Comment on “Laparoscopic Myomectomy of a Symptomatic Uterine Leiomyoma in a 15-Year-Old Adolescent”

We read the article by Salehi and Tysonl concerning the first degenerative leiomyoma managed using laparoscopic surgery in a pediatric patient. The authors focus on the effectiveness and safety of laparoscopy in rare pediatric leiomyoma management in which guidelines on pediatric fibroids do not currently exist. We agree with the authors about the abstention of the use of leuprolide before the surgery but the authors do not discuss other possible medical approaches in adolescents. Aromatase inhibitors and gonadotropin-releasing hormone analogues are widely used in adult leiomyoma treatment, however, they have not been tested in the adolescent population. These drugs are also used off-label in some pediatric conditions with acceptable safety, except for some US Food and Drug Administration alerts. ^,  Loss of bone mineral density using gonadotropin-releasing hormone analogues has to be considered, however studies only in adults have shown their safety. Ulipristal acetate showed efficacy and safety in reduction of leiomyoma symptoms and volume in adults. Because of the good manageability, it could be interesting to evaluate the use of ulipristal acetate in nondegenerative pediatric leiomyoma. Concerning the surgical approach, the authors did not support the usefulness of robotic-assisted (RA) laparoscopic myomectomy (LM) in pediatric leiomyoma management although no doubt exists about the efficacy of LM. Taking fertility as a primary outcome in young women, LM has a rate of uterine rupture in pregnant women after surgery of 0.6%, with a good conception rate (68%). ^{,  ,}  Compared with RA myomectomy, LM showed no significant difference in terms of duration, estimated blood loss, length of hospital stay, postoperative stay, complication rate, and postoperative fertility outcome in adult women. However, the use of RALM increases the surgical suture precision and strength, which allows a greater accuracy of wound closure of uterine defects and ensures a better anatomical reconstruction of wall defect. Bernardi et al showed an interval time between LM and first postoperative conception of 23.2 months in women aged 23-42 years. This period is certainly prolonged in adolescent woman, permitting a better wound process repair. These aspects could justify the cost of robotic use in adolescent surgery, where fertility is a primary outcome and everything should be done to allow safe spontaneous deliveries with a high success rate. ^,  The suture technique and its strength take a crucial role in uterine pregnancy rupture rate and evidence suggests that a barbed suture might improve tensile strength. Moreover, data support that alternative ultrasonic energy sources compared with electrosurgery improve wound reparation and endurance. These options were not used by the authors and should be applied more appropriately in adolescent women. Despite a lack of evidence in the literature, we consider RALM a suitable choice in adolescent woman, with the capability of reaching a complete long-term wound repair, consequently, to reduce the rate of Cesarean sections, and reach a good fertility preservation rate without any interference with the hormonal milieu of the developing teenager. In conclusion, specific adolescent trials should be done to determine more accurately the effect of fertility outcome after RALM in adolescent women and whether an improvement in women's fertility rate and spontaneous delivery rate could justify the cost of this technique.