Minimally Invasive Myomectomy: A Systematic Review of Techniques, Challenges, and Fertility Outcomes.

Abstract

Uterine fibroids represent a prevalent gynecological condition with significant implications for fertility and quality of life. This systematic review evaluates the efficacy, safety, and fertility outcomes of minimally invasive myomectomy (MIM) techniques, including laparoscopic myomectomy (LM), robot-assisted laparoscopic myomectomy (RALM), and single-port laparoscopic myomectomy (SPLM), and non-invasive approaches such as ultrasound-guided high-intensity focused ultrasound (USgHIFU). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we analyzed 17 studies encompassing diverse surgical methods and reproductive outcomes, with quality assessment performed using the Newcastle-Ottawa scale (NOS). Key findings demonstrate that MIM techniques yield favorable fertility outcomes compared to traditional abdominal myomectomy. Among the included studies, 10 were rated as low risk of bias and 7 as moderate risk on the NOS. Laparoendoscopic single-site myomectomy (LESS-M) and SPLM were associated with higher pregnancy rates (66.7% and 75%, respectively) and shorter time to conception (7.6 vs. 10.1 months for LESS-M vs. conventional LM). RALM showed promise in complex cases, with pregnancy rates of 13-66.7% and no reported uterine ruptures. Non-invasive USgHIFU offered comparable pregnancy rates to LM but was linked to shorter conception times and mixed fetal outcomes, including higher preterm birth rates. Surgical nuances, such as barbed versus nonbarbed sutures, did not significantly impact fertility, while fibroid characteristics and surgeon expertise played pivotal roles. Vaginal birth after LM was deemed safe, with no uterine ruptures reported in large cohorts. However, heterogeneity in study designs, retrospective biases, and limited long-term follow-up data underscore the need for standardized protocols and prospective trials. MIM techniques are a viable option for women seeking fertility preservation, offering reduced morbidity and comparable or superior reproductive outcomes. Future research should prioritize multicenter studies to optimize patient selection and surgical standardization.