Reducing Blood Loss During Myomectomy:Uterine Artery Ligation Vs Pericervical Tourniquet

Uterine fibroids are among the most common benign gynecologic tumors and may cause heavy menstrual bleeding, pelvic pain, pressure symptoms, infertility, and other reproductive problems. For women who desire uterine preservation, myomectomy remains an important treatment option. In patients with large, multiple, or deeply located fibroids, transabdominal myomectomy is still widely performed. However, one of its major challenges is significant intraoperative bleeding, which may increase operative difficulty, prolong surgery, increase postoperative morbidity, and raise the need for blood transfusion.

Several methods have been used to reduce bleeding during myomectomy. Among the commonly used surgical approaches are bilateral uterine artery ligation and pericervical mechanical tourniquet application. Bilateral uterine artery ligation reduces uterine arterial inflow before myoma enucleation and may provide sustained hemostasis during surgery. Pericervical tourniquet application is a simple mechanical method that temporarily compresses the uterine vessels at the cervico-isthmic level during the procedure. Although both techniques are used in practice, comparative evidence remains limited, and further evaluation is needed to determine the more effective and safe method for blood loss reduction during fertility-sparing surgery.

This study is a prospective, randomized, comparative clinical trial conducted at the Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Egypt. Women scheduled for elective transabdominal myomectomy for symptomatic uterine fibroids will be recruited and randomized into two parallel groups. One group will undergo bilateral uterine artery ligation before myoma enucleation, while the other group will undergo pericervical mechanical tourniquet application using a Foley catheter at the level of the internal os before myoma enucleation. All procedures will be performed by the same experienced surgical team under standardized perioperative conditions to reduce inter-operator variability.

During surgery, after the assigned vascular control technique is applied, myoma enucleation and uterine repair will proceed according to a standardized operative technique. Blood loss assessment will include intraoperative blood loss measured from surgical swabs and suctioned blood, as well as postoperative blood loss measured from the intraperitoneal drain. The trial is designed to determine whether bilateral uterine artery ligation provides superior hemostatic control compared with pericervical mechanical tourniquet application, while also evaluating perioperative safety and recovery outcomes.

• Bilateral Uterine Artery Ligation (Procedure), also known as Uterine artery ligation: A surgical hemostatic procedure performed before myoma enucleation during transabdominal myomectomy to reduce uterine arterial blood flow and intraoperative bleeding. Bilateral ligation is carried out at the level of the internal cervical os using absorbable sutures as part of the assigned vascular control technique.
• Pericervical Mechanical Tourniquet Application (Procedure), also known as Pericervical tourniquet, Foley catheter tourniquet: A temporary mechanical vascular control technique performed before myoma enucleation during transabdominal myomectomy to reduce uterine blood flow and intraoperative bleeding. A sterile Foley catheter is placed around the cervico-isthmic region at the level of the internal os and removed after uterine repair and hemostasis are completed

Primary outcomes

• Estimated blood loss [During surgery and until drain removal on the second postoperative day]: Total blood loss measured as the sum of intraoperative blood loss and postoperative blood loss. Intraoperative blood loss will be assessed by weighing surgical swabs and measuring suctioned blood volume, while postoperative blood loss will be measured from the intraperitoneal drain.

Secondary outcomes

• Need for blood transfusion [From surgery until hospital discharge, assessed up to 3 days.]: Number of participants requiring blood transfusion as an indicator of significant perioperative hemorrhage.

Sex: Female, ages: 25 Years to 48 Years

* Inclusion Criteria:

  * Female participants aged 25 to 48 years
  * Body mass index less than 35 kg/m²
  * Symptomatic uterine myomas requiring surgical treatment
  * Intramural myomas classified as FIGO types 3 to 6
  * Diagnosis confirmed by transvaginal ultrasound and/or magnetic resonance imaging
  * Maximum diameter of the largest myoma 20 cm or less
  * Scheduled for elective transabdominal myomectomy
  * Able and willing to provide written informed consent
* Exclusion Criteria:

  * Submucosal, intracavitary, pedunculated subserosal, cervical, or adnexal myomas
  * FIGO types 0, 1, 2, 7, or 8 myomas
  * History of pelvic inflammatory disease or peritonitis
  * Previous abdominal or pelvic surgery for non-obstetric causes
  * Previous uterine surgery
  * Use of hormonal therapy within the previous 3 months
  * Known bleeding disorder
  * Use of anticoagulant or antiplatelet therapy
  * Preoperative hemoglobin less than 10 g/dL
  * Body mass index 35 kg/m² or greater
  * Intraoperative conversion from myomectomy to hysterectomy