 3)-were compared. Anti-Müllerian hormone (AMH) levels were measured before, and 1 and 6 months after surgery to determine changes in ovarian function. RESULTS: Following surgery, AMH levels decreased in all the groups; however, this decrease was not statistically significant. Comparison between groups showed no statistically significant differences in AMH levels between the three hemostatic techniques used. Six months after surgery, median AMH levels were: 1.65 ng/mL (interquartile range [IQR] 0.62-2.08 ng/mL) in Group 1, 1.87 ng/mL (IQR 1.27-2.97 ng/mL) in Group 2, and 1.53 ng/mL (IQR 1.18-2.44 ng/mL) in Group 3. CONCLUSION: The present study suggests that there is no difference between the different hemostatic techniques used in laparoscopic cystectomy for the treatment of unilateral endometriomas. Registered at ClinicalTrials.gov: NCT03430609. https://clinicaltrials.gov/ct2/show/NCT03430609.
Assuntos
Endometriose , Hemostáticos , Laparoscopia , Cistos Ovarianos , Reserva Ovariana , Hormônio Antimülleriano , Endometriose/cirurgia , Feminino , Técnicas Hemostáticas , Hemostáticos/uso terapêutico , Humanos , Laparoscopia/métodos , Cistos Ovarianos/cirurgiaRESUMO
BACKGROUND: Laparoscopic cystectomy is currently considered the gold standard for the treatment of ovarian endometrioma, resulting in an improvement in symptoms, a lower recurrence rate, and a higher pregnancy rate among infertile patients. However, this treatment is not free from risk, since it is associated with a reduction in ovarian reserve. There is still controversy in the literature regarding whether the cause of the reduction in ovarian reserve is due to damage caused by the coagulation energy during hemostasis or whether the procedure itself is the cause of the damage irrespective of the hemostatic method used. The aim of this study is to compare the effects of different hemostatic methods on the ovarian function of women subjected to laparoscopic surgery for ovarian endometrioma. METHODS: An open-label randomized clinical trial to be conducted at the Lauro Wanderley University Hospital between December 2017 and August 2020. Eighty-four patients will be randomly allocated to three groups according to the hemostatic technique used during laparoscopic surgery for ovarian endometrioma: bipolar coagulation; laparoscopic suture; and hemostatic matrix. Ovarian function will be assessed by serum anti-Müllerian hormone measurement and by performing an antral follicle count using ultrasound before surgery and one, three, and six months after surgery. The internal review board of the Medical Sciences Center, Federal University of Paraíba approved the study protocol under reference CAAE 71621717.9.0000.8069. DISCUSSION: Bearing in mind the need for more randomized clinical trials to clarify this issue, we hope to contribute with data that will determine whether there is any difference between hemostatic methods despite the rational use of bipolar energy or whether the procedure itself explains the ovarian damage irrespective of the hemostatic technique used. TRIAL REGISTRATION: ClinicalTrials.gov, NTC03430609 . Registered on XX.10/31/2017. ISRCTN Registry, ISRCTN11469394 . Registered on XX.17/12/2017. Unique Protocol ID: U1111-1203-2508.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Endometriose/cirurgia , Procedimentos Cirúrgicos em Ginecologia , Técnicas Hemostáticas , Laparoscopia , Cistos Ovarianos/cirurgia , Reserva Ovariana , Hormônio Antimülleriano/sangue , Biomarcadores/sangue , Brasil , Endometriose/diagnóstico por imagem , Endometriose/fisiopatologia , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Técnicas Hemostáticas/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Cistos Ovarianos/diagnóstico por imagem , Cistos Ovarianos/fisiopatologia , Folículo Ovariano/diagnóstico por imagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this review was to analyze the impact on ovarian reserve of the different hemostatic methods used during laparoscopic cystectomy. DATA SOURCES: The studies were identified by searching electronic databases (MEDLINE, Embase, Cochrane, LILACS) and scanning reference lists of articles. METHODS OF STUDY SELECTION: We selected clinical trials that assessed the influence of hemostatic techniques on ovarian reserve in patients with ovarian cysts with benign sonographic appearance submitted to laparoscopic cystectomy by stripping technique. The included trials compared different laparoscopic hemostatic techniques: suture, bipolar electrocoagulation, ultrasonic energy and hemostatic sealants. The outcomes evaluated were level of serum anti-Mullerian hormone (AMH) and antral follicle count (AFC). The possibility of publication bias was evaluated by funnel plots. TABULATION, INTEGRATION AND RESULTS: Twelve trials involving 1,047 patients were evaluated. Laparoscopic suture was superior to bipolar coagulation when evaluating serum AMH and AFC, in the 1st, 3rd, 6th and 12th month after surgery. In the comparison between bipolar and hemostatic sealants, the results favored the use of hemostatic agents. The use of ultrasonic energy was not superior to the use of bipolar energy. CONCLUSION: We recommend suture for hemostasis during laparoscopic cystectomy.
OBJETIVO: O objetivo desta revisão foi comparar o impacto dos diferentes métodos hemostáticos na reserva ovariana durante a ooforoplastia laparoscópica. FONTES DE DADOS: Os estudos foram identificados através da pesquisa de bases de dados eletrônicas (MEDLINE, Embase, Cochrane, LILACS) e listas de referência de artigos. SELEçãO DOS ESTUDOS: Selecionamos ensaios clínicos que avaliaram a influência das técnicas hemostáticas na reserva ovariana em pacientes com cistos ovarianos com aspecto ultrassonográfico benigno submetidos à ooforoplastia laparoscópica pela técnica de tração e contra-tração. Os estudos incluídos compararam as técnicas hemostáticas: sutura, energia bipolar, energia ultrassônica e selantes hemostáticos. COLETA DE DADOS: Os desfechos avaliados foram o hormônio antimülleriano e a contagem de folículos antrais. A possibilidade de viés de publicação foi avaliada por gráficos de funil. SíNTESE DOS DADOS: Doze estudos envolvendo 1.047 pacientes foram avaliados. A sutura foi superior à coagulação bipolar, e, na comparação entre selantes e energia bipolar, os resultados favoreceram o uso do primeiro grupo. O uso de energia ultrassônica não foi superior ao uso da energia bipolar. CONCLUSãO: Em conclusão, recomendamos a sutura para hemostasia durante a ooforoplastia laparoscópica.
Assuntos
Cistectomia , Hemostasia/fisiologia , Laparoscopia , Cistos Ovarianos/cirurgia , Reserva Ovariana/fisiologia , Adulto , Cistectomia/métodos , Feminino , Humanos , Laparoscopia/métodos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Abstract Objective The objective of this review was to analyze the impact on ovarian reserve of the different hemostatic methods used during laparoscopic cystectomy. Data Sources The studies were identified by searching electronic databases (MEDLINE, Embase, Cochrane, LILACS) and scanning reference lists of articles. Methods of Study Selection We selected clinical trials that assessed the influence of hemostatic techniques on ovarian reserve in patients with ovarian cysts with benign sonographic appearance submitted to laparoscopic cystectomy by stripping technique. The included trials compared different laparoscopic hemostatic techniques: suture, bipolar electrocoagulation, ultrasonic energy and hemostatic sealants. The outcomes evaluated were level of serum anti-Mullerian hormone (AMH) and antral follicle count (AFC). The possibility of publication bias was evaluated by funnel plots. Tabulation, Integration and Results Twelve trials involving 1,047 patients were evaluated. Laparoscopic suturewas superior to bipolar coagulationwhen evaluating serum AMHand AFC, in the 1st, 3rd, 6th and 12thmonth after surgery. In the comparison between bipolar and hemostatic sealants, the results favored the use of hemostatic agents. The use of ultrasonic energy was not superior to the use of bipolar energy. Conclusion We recommend suture for hemostasis during laparoscopic cystectomy.
Resumo Objetivo O objetivo desta revisão foi comparar o impacto dos diferentes métodos hemostáticos na reserva ovariana durante a ooforoplastia laparoscópica. Fontes de Dados Os estudos foram identificados através da pesquisa de bases de dados eletrônicas (MEDLINE, Embase, Cochrane, LILACS) e listas de referência de artigos. Seleção dos estudos Selecionamos ensaios clínicos que avaliaram a influência das técnicas hemostáticas na reserva ovariana em pacientes com cistos ovarianos com aspecto ultrassonográfico benigno submetidos à ooforoplastia laparoscópica pela técnica de tração e contra-tração. Os estudos incluídos compararam as técnicas hemostáticas: sutura, energia bipolar, energia ultrassônica e selantes hemostáticos. Coleta de dados Os desfechos avaliados foram o hormônio antimülleriano e a contagem de folículos antrais. A possibilidade de viés de publicação foi avaliada por gráficos de funil. Síntese dos dados Doze estudos envolvendo 1.047 pacientes foram avaliados. A sutura foi superior à coagulação bipolar, e, na comparação entre selantes e energia bipolar, os resultados favoreceram o uso do primeiro grupo. O uso de energia ultrassônica não foi superior ao uso da energia bipolar. Conclusão Em conclusão, recomendamos a sutura para hemostasia durante a ooforoplastia laparoscópica.