Single-Port Fertility-Preserving Gynecologic Surgery: Clinical Advances and Evidence-Based Practice

Abstract

Single-port fertility-preserving gynecologic surgery has emerged as a minimally invasive alternative to conventional multi-port laparoscopy for reproductive-age women requiring surgical intervention while maintaining fertility potential. This article critically reviews the current evidence on single-port techniques in benign and selected malignant gynecologic conditions, emphasizing surgical indications, patient selection, perioperative outcomes, and the latest advancements. The discussion integrates recent guideline recommendations and clinical implications for gynecologic surgeons, providing a comprehensive overview for optimizing patient care and reproductive health outcomes.

Introduction

Fertility-preserving surgical approaches in gynecology are paramount for women of reproductive age facing benign or early malignant conditions necessitating intervention. The advent of single-port laparoscopy also termed single-incision laparoscopic surgery (SILS) or laparoendoscopic single-site surgery (LESS) represents a significant evolution in minimally invasive surgery. By consolidating operative instrumentation through a single umbilical incision, this technique aims to minimize tissue trauma, reduce postoperative pain, enhance cosmesis, and potentially expedite recovery compared to traditional multi-port laparoscopy. This review synthesizes current literature and recent guideline-based recommendations regarding single-port fertility-preserving procedures, including myomectomy, ovarian cystectomy, adnexal mass excision, and management of early-stage gynecologic malignancies.

Epidemiology / Disease Burden

Benign gynecologic disorders such as uterine fibroids, endometriosis, and ovarian cysts are prevalent in women of reproductive age, often impairing fertility or causing significant morbidity. Uterine fibroids affect up to 70% of women by age 50, with a substantial subset presenting during peak reproductive years. Ovarian cysts and benign adnexal masses are detected in approximately 10% of women during their lifetime, many requiring surgical intervention. Early-stage gynecologic malignancies, while less common, pose unique challenges in balancing oncologic safety with fertility preservation. The increasing demand for minimally invasive, fertility-sparing solutions underscores the relevance of single-port techniques in contemporary gynecologic practice.

Pathophysiology

Preserving fertility necessitates precise surgical techniques that minimize collateral damage to reproductive organs and preserve ovarian reserve, uterine integrity, and tubal patency. Pathophysiological considerations differ by disease: myomas may distort uterine architecture, endometriosis leads to adhesions and inflammation, and benign cysts or neoplasms can compromise ovarian function. In early-stage malignancies such as borderline ovarian tumors or select endometrial carcinomas, meticulous surgical planning is crucial to ensure oncologic safety while retaining fertility potential. Single-port access allows for direct visualization and targeted intervention, potentially reducing the risk of adhesion formation and iatrogenic injury compared to open or multi-port approaches.

Risk Factors

Several patient and disease-specific factors influence suitability for single-port fertility-preserving surgery. Key considerations include patient BMI, prior abdominal surgeries, lesion size and location, suspected malignancy, and baseline ovarian reserve. Elevated BMI may increase technical complexity, while extensive adhesions can limit operative field visualization. Large myomas or cysts may challenge specimen extraction through a single site, requiring advanced morcellation or tissue retrieval strategies. Oncologic risk must be judiciously assessed preoperatively to avoid compromising cancer outcomes for fertility preservation.

Clinical Features

Indications for fertility-preserving single-port procedures mirror those for traditional laparoscopy and include symptomatic myomas, persistent or symptomatic ovarian cysts, adnexal masses, endometriosis with pain or infertility, and select early-stage malignancies. Patients typically present with abnormal uterine bleeding, pelvic pain, infertility, or incidentally discovered masses. The minimally invasive nature of single-port surgery offers improved postoperative symptom control, reduced wound morbidity, and potentially better cosmetic satisfaction, factors increasingly prioritized by reproductive-age women.

Diagnosis

Accurate preoperative diagnosis integrates clinical assessment, transvaginal ultrasonography, pelvic MRI for complex cases, and serum markers (e.g., CA-125 for adnexal masses). Fertility preservation mandates careful evaluation of ovarian reserve (AMH, antral follicle count), uterine cavity assessment (sonohysterography or hysteroscopy), and exclusion of advanced malignancy. Intraoperative frozen section may be required for indeterminate masses. Preoperative counseling should address surgical risks, fertility prognosis, and alternative management strategies.

Treatment & Management

Single-port fertility-preserving surgery encompasses myomectomy, cystectomy, oophoroplasty, adhesiolysis, and fertility-sparing staging for certain malignancies. The single umbilical incision accommodates a multi-channel port, allowing introduction of laparoscope and articulating instruments. Myomectomy involves careful enucleation of fibroids with meticulous multilayer uterine repair to preserve myometrial integrity. Ovarian cystectomy entails cyst wall excision while conserving normal ovarian tissue. For endometriosis, excision or ablation of lesions and adhesiolysis are performed. In early-stage gynecologic cancers, fertility-sparing procedures (e.g., unilateral salpingo-oophorectomy, radical trachelectomy) may be performed via single-port access where feasible, adhering to oncologic principles. Intraoperative challenges such as instrument collision and limited triangulation are mitigated by advanced port designs and surgeon expertise.

Recent Advances / Emerging Therapies

Technological innovations have addressed many technical limitations of initial single-port procedures. Articulating, roticulating, and flexible instruments enhance dexterity within the confined operative space. Miniaturized high-definition laparoscopes provide superior visualization. Robotic single-port platforms, though currently limited by device availability and cost, offer further ergonomic and visualization advantages. Adjuncts such as barbed sutures expedite tissue closure, and contained morcellation devices facilitate safe tissue retrieval, particularly for large myomas or cysts. Enhanced recovery protocols complement minimally invasive approaches, promoting same-day discharge and rapid return to fertility treatment or conception attempts.

Guideline Recommendations

Major gynecologic societies including ACOG, ESGE, and FIGO recognize single-port laparoscopy as an acceptable alternative to multi-port techniques for appropriately selected patients, provided surgical expertise is available. Fertility preservation should be prioritized in reproductive-age women with benign disease and select early-stage malignancies after thorough multidisciplinary assessment. Guidelines emphasize individualized preoperative counseling, comprehensive evaluation of oncologic risk, and long-term follow-up of reproductive and oncologic outcomes. Single-port surgery is not universally indicated; patient selection, surgeon experience, and institutional resources remain critical determinants of success.

Conclusion

Single-port fertility-preserving gynecologic surgery represents a significant advance in minimally invasive care for women seeking symptom relief and maintenance of reproductive potential. Recent evidence supports its feasibility, safety, and favorable cosmetic and postoperative outcomes in carefully selected patients. Ongoing technological progress and accumulating outcome data will further refine patient selection and expand indications. Multidisciplinary collaboration and adherence to evidence-based guidelines are essential for optimizing clinical and reproductive outcomes in this evolving field.