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Tang. Mini-invasive Surg 2020;4:24 I http://dx.doi.org/10.20517/2574-1225.2019.60 Page 11 of 13

There is scant literature on the topic of laparoscopic gynecology surgery in virgins. Most of the reports are
[28]
for diagnostic purposes or case studies on adnexal surgery [29-35] . There is one case report on performing
[35]
a posterior colpotomy laparoscopically to remove a prolapsed myoma in a virgin’s vagina to preserve
her virginity. However, this is done by multiport laparoscope. There is a retrospective study of 297 cases
of laparoscopic-assisted vaginal hysterectomy in virgins and nulliparas using Biswas uterine vaginal
elevator , but the elevator should be removed laparoscopically after uterus is excised completely. It is not
[36]
suitable in laparoscopic myomectomy because colpotomy is not necessary. Furthermore, this research is
done by multiport laparoscopy.

For virgins with symptomatic myoma, medical treatment can be used. Ulipristal acetate can achieve
[37]
[38]
amenorrhea state sooner than placebo and improves quality of life . In some research, it is used
[39]
preoperatively, but the benefit is inconclusive . However, there are sporadic cases of liver injuries and
hepatic failure reported, and its use should be restricted to those whose liver condition is healthy, and
[40]
periodic liver monitoring before, during, and after treatment is suggested . The long-term effect of
ulipristal acetate on pregnancy still lacks high quality data. Besides, for patient with large myoma, the mass
effect does not disappear with its use. Thus, surgery is needed in these patients.

Uterine artery embolization (UAE) is another choice for those group. According to the 10-year outcomes
of the randomized EMMY (Embolization vs. Hysterectomy) trial, about two thirds of hysterectomies
can be avoided and health-related quality of life remains comparatively stable. However, 35% of patients
[41]
need secondary hysterectomy after UAE . Furthermore, the pregnancy rate was found to be lower and
miscarriage rate higher after UAE than after myomectomy .
[42]
High intensity focused ultrasound is a newer method for treating myoma. The response rate ranges 40%-
[43]
85% in different modalities and studies . However, it is expensive in Taiwan, and the mass shrinks slowly.
The long-term effect of high intensity focused ultrasound treatment is still not clearly known for myoma.

Surgery is the only way to remove mass and improve symptoms, especially mass-induced ones. The
specimen can be obtained by pathologic examination.

The limitation of this study is that it was a retrospective chart review. Further large-scale randomized
research is needed to compare with other methods to clarify its limitations and safety.

In conclusion, this is the first report on single-port laparoscopic myomectomy on the virgin womb. In our
31 consecutive cases, the operation time, blood loss, and postoperative VAS score were all comparable to
the previous published literature. Without using uterine manipulator, we could still complete the operation
successfully without major complications. The manipulation of the uterus could be achieved by myoma
screw or suture string when needed. It is feasible for virgin women with symptomatic myoma to receive
single-port laparoscopic myomectomy.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.