Uterine fibroids are common pathology among reproductive-aged women, causing: - abnormal uterine bleeding, pelvic discomfort, and fertility problems (RPL, BOH, Subfertility). Many women opt for laparoscopic myomectomy (LM) to conserve their uterus for fertility &/or menstrual function. [1,2] LM is perhaps better than open in terms of fertility & obstetrical outcomes, with decreased intra-op bleeding & post-op disability.[3] hereby, presenting our small 3-year, single centre experience of these case series. Aims and Objectives • Primary- i. Reproductive outcomes ii. Menstrual patterns • Secondary- i. Complications (Intra-Op, Post-Op) ii. Average Surgical Time

This is a single Centre, retrospective observational case series conducted in the department of Gynecology at Shri Mahaveer Hospital, Raipur. 28 women of reproductive age group with myoma(s), desirous of uterine preservation were recruited. Laparoscopic Myomectomy (LM) was done in these females. Medical records of LM cases & telephonic follow up for menstrual & reproductive outcomes was done for data collection from April 2022 - March 2025. Technique Standard Technique with 3/4 ancillary ports was used for Laparoscopic Myomectomy. Use of Vasopressin injection was employed. Mechanical Myoma Enucleation was conducted. Multilayer Suturing of dead space, with barbed/ strata fix/ vicryl sutures was done with use of intra-corporeal tying.

There is total 42 Cases enrolled during study duration is as follows: Abdominal (+/- AH, Broad Ligament) = 6, Vaginal (Fibroid Polyp, Central Cervical) = 4, Conversion (POD Adhesions, Vascularity) = 4, Laparoscopic = 28, these cases were further analyzed for this study. Baseline characteristics is summarized in Table no. 1. Table 1: Baseline characteristics S. N. Patient characteristics Mean(+/-SD) Range/% 1 Age [years] 29.36+/-2.93 25-35 2 BMI [kg/m2] 28.58+/-2.35 23.7-35 3 Gravida - 0-3 4 Parity - 0-2 5 Presentation AUB Subfertility Pain/pressure Asymptomatic 22 20 10 6 78.57% 71.43% 35.31% 21.43% 6 Myoma volume[ml] average 60.89 12.25-226 7 Diameter of myoma [in cm] average 5.9+/-1.12 3-8.5 8 No. of myoma 56 total 8 single, 20 multiple 9 Location Intramural Sub-Serosal Sub-Mucosal 52 4 0 92.86% 7.14% 0 The mean age was 29.36± 2.93 years, mean BMI 28±2.35. Patients presented with abnormal uterine bleeding [78.57%], subfertility [71.43%], pain [35.71%], asymptomatic [21.43%]. Mean myoma volume was 60.89 ml, mean myoma diameter was 5.9±1.12cm. mostly myoma located in intramural [92.86%], sub-serosal [7.14%] location. Procedural details are summarized in Table no. 2. Table 2: Procedural details S.N. Parameter Mean value [range] 1 No. of myoma removed 56 2 Largest myoma removed 8.5*7.0*8.7 cm 3 Largest volume 266 ml 4 Operative time [average, range] 100+/-24 min 70-140 min 5 Need of BT 10 6 Add-on procedures In 10 cases 7 Complications Grade-1 Grade-2 14 10 8 LOS [days] 2.75; [2-4] The mean time for operative procedure was 100±24min [70-140min], length of stay 2.75 [2-4 days]. Multiple Myomas were removed in 20 cases, Intramural-type lesions occurred in 26 of cases, and Mean Myoma Diameter was 5.9 cm. Need for preop BT arose in 10 patients, 8pre-op, 2 post op (2 PCV). Need for transfusion was not directly related to operative blood loss, as all had preoperative anaemia. Average Surgical time was 100 +/- 20 minutes. No severe complications were reported in any of our cases. Of mention was a case of Intravenous Leiomyomatosis diagnosed on histopathology post operatively, which was fully evaluated and followed up for 1.5 years as per standard guidelines. The myoma characteristics in those who conceived post procedure were analysed and has been compiled in Table No. 3. Table No. 3 Myoma characteristics Sr. No Characteristic Pregnancy (14) No Preg (14) P value, S/NS 1 Age (in Yrs) 28.57 ± 2.99 30.14 ± 2.85 0.34, NS 2 BMI (in kg/m²) 29.08 ± 5.47 28.09 ± 4.26 0.71, NS 3 Infertility Duration (in months) 30.43 ± 10.06 31.86 ± 26.18 0.89, NS 4 Dominant Type Intra Mural Intra Mural - 5 Myoma Volume (in ml) 134.74 ± 67.5 108.84 ± 13.1 0.34, NS 6 Myoma Size (in cms) 12.39 ± 3.67 10.59 ± 2.34 0.29, NS 7 No. of Enucleated Myomas (Total number) 32 24 - 8 Duration of Operation (in min) 117.14 ± 18.9 84.29 ± 17.2 0.09, NS 9 Blood Transfusion 10 0 - There was no any significant association found between age, BMI, duration of infertility, myoma type, volume, size, number, and duration of operation between pregnant and non-pregnant females. Antenatal, delivery & fetal outcomes v/s myoma characteristics have been complied in Table No. 4. Pregnancy outcomes after LM: - (n=14); FT=10, PT=4 & CS=12, 2=VD. The Mean Interval between LM and Pregnancy was 14 months, and NO cases of Uterine Rupture occurred during pregnancy. Menstrual pattern was studied in all the cases. 22 cases had heavy menstrual bleeding in the preoperative period and only 6 patients had normal bleeding pattern. Following a period of greater than 6 months follow up we noted that Heavy menstrual bleeding was not found in any patient and it had resolved. 22 have normal Menstrual Patterns post LM, while remaining 6 have scanty cycles. Table No. 4: Antenatal, delivery & fetal outcomes v/s myoma characteristics Sr. No Parameter N/mean 1 Interval to Conceive (Mean months) 14 2 ANC: - Abortion (< 12wks) 0 3 Preterm Delivery 4 4 Full Term 10 5 LBR 14 6 VD/CS 2/12 7 Rupture/Dehiscence 0 8 Fetal Outcome: - Fetal Weight 1.7-2.8 9 APGAR 8/10-9/10

The present study evaluates surgical characteristics, perioperative outcomes, and reproductive performance following laparoscopic myomectomy (LM) in a cohort of 42 patients managed over the study period. The predominance of laparoscopic procedures (28/42 cases) reflects the growing preference for minimally invasive approaches in the management of uterine fibroids, owing to their well-documented benefits in terms of reduced morbidity, shorter hospital stay, and faster recovery. [4,5] In our series, abdominal myomectomy, including cases with associated adenomyosis or broad ligament fibroids, constituted a relatively small proportion (6 cases), while vaginal approaches were utilized selectively (4 cases) for fibroid polyp and central cervical fibroids. Conversion to open surgery occurred in 4 cases, primarily due to dense postoperative adhesions and increased vascularity. This conversion rate aligns with previously reported rates (5–15%) and underscores the importance of careful intraoperative assessment and readiness to convert when patient safety is a concern. Importantly, conversion should not be viewed as a complication but rather as a judicious surgical decision. Multiple myomas were encountered in nearly half of the cases (20/42), and intramural fibroids were the most common subtype (24 cases). The mean myoma diameter of 5.9 cm falls within the range considered suitable for laparoscopic removal, supporting the feasibility of LM even in moderately large fibroids when performed by experienced surgeons. The ability to manage multiple and intramural fibroids laparoscopically highlights advancements in surgical skill, instrumentation, and suturing techniques. Blood transfusion was required in 10 patients, with the majority (8 patients) needing preoperative transfusion due to pre-existing anaemia, and only 2 patients requiring postoperative packed cell volume transfusion. Notably, the need for transfusion was not directly related to intraoperative blood loss, emphasizing that baseline haematological status plays a critical role in perioperative transfusion requirements. This finding reinforces the importance of optimizing haemoglobin levels preoperatively, particularly in patients with fibroid-related menorrhagia. [6,7,8] The average operative time of 100 ± 20 minutes is comparable with other published series of LM and reflects procedural efficiency despite the presence of multiple and intramural fibroids. Furthermore, no statistically significant association was observed between age, body mass index, duration of infertility, myoma size, operative duration, or myoma volume when comparing pregnant and non-pregnant patients.[9-11] This suggests that successful reproductive outcomes following LM may depend more on restoration of uterine anatomy than on individual fibroid characteristics alone. Reproductive outcomes following LM were encouraging. Fourteen patients conceived during the follow-up period. Of the remaining 14 patients, 4 are undergoing treatment for spontaneous conception, 3 are unmarried, 1 is separated, and 6 are not currently planning pregnancy. A mean interval of 14 months between surgery and conception, which is consistent with the recommended healing period before attempting pregnancy. Among these pregnancies, the majority resulted in full-term deliveries (10 cases), while four were preterm. The high Cesarean section rate (12 out of 14 pregnancies) reflects prevailing obstetric caution following uterine surgery rather than an absolute necessity, as evidenced by two successful vaginal deliveries. Importantly, no cases of uterine rupture were observed, supporting the structural integrity of the uterine scar after laparoscopic sutured myomectomy, as consistent with literature. [12] Menstrual outcomes further support the efficacy of LM, with 22 patients reporting normalization of menstrual patterns postoperatively. Only six patients experienced scanty cycles, which may be attributed to endometrial disruption or altered uterine vascularity, though these changes were not associated with adverse reproductive outcomes in this cohort. Overall, the findings of this study reinforce the safety and effectiveness of laparoscopic myomectomy in appropriately selected patients. LM provides satisfactory surgical outcomes, preserves fertility, and is associated with favourable obstetric and menstrual results.[13-15] The absence of uterine rupture and the lack of significant predictors distinguishing pregnant from non-pregnant patients further strengthen the role of LM as a preferred approach for women desiring future fertility. Larger prospective studies with longer follow-up are warranted to further validate these findings and refine patient selection criteria. Similar results and observations have been found in various Indian studies which has been compiled in Table No. 5. Table No. 9: Recurrence rate comparison Sr. No Author (Year) N Recurrence Rate 1 A. Rosetti (2001) 81, 78 27%, 21.7% (75%, 10–30 months) 2 Yoo EH (2007) 512 11.7% (1 year), 36.1% (3 years), 52.9% (5 years), 84.4% (8 years) 3 Sinha (2008) 505 1.19% (6/505 TLH, 4–6 years) 4 Flyckt RL, Falcone (2016) 134 (LAP = 28) 23.88% (4 hysterectomy, 28 fibroid surgery) Table No. 5: Study comparison with Indian studies No. Author (Year) N No. of Myomas Removed (Average, Range) Site Largest Myoma Removed (cm) (Average, Range) BT / EBL (ml) Operating Duration (min) LOS (days) 1 Sinha (2008) [4] 505 1.85 ± 5.706; 36.4% multiple – 5.86 ± 3.3; Weight: 227.74 ± 325.801 g (median 100 g) 90 (40–2000) 60 (30–270); 136.67 ± 38.28 – 2 Paul (2010) [9,15] 1001 1.97 (1–17); 42.8% multiple IM = 49.52%; SS = 36.8% 1–20 250.5 (20–1000); Hb drop = 1.43 g% 95 (20–280) 1.3 (1–5) 3 Nazer et al. (2016) [9,15] 31 – IM = 51.6% 5 (1.5–12) – 161 ± 31.2 2 4 Rooma Sinha et al (2024) [17] 114 - Anterior- 36 Posterior- 19 Lateral- 11 Fundal- 20 3-5 cm 110.47 ±70.41 147.33 ±58.49 We have also reviewed international studies to understand the importance of the technique and the observations have been compiled in Table No. 6. Table 6: Study comparison with international studies No. Author (Year) N No. of Myomas Removed (Average, Range) Largest Myoma Removed (cm) (Average, Range) EBL (ml) Operating Duration (min) LOS (days) 1 Malzoni (2006) 982 2.23 (1–8) 6.72 ± 2.71 (1–20) 104.5 (30–360) – 2.02 ± 0.61 2 Rosetti (2007) 332 2.23 ± 1.7 (1–8) 6.2 ± 2.7 (1–20) 124.02 ± 52.2 – 2.0 ± 0.57 3 Sizzi (2007) 2050 2.26 ± 1.8 (1–15) 6.40 ± 2.6 (1–20) 107.71 ± 43.42 – 1.99 ± 0.9 4 Saccardi (2014) 444 – 7.6 ± 2.7 184.1 ± 233.5 77.2 ± 33 2.54 ± 1.1 5 Zhang RC et al. (2019) 68 – – 23.53 ± 23.1 29.55 ± 3.14 3.58 ± 1.73 6 Kan X, Sen X et al. (2021) 86 (42,44) 2.75 ± 1.98 7.47 ± 2.60 44.4 ± 5.82 70.21 ± 7.83 8.12 ± 2.1 7 Nikolai et al (2024) [16] 38 - Subserous (FIGO- 7)- 5 Intramural-subserous (FIGO 5 OR 6)- 19 Intra mural (FIGO 4)= 14 3-5 cm Complications from various studies have been compiled in Table No. 7. Table No: 7: Complications from various studies [7] No Author (Yr) N Complication Rate % 1 Sizzi 2007 2050 2.02, haemorrhage (0.68%), postop hematoma (0.48%), bowel injury (0.04%), emergency hysterectomy (0.09%) 2 Sinha 2008 505 BT=39.2%, 2 cases LMS, 1= Parasitic Myoma 3 Paul 2010 1001 Major=0.5, Minor=3.8, 2.62, 1=Death (Pul. TE), 1=Bleeding Re-open, 14=SSI, 0.9%=BT 4 Nazer et Al, 2016 31 3.2 Vessel Injury, 5.8=BT 5 Bean EM, 2017 514 2 (0-2.4) 6 Rebecca Mallick Et Al, 2017 [8] 323 2.79 (1= Reopen-Bleeding, 2=U. Retention, 4=Port Hernia) 7 Kan X, Sen X Et Al, 2021 [11] 86 (42,44) 9.52, 1 each UTI, Pain, 2 Pelvic Adhesions 8 Zhang RC Et Al, 2019 68 1.47% subcutaneous emphysema 9 Rooma et al, 2024 114 No any complication 10 OUR STUDY 2022-25 28 Major=0; Minor=24; Gr1=14 (mild Fever 8, Vomiting 3, UTI 2, Headache 1); Gr2=10 (BT) Reproductive outcome has been compiled in Table No.8. Table No. 8: Reproductive outcome No Author (Yr) N Conception/Fertility Rate (A=Abortion, PT= Preterm Birth, CS= Caesarean Birth, R= Rupture) 1 Sizzi et al. 2007 2050 ~70% pregnancy success rate 1 Fagherazzi Et Al, (2014) 115 62.2, A= 38, E= 2, PT= 7, CS= 63.4%, VD= 36.6% 2 Yu-Jin Koo Et Al, (2015) 523 PT/A= 4.4 FT= 76.5% , VD= 19.1% 3 Pepin K Et Al, (2020) [14] 240 71% PT= 8/110, CS= 90% 4 Kan X, Sen X Et Al, (2021) 86 (42,44) 47.62 (12MTH), 90.48 (24Mths) 5 Nikolia et al, 2024 38 63% pregnant within 2 years, 13 (54.1%) were delivered by Cesarean section, and 11 (45.9%) were delivered naturally. 6 Rooma et al, 2024 114 49 cases conceived spontaneously and 37 by IVF, pregnancy rate – 86%, Live birth rate 73.3%; similar outcomes by spontaneous or IVF conception 7 OUR STUDY 2022-25 28 50% Pregnancy and Live Birth Rate, A=0, PT= 28.57%, FT= 71.43% VD= 28.57%, CS= 71.43% Recurrence rate has been compiled and compared in Table No. 9.

Laparoscopic Myomectomy is a viable option in women with symptomatic fibroids who want to retain their uterus. The procedure is safe in hands of skilled surgeon. Reassuring favourable Peri & Post-Operative outcomes should prompt consideration of minimally invasive myomectomy whenever possible. Larger prospective, multi centre studies should be undertaken to investigate Reproductive and Menstrual results, with aim to identify variables that predict successful Live Births and Quality of Life improvement. Ongoing Self-Audit of outcomes and dedicated Enhanced Recovery Protocol (ERP) approach are essential to improve outcomes. Limitations • Small number of cases • Retrospective nature However given the infrequency of LM surgery being performed, we felt this to be a reasonable study design for Research & Audit Objectives, along with further Continued Improvements in our Patient Management.

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