Abstract
Excessive intraoperative bleeding remains a major challenge during open myomectomy and may lead to postoperative anemia and increased morbidity. Numerous methods have been suggested to minimize hemorrhage; however, evidence regarding their effectiveness in open surgery is limited. This study sought to evaluate the impact of tourniquet application, uterine artery bulldog clamping, and no-compression techniques on intraoperative blood loss and postoperative hematological outcomes in patients undergoing open myomectomy. This prospective randomized controlled trial comprised 120 patients undergoing open myomectomy, who were randomly assigned to three groups: tourniquet group (n = 40), uterine artery bulldog clamp group (n = 40), and no-compression group (n = 40). The primary outcome was intraoperative blood loss. Secondary outcomes were hemoglobin (Hb) and hematocrit (Hct) levels at 24 and 48 h post-operatively. Myoma volume was calculated using the spherical formula based on the maximum myoma diameter. Statistical analyses were conducted using one-way ANOVA with Tukey HSD post hoc test for normally distributed variables, or the Kruskal-Wallis test with Bonferroni-corrected Mann-Whitney U post hoc comparisons for non-normally distributed variables, as determined by the Shapiro-Wilk test. Multicollinearity was assessed using the variance inflation factor (VIF) prior to multivariate linear regression analysis. Baseline demographic and surgical characteristics, including number of myomas, largest myoma diameter, myoma volume, and FIGO classification, were comparable among the three groups (p > 0.05). Intraoperative blood loss differed significantly among the groups (p = 0.002) and was significantly higher in the no-compression group compared to both the tourniquet and bulldog clamp groups. No notable disparity in blood loss was detected between the tourniquet and bulldog clamp cohorts. Postoperative Hb and Hct levels at 24 and 48 h were higher in the bulldog clamp group compared to the tourniquet and no-compression groups (p < 0.001 for both). Operative time and postoperative platelet levels did not differ significantly among the groups. Multivariate regression analysis demonstrated that the surgical technique applied and operative time were independently associated with intraoperative blood loss (p = 0.011 and p = 0.008, respectively). Temporary uterine artery occlusion using a bulldog clamp during open myomectomy was associated with significantly better preservation of postoperative hemoglobin and hematocrit levels compared with tourniquet application and no-compression, without increasing operative time. Although intraoperative estimated blood loss did not differ significantly between the bulldog clamp and tourniquet groups, the superior hematological outcomes suggest that the bulldog clamp technique may represent an effective alternative strategy for preserving postoperative hematological parameters during open myomectomy.Clinical trial registration: The trial was registered retrospectively at ClinicalTrials.gov (Registration number NCT07553091 Registration date 22 April 2026). Reasons for retrospective registration and details of the predefined protocol are explained in the Methods and Limitations sections.