Efficacy of laparoscopic adenomyomectomy using double-flap method for diffuse uterine adenomyosis

Effects of pretreatment strategies on fertility outcomes in patients with adenomyosis

Adenomyosis is a commonly encountered pathology in women of reproductive age and frequently coexists with infertility. The effect of adenomyosis on fertility, particularly on in vitro fertilisation and intracytoplasmic sperm injection outcomes, is not well understood. Various pretreatment modalities have been used to improve pregnancy rates and live birth outcomes; however, because of a lack of high-quality evidence, there is no clear consensus on the best pretreatment option. This review was conducted through a PubMed search aiming to highlight the relationship between pretreatment and fertility in women with adenomyosis. Medical, ablative surgical, and non-surgical therapies were reviewed. According to the current literature, gonadotropin-releasing hormone agonist therapy and placement of a levonorgestrel intrauterine system are two suitable medical pretreatment strategies that can improve the clinical pregnancy rates of patients with adenomyosis. Surgical ablation of adenomyosis can also be beneficial, although surgical management can be challenging. Non-surgical thermal techniques, including high-intensity focused ultrasound ablation, percutaneous microwave ablation, and radiofrequency ablation, are much less invasive techniques that have shown effectiveness in improving fertility. Although evidence remains limited, all these procedures have demonstrated a favourable safety profile. Further studies are needed to better develop these techniques and demonstrate their effectiveness.

Adenomyosis and fertility-sparing surgery: A literature appraisal

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Alternative treatments of adenomyosis - an update in procedural management and clinical outcomes

PURPOSE OF REVIEW

Adenomyosis is a common cause of abnormal uterine bleeding (AUB), dysmenorrhea, and pelvic pain. Definitive diagnosis and treatment have historically been by uterine histopathology at time of hysterectomy; however, advances in imaging have supported earlier diagnosis and subsequent conservative treatment. This review aims to update the evidence supporting the uterine-sparing, procedural management options with a focus on clinical outcomes.

RECENT FINDINGS

Uterine artery embolization (UAE), radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA), and adenomyomectomy are minimally invasive interventions proven to be effective in reducing AUB and dysmenorrhea due to adenomyosis. Symptom improvement is associated with a decrease in uterine volume. Studies support the use of alternative treatment options given the overall low rates of symptom recurrence and reintervention. Combination therapy may be more effective than monotherapy.

SUMMARY

This review provides the current evidence for use of alternative treatment options for adenomyosis. Access to ablative therapies in the USA is limited and primarily off label, given lack of FDA approval. High-quality prospective and randomized controlled trials are needed in order to further delineate treatment comparisons, efficacy, safety, and ideal patient selection for these treatments. More data are needed to assess safety and utility in those desiring future fertility.

Reproductive surgery remains an essential element of reproductive medicine

Background

Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns.

Objectives

To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management.

Materials and Methods

Narrative review based on literature and the cumulative experience of the authors.

Main outcome measures

The paper does not address specific research questions.

Conclusions

Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology.

What is new?

A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.

Chromosomal Instability in Gastric Cancer: Role in Tumor Development, Progression, and Therapy

According to the Cancer Genome Atlas (TCGA), gastric cancers are classified into four molecular subtypes: Epstein-Barr virus-positive (EBV+), tumors with microsatellite instability (MSI), tumors with chromosomal instability (CIN), and genomically stable (GS) tumors. However, the gastric cancer (GC) with chromosomal instability remains insufficiently described and does not have effective markers for molecular and histological verification and diagnosis. The CIN subtype of GC is characterized by chromosomal instability, which is manifested by an increased frequency of aneuploidies and/or structural chromosomal rearrangements in tumor cells. Structural rearrangements in the CIN subtype of GC are not accidental and are commonly detected in chromosomal loci, being abnormal because of specific structural organization. The causes of CIN are still being discussed; however, according to recent data, aberrations in the TP53 gene may cause CIN development or worsen its phenotype. Clinically, patients with the CIN subtype of GC demonstrate poor survival, but receive the maximum benefit from adjuvant chemotherapy. In the review, we consider the molecular mechanisms and possible causes of chromosomal instability in GC, the common rearrangements of chromosomal loci and their impact on the development and clinical course of the disease, as well as the driver genes, their functions, and perspectives on their targeting in the CIN subtype of GC.

Uterine Rupture With Placenta Percreta Following Multiple Adenomyomectomies

Pregnancy following adenomyomectomy is challenging because uterine rupture or placenta accreta spectrum (PAS) is more likely to occur; however, optimal management has not yet been established. We herein present a case of uterine rupture with placenta percreta in a pregnant woman who underwent adenomyomectomy twice before pregnancy. Magnetic resonance imaging (MRI) was performed in the second trimester and imminent uterine rupture concomitant with PAS was suspected. The patient was immediately admitted to hospital for careful management. Although failed tocolysis forced delivery at 29 weeks of gestation, managed hospitalization allowed cesarean hysterectomy to be performed uneventfully. Extensive PAS was proven pathologically in the removed uterus. Pregnancies following multiple adenomyomectomies are considered to be high-risk. Therefore, a sufficient explanation of the risks associated with future pregnancies is needed, particularly following second adenomyomectomy.

Fertility-sparing surgery for diffuse adenomyosis: a narrated, stepwise approach to the Osada procedure

OBJECTIVE

To equip reproductive surgeons with an approach to the Osada procedure and critical prophylactic hemostatic measures that optimize perioperative outcomes.

DESIGN

Stepwise demonstration of the Osada procedure with narrated video footage.

SETTING

Definitive management of symptomatic adenomyosis requires hysterectomy. However, adenomyomectomy can improve symptoms and restore anatomy while maintaining fertility potential. Limited but comparable perioperative outcomes exist for minimally invasive methods of adenomyomectomy, and most involve resection of focal, not diffuse, adenomyosis. Among the literature involving resection of diffuse adenomyosis using minimally invasive methods, relatively small volumes of resected tissue are reported and none include obstetric outcomes. Most published reports for excision of diffuse adenomyosis involve laparotomic resection, likely because of specific intraoperative challenges curtailed by this approach. In response, a laparoscopic-assisted laparotomic approach was developed in 2011 by Dr. Hisao Osada, a reproductive surgeon in Japan. This procedure involves aggressive excision of adenomyotic tissue with prophylactic hemostatic techniques and subsequent uterine wall reconstruction using a triple-flap method. Compared with other excisional methods for diffuse adenomyomectomy, the Osada procedure has the best reported obstetric outcomes.

PATIENT(S)

A 37-year-old nulliparous female presented with pelvic pain, bulk symptoms, abnormal uterine bleeding, and infertility. Physical examination demonstrated a 20-week, bulky uterus with limited bimanual mobility. Her endometrial cavity was inaccessible because of marked anatomic distortion. Magnetic resonance imaging revealed marked abnormality of her endometrial contour because of a 15 cm adenomyoma with diffuse adenomyomatous tissue in the posterior uterine compartment. Prior interventions included a trial of combined hormonal contraceptive, leuprolide acetate, and tranexamic acid. She was interested in fertility-sparing adenomyomectomy to address symptoms and fertility potential and chose to proceed with the Osada procedure. She was optimized medically with oral and parenteral iron therapy to bring her hemoglobin from 55-111 g/L preoperatively. Institutional review board approval and informed consent from the patient were obtained.

INTERVENTION(S)

The Osada procedure was performed using the following 8 surgical steps: Systemic administration of tranexamic acid was also administered intraoperatively.

MAIN OUTCOME MEASURE(S)

Perioperative blood loss, anatomic normalization, symptom remediation, and maintenance of fertility potential.

RESULTS

Perioperative blood loss was minimal, 469 g of adenomyotic tissue was extracted, and discharge was on postoperative day 2 without any complications. Three months later, cyclic pain and bleeding had improved markedly, ultrasound confirmed Doppler flow throughout the uterus, hysterosalpingogram demonstrated a nonobliterated endometrial cavity and tubal patency, and magnetic resonance imaging confirmed normalized uterine dimensions measuring 11 × 7 cm from 19 × 10 cm. Most literature supports waiting at least 6-12 months and until demonstration of normalized uterine blood flow in the operated area before attempting conception.

CONCLUSION

Fertility-sparing excision of diffuse adenomyosis can be achieved safely using the Osada procedure, following the 8 discrete steps demonstrated in this video. Reproductive surgeons can reference this video to teach and maintain this important procedure.

Application of modified subtotal resection of adenomyosis combined with LNG-IUS and GnRH-a sequential therapy in severe adenomyosis: A case series

Background and Objective

Adenomyosis focus resection has always been the main surgical method for patients with uterine preservation, but its curative effect and surgical method are still controversial. We improved this method on the basis of the “double-flap method” and combined it with the levonorgestrel intrauterine delivery system (LNG-IUS) and gonadotropin-releasing hormone agonist (GnRH-a) sequential treatment to determine the clinical effect and feasibility of this scheme in the treatment of severe adenomyosis.

Methods

This is a retrospective review. A total of 64 patients with severe adenomyosis were treated in the Department of Gynecology of Changzhou Second People's Hospital, which is affiliated to Nanjing Medical University, from December 2017 to September 2021. The transabdominal approach and laparoscopic approach were adopted for the purposes of treatment in this study. Hence, the patients were subdivided into the transabdominal approach subgroup and the laparoscopic approach subgroup. The hemoglobin, visual analog score (VAS) score, menstruation score, and other indices of each patient before and after treatment were observed, recorded, and analyzed.

Results

All 64 patients underwent the operation successfully. After the completion of sequential treatment, the CA125 decreased significantly 1 month after the operation, the average uterine volume significantly reduced, the hemoglobin value increased to a certain extent 3 months after the operation, and the menstrual score and dysmenorrhea during the first menstruation were significantly lower than they were before the operation. After the treatment, the therapeutic results of the transabdominal approach subgroup and endoscopic approach subgroup were compared on the basis of the observed indices, and no significant difference was observed (P > 0.05). Only one patient had a downward movement of the LNG-IUS, and the vaginal ultrasound showed that the upper end of the LNG-IUS was approximately 1.5 cm from the bottom of the uterine cavity. The average follow-up period was 24.02 ± 11.77 months, and no lesion progression was found in any patients.

Conclusion

For patients suffering from severe adenomyosis who have no pregnancy plans and require uterine preservation, transabdominal or laparoscopic subtotal resection of the focus of adenomyosis, combined with the LNG-IUS + GnRH-a sequential treatment, may be a safe and effective alternative when conservative treatments such as drugs fail.

Long-Term Pregnancy Outcomes of Patients with Diffuse Adenomyosis after Double-Flap Adenomyomectomy

Although many studies show that patients with diffuse adenomyosis who underwent fertility-sparing surgery can have a successful pregnancy, their pregnancy outcomes are still controversial. The objective of this study was to determine long-term pregnancy outcomes and possible influencing factors after double-flap adenomyomectomy for patients with diffuse adenomyosis. A total of 137 patients with diffuse adenomyosis who underwent double-flap adenomyomectomy between January 2011 and December 2019 were studied, and correlations between pregnancy outcomes and clinical data, including age and junctional zone measured by magnetic resonance imaging (JZmax-A), were analyzed. The results show that 56 patients (40.9%, 56/137) had 62 pregnancies, including 35 natural pregnancies and 27 assisted reproduction pregnancies, after operation. A univariate regression analysis showed that the pregnancy outcomes were related to age at surgery, visual analog scale (VAS) score of preoperative dysmenorrhea, parity experience, length of infertility, and postoperative JZmax-A. A multivariate regression analysis showed that age at surgery, VAS score of preoperative dysmenorrhea, and postoperative JZmax-A were the independent indicators correlated with pregnancy outcomes. A receiver operating characteristic curve analysis showed that postoperative JZmax-A was the most valuable indicator for predicting pregnancy outcomes. Cumulative pregnancy rates during the first 3 years were 70.1% and 20.9% in the postoperative JZmax-A ≤ 8.5 mm and the postoperative JZmax-A > 8.5 mm groups, respectively. In conclusion, double-flap adenomyomectomy could improve fertility for diffuse adenomyosis, and postoperative JZmax-A might be a promising indicator for predicting pregnancy outcomes.

Advanced Laparoscopic Adenomyomectomy Technique for Focal Uterine Adenomyosis by Three-step Approach

Background and Objective

Owing to the increasing trend of preserving fertility in adenomyomectomy, the need for laparoscopic adenomyomectomy has increased. This study aimed to introduce a new surgical technique, an advanced laparoscopic adenomyomectomy technique, and to evaluate its efficacy, benefits, and safety in focal uterine adenomyosis.

Methods

From February 1, 2019 to February 29, 2020, 47 patients who underwent laparoscopic adenomyomectomy using the new surgical technique were enrolled in the study. The inclusion criteria were: (1) Focal-type adenomyosis, diagnosed by ultrasound or magnetic resonance imaging that was refractory to medical treatments. (2) A strong desire to preserve the uterus. All the operations were performed by a single surgeon with a uniform technique.

Results

The mean patient age was 40.53 ± 5.93 years (median 38.5, range 32-47). The mean diameter of the adenomyoma lesions was 4.57 ± 1.21 cm and the mean weight of the excised lesions was 40.53 ± 35.65g (range, 15-209 g). The mean total operation time was 70.11 ± 15.05 minutes. The mean estimated blood loss was 88.88 ± 20.0 mL (20 - 500 ml). There was no conversion to laparotomy or major complications requiring reoperation. At the seven-month follow-up, there was complete remission of dysmenorrhea and menorrhagia in 97.4% and 88.9% of the patients, respectively.

Conclusions

The new advanced laparoscopic adenomyomectomy technique with a three-step approach could be a safe and effective therapeutic method.

Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

STUDY OBJECTIVE

Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy.

DESIGN

A retrospective study.

SETTING

Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague.

PATIENTS

A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential.

INTERVENTIONS

Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively.

MEASUREMENTS AND MAIN RESULTS

Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01).

CONCLUSION

In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.

A systematic review of outcome reporting and outcome measures in studies investigating uterine-sparing treatment for adenomyosis

STUDY QUESTION

Which outcomes and outcome measures are reported in interventional trials evaluating the treatment of adenomyosis?

SUMMARY ANSWER

We identified 38 studies, reporting on 203 outcomes using 133 outcome measures.

WHAT IS KNOWN ALREADY

Heterogeneity in outcome evaluation and reporting has been demonstrated for several gynaecological conditions and in fertility studies. In adenomyosis, previous systematic reviews have failed to perform a quantitative analysis for central outcomes, due to variations in outcome reporting and measuring.

STUDY DESIGN, SIZE, DURATION

A systematic search of Embase, Medline and Cochrane Register of Controlled Trials (CENTRAL) was performed with a timeframe from 1950 until February 2021, following the preferred reporting items for systematic reviews and meta-analysis (PRISMA).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Studies reporting on any uterus-sparing intervention to treat adenomyosis, both prospective and retrospective, were eligible for inclusion. Inclusion criteria were a clear definition of diagnostic criteria for adenomyosis and the modality used to make the diagnosis, a clear description of the intervention, a follow-up time of ≥6 months, a study population of n ≥ 20, a follow-up rate of at least 80%, and English language. The population included premenopausal women with adenomyosis. Risk of bias was assessed using the Evidence Project risk of bias tool.

MAIN RESULTS AND THE ROLE OF CHANCE

We included 38 studies (6 randomized controlled trials and 32 cohort studies), including 5175 participants with adenomyosis. The studies described 10 interventions and reported on 203 outcomes, including 43 classified as harms, in 29 predefined domains. Dysmenorrhoea (reported in 82%), heavy menstrual bleeding (HMB) (in 79%) and uterine volume (in 71%) were the most common outcomes. Fourteen different outcome measures were used for dysmenorrhoea and 17 for HMB. Quality of life was reported in 9 (24%) studies, patient satisfaction with treatment in 1 (3%). A clear primary outcome was stated in only 18%.

LIMITATIONS, REASONS FOR CAUTION

This review includes studies with a high risk of bias.

WIDER IMPLICATIONS OF THE FINDINGS

Shortcomings in the definition and choice of outcomes and outcome measures limit the value of the conducted research. The development and implementation of a core outcome set (COS) for interventional studies in adenomyosis could improve research quality. This review suggests a lack of patient-centred research in adenomyosis and people with adenomyosis should be involved in the development and implementation of the COS.

STUDY FUNDING/COMPETING INTERESTS

No funds specifically for this work were received. T.T. receives fees from General Electrics for lectures on ultrasound independently of this project.

TRIAL REGISTRATION NUMBER

This review is registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020177466) and the Core Outcome Measures in Effectiveness Trials (COMET) initiative (registration number 1649).

MiR-30c-5p Directly Targets MAPK1 to Regulate the Proliferation, Migration and Invasion of Adenomyotic Epithelial Cells in Adenomyosis

The purpose of our study was to elucidate the functions of miR-30c-5p on adenomyosis for exploring novel treatment strategies. We first detected the expression of miR-30c-5p in clinical adenomyotic tissues and isolated endometrial cells from adenomyotic tissues. Next, gain and loss-of-function assays were performed to detect the effect of miR-30c-5p on adenomyotic endometrial cells. Further, luciferase assay and real-time polymerase chain reaction as well as western blot were conducted to investigate the potential target of miR-30c-5p; and transwell assay, wound-healing assay and CCK-8 assay were used to evaluate the effects of miR-30c-5p and its target on regulating biological functions of adenomyotic endometrial cells. Our results found that miR-30c-5p was down-regulated in both adenomyosis tissues and adenomyotic epithelial cells, which correlated with dysmenorrhea, longer duration of symptoms and more menstrual bleeding. Moreover, the overexpression of miR-30c-5p inhibited the proliferation, migration and invasion of adenomyotic epithelial cells, where miR-30c-5p knockdown had an opposite effect. Furthermore, we confirmed mitogen-activated protein kinase 1 (MAPK1) was one of the direct targets of miR-30c-5p, indicating its important role in miR-30c-5p-mediated suppression of proliferation, invasion and migration in adenomyotic epithelial cells. This study showed that the interaction of miR-30c-5p with MAPK1 can regulate the proliferation, invasion and migration in adenomyotic epithelial cells.

Laparoscopically assisted Adenomyomectomy Using the Double/Multiple-Flap Method with Temporary Occlusion of the Bilateral Uterine Artery and Utero-Ovarian Vessels in Comparison with the Double/Multiple-Flap Only Method

Introduction Adenomyomectomy is the most conservative surgical treatment for adenomyosis. However, the surgical efficacy of this treatment and the best approach to use are still debated. We aimed to evaluate the efficacy of laparoscopic adenomyomectomy using the double/multiple-flap method combined with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels to treat symptomatic adenomyosis.

Patients We recruited 155 patients with symptomatic adenomyosis and divided them into group A (n = 76) and group B (n = 79), with each group treated using a different surgical approach. All eligible women were informed of the potential complications, benefits, and alternatives of each approach before they were assigned into one of the two groups. In group A, we performed laparoscopic adenomyomectomy with the double/multiple-flap method while in group B, we performed a double/multiple-flap adenomyomectomy combined with temporary occlusion of the bilateral uterine artery and utero-ovarian vessels. Over a 24-month follow-up period, we evaluated operating time, intraoperative blood loss, visual analog scale (VAS) scores, anti-Mullerian hormone levels, uterine volume, and relief of menorrhagia.

Results There were no significant differences between groups A and B with respect to VAS scores, relief of menorrhagia and uterine volume at 3 months, 6 months, 12 months and 24 months after surgery (p > 0.05). Both groups showed significant improvement of these parameters after surgery compared with preoperative values (p < 0.05). Blood loss in group B was significantly lower than in group A (p < 0.001) while there was no significant difference in operating times (p > 0.05). Levels of AMH did not differ significantly between the groups throughout the follow-up period (p > 0.05).

Conclusion Laparoscopic adenomyomectomy with temporary occlusion of the bilateral uterine artery and the utero-ovarian vessels offers a feasible surgical option to treat symptomatic adenomyoma.

Study of dienogest clinical efficacy in the treatment of adenomyosis

Background:

A number of works provide information on the effectiveness of dienogest in uterine adenomyosis. However, information on the use of the drug at various degrees of the adenomatous nodes, is not presented in the available literature.

Aim:

The aim of the study was to evaluate the clinical efficacy of dienogest in the treatment of patients with adenomyosis 2nd and 3rd stage and chronic pelvic pain.

Materials and methods:

A comprehensive clinical survey and treatment of 46 patients with signs of adenomyosis were carried out. Patients were divided into two groups: 28 patients with stage 2 adenomyosis, 18 patients with type 3 adenomyosis were included in the 2nd group. On the first phase of the menstrual cycle all patients underwent hysteroscopy for endoscopic verification of the diagnosis using the traditional Karl Storz hysteroscopic stand with separate treatment and diagnostic curettage of the uterine cavity and cervical canal, followed by histological examination. After surgical treatment all patients received dienogest at a dose 2 mg/day for 6 months. The treatment was performed during 6 months. After 3, 6, and 12 months of the study, the patients included in the survey underwent a comprehensive examination with a clinical assessment of the manifestations of the disease. The level of pain manifestations was evaluated on a visual analog scale (VAS) with a range of 0–10 points. During pain assessment, its manifestations were differentiated—pain due to dyspareunia, dysmenorrhea, dyschezia, and chronic pelvic pain were evaluated.

Results:

In the group of patients with 2nd adenomyosis stage, the intake of dienogest for 6 months led to the absence of manifestations of uterine bleeding and dyschezia, a decrease in the frequency of dyspareunia—by 7.7 times. In patients with the 3rd stage of the disease, the decrease in the symptoms of adenomyosis was less pronounced, however, after taking the drug, a decrease in the frequency of uterine bleeding was found to be 6 times, dyspareunia 4 times, and dyschezia 5 times. Twelve months after the start of observation (6 months after the end of treatment), none of the patients with 2nd stage of disease showed severe pelvic pain, in the group with 3rd stage of adenomyosis there were only two of these patients (11.1%). At the same time, the vast majority of patients included in the study did not have manifestations of chronic pelvic pain—78.6% of patients with 2nd stage of adenomyosis and 55.6% of patients with 3rd stage of disease, the remaining 21.4% and 33.3% of patients of the first and second groups reported a significant decrease in the severity of pain.

Conclusions:

The inclusion of dienogest in the combined treatment of adenomyosis is clinically effective, contributing to the rapid and reliable relief of the main manifestations of the disease in patients with adenomyosis with grade 2 and 3 nodes. Treatment of adenomyosis with the use of dienogest is clinically effective, contributing to the rapid and reliable relief of the main manifestation of the disease.

Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system in the treatment of adenomyosis: Feasibility and effectiveness

AIM

To evaluate the clinical efficacy and safety of laparoscopic adenomyomectomy combined with intraoperative replacement of levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of symptomatic adenomyosis.

METHODS

This is a case-series study in a university medical center. A total of 52 patients with symptomatic adenomyosis were treated by laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS from January 2015 to July 2018. Visual analog scale, menstrual flow and uterine volume were compared before and after the surgery (3, 12 and 24 months). Meanwhile, LNG-IUS-induced adverse reactions (e.g. irregular vaginal bleeding, amenorrhea, expulsion, and perforation) were also recorded.

RESULTS

All operations were successfully completed via laparoscopy without conversion to laparotomy. No severe complications were noted during the surgical procedure or follow-up period. The mean postoperative visual analog scale and menstrual flow scores and the volume of the uterus were significantly decreased (all P < 0.001) at 3, 12, and 24 months postoperatively, compared with preoperative scores. The clinical effective rates among the patients with dysmenorrhea were 98%, 96% and 96% at 3, 12 and 24 months after the operation, respectively. And the clinical effectiveness rate of menorrhagia was 97.6%, 95.2% and 95.2% at 3, 12 and 24 months after treatment, respectively. Among all related adverse reactions, amenorrhea was the most common (n = 12, 23.1%). There was one case of LNG-IUS perforation (1.9%) and two cases of expulsion (3.8%).

CONCLUSION

Laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS is a novel and effective conservative surgical procedure for symptomatic adenomyosis treatment.

Current and Future Surgical and Interventional Management Options for Adenomyosis

Historically, hysterectomy has been the recommended treatment for patients with adenomyosis. However, in the past two decades, various uterine-sparing treatment methods have emerged. These range from excisional techniques such as adenomyomectomy or wedge resection to uterine artery embolization, radiofrequency thermal ablation, hysteroscopic excision, endometrial ablation, and high-intensity focused ultrasound. While largely investigative for the treatment of adenomyosis, these procedures have demonstrated improvement in symptoms including abnormal uterine bleeding, dysmenorrhea, pelvic pain, and overall quality of life. However, long-term data including fertility and obstetric outcomes are needed. Future research is needed to better understand the impact of these uterine-preserving techniques to expand our armamentarium for the treatment of adenomyosis.

A critical review of recent advances in the diagnosis, classification, and management of uterine adenomyosis

PURPOSE OF REVIEW

The purpose of this review is to summarize and highlight recent critical advances in the diagnosis, classification, and management of adenomyosis.

RECENT FINDINGS

Recent studies have clarified the specific mechanism through which adenomyotic lesions invade the underlying myometrium by epithelial-mesenchymal transition. Correlation studies using diagnostic MRI also strongly support the hypothesis of a different pathogenesis between the inner and outer myometrium forms of adenomyosis. Given advances in diagnostic imaging, several international organizations have also highlighted the importance of classification systems for adenomyosis. Finally, selective progesterone receptor modulators and gonadotropin-releasing hormone antagonists have demonstrated significant promise for treating pelvic pain and bleeding associated with adenomyosis, whereas novel fertility-preserving surgical techniques have been introduced to excise diffuse adenomyotic pathology while maintaining adequate uterine integrity.

SUMMARY

Recent attempts at a uniform and reproducible classification system likely represent the first step for the development of a staging system for adenomyosis that can be correlated with the severity of clinical symptoms and promote an individualized therapeutic approach. Simultaneously, further insights into the etiology and pathogenesis as outlined in this review may also help in the development of targeted medical therapies.

Comparisons of the efficacy and recurrence of adenomyomectomy for severe uterine diffuse adenomyosis via laparotomy versus laparoscopy: a long-term result in a single institution

Purpose

Studies have shown that adenomyomectomy can effectively treat women with adenomyosis in a short period of time. However, the long-term efficacy of adenomyomectomy has rarely been reported. The objective of this study was to determine whether laparotomy is superior to laparoscopic surgery in the long-term efficacy of double-flap method adenomyomectomy for severe diffuse adenomyosis.

Methods

Between March 2011 and September 2018, a total of 148 patients with severe uterine diffuse adenomyosis who underwent laparoscopic (group A, n=72) and laparotomic (group B, n=76) double-flap adenomyomectomy were recruited. Adenomyomectomy efficacy and adenomyosis recurrence after surgery between groups A and B were comparatively analyzed.

Results

The effective rate at 6-year follow up after surgery was higher in group B (75.0%) than that in group A (62.1%), while the 6-year cumulative recurrence rate was higher in group A (27.8%) than that in group B (17.1%), but the differences did not reach statistical significance between the two groups (P>0.05). The recurrence rate was lower in patients who were treated with gonadotropin-releasing hormone agonist (GnRHa) plus Mirena or oral contraceptives post-surgically than that in patients who were treated with only GnRHa post-surgically in groups A (51.6% vs 9.8%, P<0.01) and B (33.3% vs 6.5%, P<0.05). Moreover, the recurrence rate of adenomyosis patients with endometriosis was higher than that of adenomyosis patients without endometriosis in group A (55.0% vs 17.3%, P<0.05) and group B (36.0% vs 7.8%, P<0.05).

Conclusion

The long-term outcomes of laparoscopic and laparotomic double-flap adenomyomectomy can be achieved for severe diffuse uterine adenomyosis, but laparotomy seems to have advantages over laparoscopy. Postoperative drug use may be beneficial to reduce the recurrence of adenomyosis, especially for adenomyosis with endometriosis.

A comparison of surgical outcomes between robot and laparoscopy-assisted adenomyomectomy

We aimed to investigate the feasibility of robotic adenomyomectomy and compared surgical outcomes between laparoscopic and robotic approaches for adenomyomectomy.We retrospectively reviewed the data of women who were diagnosed with adenomyosis and underwent adenomyomectomy through a minimally invasive approach between January 2014 and March 2018 at the CHA Gangnam Medical Center, Seoul, Republic of Korea. Patient demographics and operation-related outcomes were compared between the robotic and laparoscopic surgery groups.We evaluated 43 women who underwent adenomyomectomy through a minimally invasive approach (21 underwent a laparoscopic and 22 underwent a robotic adenomyomectomy). All 22 women who had originally been scheduled to undergo robotic adenomyomectomy could successfully undergo the robotic surgery without requiring conversion to laparotomy and/or serious complications. No statistically significant differences in patient demographics were observed between the robotic and the laparoscopic surgery groups. No significant intergroup difference was observed in the operative time, estimated blood loss, weight of the resected nodule, and length of hospitalization (160.0 vs 212.5 min, P = .106; 500.0 vs 300.0 mL, P = .309; 60.0 vs 70.0 g, P = .932; and 5.0 vs 6.0 days, P = .277). No serious perioperative complications were observed in either group.Robotic adenomyomectomy is feasible for women with adenomyosis. Surgical outcomes of robotic adenomyomectomy were comparable to those of a laparoscopic approach. There was, however, no superiority of robotic adenomyomectomy in terms of surgical outcomes. Further multicenter prospective studies using standardized surgical procedures are needed to confirm the conclusion of this study.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

[Stratified treatment and management of adenomyosis]

In recent years, surgical and non-surgical excision and drug therapy have replaced hysterectomy as the main therapeutic modalities for adenomyosis. It is suggested that the precise clinical diagnosis should be based on the reconstruction of digitized three-dimensional model with original image data of adenomyosis. Patients' age and clinical manifestations should also be considered, and the patients should be stratified according to reproductive requirements, so as to determine the best treatment. In view of the infiltration and diffuse growth of adenomyosis lesions in the myometrium of the uterus, it is suggested that long-term drug management should be adopted after surgical or non-surgical lesion resection.Gonadotropin releasing hormone agonists, levonorgestrel-releasing intrauterine system, dienogest and short-acting oral contraceptives should be recommended to consolidate the curative effect in order to delay the progress of the disease and prevent recurrence.

Clinical efficacy of adenomyomectomy using "H" type incision combined with Mirena in the treatment of adenomyosis

To evaluate the clinical efficacy and safety of adenomyomectomy using "H" type incision combined with Mirena (LNG-IUS) in the treatment of adenomyosis.A total of 57 women with adenomyosis who underwent adenomyomectomy using "H" type incision combined with LNG-IUS were selected. Visual analog scale (VAS), menstrual flow, uterine volume, serum CA125 levels and hemoglobin amounts were compared before and after the surgery. Meanwhile, postoperative pregnancy, adverse reactions, and recurrence were observed.VAS score, menstrual flow, uterine volume, and serum CA125 levels in 53 patients were significantly reduced after surgery (P < . 001). Moreover, statistical significances were obtained for VAS score at 13 and 6 months, menstrual flow at 1, 3, 6, 12, and 24 months, uterine volume at 1, 3, 6, 12, 24, and 36 months and CA125 levels at 1 and 3 months (P < .05). Of the 5 patients with fertility requirements, 1 became pregnant after IVF-ET, progressed to preterm, and delivered healthy twins. Among all related adverse reactions, amenorrhea was the most common (n = 20, 37.7%). There were no cases of LNG-IUS removal, ectopia, expulsion, and incarceration, except in 2 patients due to pregnancy, 1 due to uterine bleeding, and 1 due to Mirena perforation from incision of the uterine fundus. All patients showed no relapse.Adenomyomectomy using "H" type incision combined with Mirena constitutes a novel and effective conservative surgical procedure for adenomyosis treatment.

Operation, hormone therapy and recovery of the patients with severe forms of adenomyosis

Endometriosis is among the prevalent gynecological diseases and diagnosed in 10% of women of reproductive age. Endometriosis/adenomyosis is becoming increasingly a health-social problem, which is associated with severe clinical manifestations and recurrent disease which has a negative effect on quality of life, women ability to work and her reproductive function. This article presents modern approaches of drug therapy to treat severe forms of adenomyosis. We have reviewed recent major studies in the field of surgical treatment of this disease, analyzed the main stages of disease progress and the results of our surgeries. Here, we are presenting our own results of long-term post-operative hormonal therapy and complex medical treatment.

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD). A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE). This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.

From Clinical Symptoms to MR Imaging: Diagnostic Steps in Adenomyosis

Adenomyosis or endometriosis genitalis interna is a frequent benign disease of women in fertile age. It causes symptoms like bleeding disorders and dysmenorrhea and seems to have a negative effect on fertility. Adenomyosis can be part of a complex genital and extragenital endometriosis but also can be found as a solitary uterine disease. While peritoneal endometriosis can be easily diagnosed by laparoscopy with subsequent biopsy, the determination of adenomyosis is difficult. In the following literature review, the diagnostic methods clinical history and symptoms, gynecological examination, 2D and 3D transvaginal ultrasound, MRI, hysteroscopy, and laparoscopy will be discussed step by step in order to evaluate their predictive value in the diagnosis of adenomyosis.

Surgery in adenomyosis

INTRODUCTION

Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium. The true prevalence is unknown and has been reported to range from 1 to 70%. It has a significantly negative impact on women's quality of life, causing abnormal uterine bleeding, dysmenorrhea, and chronic pelvic pain. The definitive treatment for adenomyosis is hysterectomy, although it does not contemplate patients who wish to preserve their fertility. The aim of this paper is to discuss the latest evidence on the surgical techniques for the treatment of adenomyosis published in medical-scientific databases.

METHOD

A comprehensive literature search for articles published from 1996 to 2017 related to surgery for adenomyosis was made in Pubmed, Medline, the Cochrane Library, and Google Scholar, in English, by the following MeSH terms: adenomyosis, surgery, pathogenesis, dysmenorrhea and infertility.

RESULTS

There is extensive evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

CONCLUSION

The management of adenomyosis is quite complex and controversial. Complications after extensive uterine reconstruction, such as uterine rupture, should be considered and discussed with the patient. There are still limited data to support surgery effectiveness, especially for infertility, and further well-designed studies are required.

The Role of Hysteroscopy in the Diagnosis and Treatment of Adenomyosis

Uterine adenomyosis is a common gynecologic disorder in women of reproductive age, characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Dysmenorrhea, abnormal uterine bleeding, chronic pelvic pain, and deep dyspareunia are common symptoms of this pathological condition. However, adenomyosis is often an incidental finding in specimens obtained from hysterectomy or uterine biopsies. The recent evolution of diagnostic imaging techniques, such as transvaginal sonography, hysterosalpingography, and magnetic resonance imaging, has contributed to improving accuracy in the identification of this pathology. Hysteroscopy offers the advantage of direct visualization of the uterine cavity while giving the option of collecting histological biopsy samples under visual control. Hysteroscopy is not a first-line treatment approach for adenomyosis and it represents a viable option only in selected cases of focal or diffuse “superficial” forms. During office hysteroscopy, it is possible to enucleate superficial focal adenomyomas or to evacuate cystic haemorrhagic lesions of less than 1.5 cm in diameter. Instead, resectoscopic treatment is indicated in cases of superficial adenomyotic nodules > 1.5 cm in size and for diffuse superficial adenomyosis. Finally, endometrial ablation may be performed with the additional removal of the underlying myometrium.

Uterine-Sparing Laparoscopic Pelvic Plexus Ablation, Uterine Artery Occlusion, and Partial Adenomyomectomy for Adenomyosis

STUDY OBJECTIVE

To evaluate safety, feasibility, and long-term clinical effects of adding laparoscopic pelvic plexus ablation to uterine-sparing procedures (uterine artery occlusion and partial adenomyomectomy) for adenomyosis.

DESIGN

A prospective controlled study (Canadian Task Force classification II-1).

SETTING

A teaching hospital.

PATIENTS

A total of 112 patients with symptomatic adenomyosis were eligible for uterine-sparing laparoscopy.

INTERVENTIONS

Laparoscopic pelvic plexus ablation, uterine artery occlusion, and partial adenomyomectomy.

MEASUREMENTS AND MAIN RESULTS

After the exclusion of patients with malignant tumors or those lost to follow-up, 102 women underwent laparoscopic uterine artery occlusion and partial adenomyomectomy; 50 of these patients also had laparoscopic uterine pelvic plexus ablation (group A) with the remaining 52 patients serving as the control group (group B). Other than operative time (107.0 ± 15.4 vs 98.9 ± 20.2 minutes, p = .02), there were no statistical differences regarding other operative parameters between groups A and B. Relief of severe dysmenorrhea (Visual Analogue Scale score ≥ 7) at 36 months was higher in group A than in group B (100% vs 76.9%, p < .01). No patient suffered constipation or uroschesis in either group.

CONCLUSION

Adding laparoscopic uterine pelvic plexus ablation to laparoscopic uterine artery occlusion and partial adenomyomectomy was more effective in relieving dysmenorrhea.