Uterine Artery Blockage via the Anterior Cul-de-Sac (Bronx Blockage) in Minimally Invasive Myomectomy (MIM): Experience of 61 Cases

INTRODUCTION: Minimizing intraoperative bleeding is pivotal in myomectomy, and blockage of the uterine arteries is reported as an effective approach. We developed and published a novel technique to temporarily occlude bilateral uterine arteries at the anterior cul-de-sac (Bronx Blockage) in complex minimally invasive myomectomy (MIM). OBJECTIVE: To evaluate the learning curve of Bronx Blockage and further demonstrate the favorable outcomes of its application in complex MIM. METHODS: This was a case series study conducted at a teaching hospital and tertiary referral center. A consecutive series of 86 patients underwent MIM by a single surgeon between September 2022 and August 2025. The Bronx Blockage was attempted in 61 cases, while 25 cases of MIM were performed without attempting blockage. RESULTS: Among the 61 cases in which Bronx Blockage was attempted, no blockage occurred in 4 cases, unilateral blockage was achieved in 7 cases, and 49 cases had bilateral blockage. The learning curve demonstrated progressive improvement: in the first 30 cases, bilateral occlusion rates ranged from 60–80%, with failures and unilateral occlusions observed. After 34 cases, bilateral success reached 100% and was consistently maintained through case 61. Surgical approaches included laparoscopic myomectomy in 17 patients, laparoscopic-assisted myomectomy (LAM) in 26 patients, and mini-laparotomy in 18 patients. Fibroid removal distribution was as follows: fewer than 3 fibroids in 14 cases, 3–4 fibroids in 8 cases, and 5 and more fibroids in 39 cases. The median size of the largest fibroid was 8.1 cm (IQR 6.2–12.0), and the median specimen weight was 430 g (IQR 205.5–772.5), with 29 cases <250 g, 18 cases 250–500 g, 11 cases 500–1000 g, and 13 cases >1000 g. The median estimated uterine size was 16 weeks (IQR 15–20), with 8 cases <15 weeks, 43 cases 15–25 weeks, and 10 cases >25 weeks. The median operative time was approximately 246 minutes (IQR, 209–281 minutes), and the median estimated blood loss (EBL) was 250 mL (IQR, 100–350 mL). Preoperative hemoglobin averaged 11.8 1.8 mg/dL, with a postoperative hemoglobin drop of 2.1±1.4 mg/dL. One intraoperative vascular complication and one intraoperative transfusion occurred. The median hospital stay was 1 day (IQR 1.0–2.0). Eight patients required postoperative transfusion, two cases experienced Clavien–Dindo class I complications, and no readmissions were reported. CONCLUSIONS: Approximately 34 cases are required for a surgeon to achieve proficiency with Bronx Blockage. Incorporating this technique facilitates the safe and feasible performance of complex MIM.Figure 1Table 1Table 2