A comprehensive treatment strategy should balance cosmetic satisfaction with individualized considerations

Dear Editor,

Uterine fibroids, also known as leiomyomas, affect approximately 20–80% of women of reproductive age[1]. The heterogeneity in fibroid size, number, location, symptom presentation, and therapeutic goals necessitates an individualized treatment approach[2]. For women desiring fertility preservation or uterine retention for other reasons, myomectomy remains the predominant treatment[3]. It also provides a pathological diagnosis to guide subsequent therapy. Compared to laparotomy, laparoscopic myomectomy offers distinct advantages, including reduced pain, faster recovery, improved cosmetic outcomes, and fewer surgical complications[4]. However, specimen extraction through an auxiliary abdominal incision poses risks of wound infection, increased postoperative discomfort, incisional hernia, and suboptimal cosmesis. Consequently, laparo-endoscopic single-site surgery (LESS) emerged to meet the demand for minimal access surgery. This technique employs a single 2–4 cm longitudinal umbilical incision housing a multichannel single-port device through which all surgical procedures – including dissection, enucleation, hemostasis, suturing, and knotting – are performed. Despite its superior aesthetic potential, this innovative technology faces significant challenges. The ergonomic limitations of LESS can lead to restricted instrument triangulation, instrument collisions, and suboptimal exposure, particularly for fibroids in certain locations[5]. These constraints may obscure any potential benefits over conventional laparoscopic myomectomy (CLM). Thus, Xie et al[6]. conducted a systematic review and meta-analysis comparing LESS myomectomy (LESS-M) to CLM for uterine myomas.

Their meta-analysis included a total of 20 articles with 2766 subjects, published between 2012 and 2024, comprising three randomized controlled trials (RCTs) and 17 non-randomized studies (NRSs). They reported that LESS-M was associated with superior cosmetic satisfaction, reduced postoperative pain at 1 hour and 12 hours, shorter postoperative ambulation time, and shorter hospital stay compared to CLM. No significant differences were found in perioperative complications, operative time, blood loss, or transfusion rates. The authors are commended for their comprehensive discussion of the current evidence regarding the safety, efficacy, and potential advantages of LESS-M for uterine myomas. However, we would like to offer several reflections to enhance the interpretation and provide extended value. We make sure our article is compliant with the TITAN Guidelines 2025[7].

First, the primary findings are largely derived from retrospective studies (16 out of 20), with only three RCTs included. These studies exhibited varied inclusion criteria, fibroid characteristics, and operative platforms. The limited number and heterogeneity of RCTs increase the risk of selection bias and confounding factors, thereby limiting the strength of causal inference. Notably, considerable between-study heterogeneity (I² > 90%) was observed for several outcomes (e.g., operative time, intraoperative blood loss, hospital stay), which was not fully addressed. The observed shorter hospital stays with LESS-M achieved statistical significance only in NRSs (P = 0.003) but not in RCTs (P = 0.60), suggesting potential exaggeration in observational data and indicating that the current evidence is insufficient to support definitive conclusions.

Second, subgroup analysis was performed solely based on study design (RCTs vs. NRSs). However, intraoperative and postoperative measures are influenced by numerous factors, including fibroid characteristics (number, size, location), medication history, pelvic adhesion, surgeon expertise, and resource availability. These factors significantly influence both treatment allocation and clinical outcomes. For instance, preoperative treatment with GnRH agonists can correct anemia, reduce fibroid size, and decrease intraoperative bleeding, potentially confounding the interpretation of results[8]. Liu Y et al[3] suggest that the increased technical difficulty and perioperative burden associated with LESS-M might outweigh its limited aesthetic advantage, especially for larger or posterior fibroids. A more nuanced understanding of these factors is crucial for guiding surgical planning and tailoring treatment approaches.

Third, although the incidence of incision-related complications associated with LESS is lower than that associated with open surgery, it warrants emphasis. Poor healing of the umbilical incision, while occasional, is a noteworthy complication imposing significant physical and mental burdens on patients. Complications such as incisional hernia, dehiscence, infection, and hematoma can lower quality of life and prolong hospital stays. Factors contributing to poor umbilical incision healing include advanced age, overweight, comorbidities, prior abdominal surgery, contaminated incisions, immunosuppression, as well as suture materials and techniques. Additionally, in our experience, the routine omission of drainage in LESS-M precludes early detection and timely management of unexpected complications like postoperative bleeding or ureteral injury, potentially delaying diagnosis. This underscores the need for an individualized therapeutic strategy and consideration of selective drainage in high-risk or technically complex myomectomy procedures.

Finally, regarding the quality of evidence, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system rated most outcome indicators (e.g., operative time, estimated blood loss, hemoglobin decrease, 48-h pain scores) as “very low” due to high risk of bias, significant heterogeneity, and wide confidence intervals. Only 1-h pain scores and satisfaction were rated “high” quality. Although funnel plot symmetry indicated no significant publication bias, small sample sizes could affect this judgment. Furthermore, the included studies primarily focused on East Asian populations (80% from China and South Korea), with limited data from Europe and the United States. This limits the generalizability of findings to other populations and clinical settings. Moreover, most studies lacked long-term follow-up data on fibroid recurrence rate, fertility outcomes, and incisional hernia to comprehensively evaluate the long-term safety and efficacy of LESS-M.

In summary, LESS-M requires a practical balance between achieving safe and effective myomectomy, protecting the umbilical incision, and meeting patient cosmetic expectations. Given the inherent limitations of this approach, surgeons must exercise vigilance throughout the procedure. Appropriate patient selection, involving closer examination stratified by age, BMI, fibroid characteristics, comorbidities, reproductive goals, cost considerations, and cosmetic demands, is essential to determine the optimal individualized technique. Future large-scale, multicenter, high-quality RCTs in diverse populations, incorporating long-term follow-up for recurrence, fertility outcomes, and conducting cost-effectiveness analyses, are warranted.

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Author contributions

T.L.I.: Conceptualization, Visualization, Writing-original draft; J.Z.: Supervision, Validation, Writing-review&editing.

Conflicts of interest disclosure

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Guarantor

Jiarong, Zhang.

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