New paradigms in the conservative surgical and interventional management of adenomyosis

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.

Efficacy of Transabdominal Ultrasound-guided Percutaneous Microwave Ablation in the Treatment of Symptomatic Adenomyosis: A Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate and compare the clinical efficacy of transabdominal ultrasound-guided percutaneous microwave ablation (PMWA) in the treatment of symptomatic focal and nonfocal adenomyosis.

DESIGN

Retrospective cohort study.

SETTING

Longyan First Affiliated Hospital of Fujian Medical University.

PATIENTS

From May 2019 to October 2021, 107 patients with symptomatic adenomyosis who refused hysterectomy received PMWA.

INTERVENTIONS

Patients were divided into a focal group (n = 47, including 40 focal adenomyosis and 7 adenomyoma cases) and a nonfocal group (n = 60, including 36 diffuse and 24 mixed adenomyosis cases) according to the extent of lesion involvement.

MEASUREMENTS AND MAIN RESULTS

We collected and analyzed preoperative baseline data on patient characteristics; postoperative efficacy measures at 3, 6, and 12 months; and intraoperative and postoperative complications. There was a significant post-treatment reduction in the uterine corpus volume and cancer antigen 125 levels, an increase in hemoglobin levels, and an improvement in the Uterine Fibroid Symptom and Health-related Quality of Life scores (consisting of the Symptom Severity Scale and the Health-related Quality of Life scale), dysmenorrhea visual analog scale, and menstrual volume score (MVS) (all p <.05). One patient had recurrence. Most adverse events (72.0%) were mild. Although the nonfocal group had significantly greater anemia severity, higher Symptom Severity Scale and MVS, lower Health-related Quality of Life scale, greater extent and severity of myometrial involvement, and larger uterine corpus volume, after treatment, the uterine corpus volume, uterine corpus reduction rate, cancer antigen 125 levels, hemoglobin levels, Uterine Fibroid Symptom and Health-related Quality of Life score, dysmenorrhea visual analog scale, MVS score, and clinical response rate were similar between the groups (p >.05).

CONCLUSION

PMWA had good, similar, short-term efficacy for symptomatic focal and nonfocal adenomyosis.

Clinical efficacy of myometrial and endometrial microwave ablation in the treatment of patients with adenomyosis who had anemia

OBJECTIVE

This study evaluated the clinical efficacy of myometrial and endometrial microwave ablation (MEWA) for treating adenomyosis in patients with anemia.

METHODS

This retrospective study enrolled 64 patients with adenomyosis who had anemia treated with either MEWA (MEWA group) or myometrial microwave ablation (MMWA group) between May 2019 and May 2021. The uterine volumes, uterine-volume reduction rates, hemoglobin (Hb) levels, cancer antigen 125 (CA125) levels, dysmenorrhea visual analog scale (VAS) scores, uterine fibroblast symptoms and health-related quality of life (UFS-QOL) scores, menstrual flow scores (MFS) before and 3, 6, and 12 months post-treatment, and adverse events and complications in both groups were collected to assess clinical efficacy.

RESULTS

No statistically significant preoperative differences were observed in any measured factors. Postoperatively, there was a significant reduction in uterine volume and CA125 level, an increase in Hb level, and improvement in the UFS-QOL, dysmenorrhea VAS score, and MFS. No differences were observed in postoperative uterine volume, CA125 level, overall response rate, and adverse event rate during the follow-up period until 12 months postoperatively. However, the MEWA group showed a better uterine-volume reduction rate 6 months postoperatively and improvement in Hb level, USF-QOL score, dysmenorrhea VAS score, and MFS postoperatively.

CONCLUSION

MEWA and MMWA demonstrated high clinical efficacy in treating adenomyosis and anemia. However, MEWA is a more effective therapy that successfully improves anemia, resulting in improved quality of life.

Conservative surgical and drug therapies for adenomyosis Medicine

Adenomyosis is a benign invasion/infiltration of endometrial glands and stroma in the uterine myometrium. The optimal choice of adenomyosis treatment remains a subject of discussion. For patients with adenomyosis without fertility requirements, hysterectomy can be performed by laparotomy or laparoscopic surgery to eliminate symptoms. However, this is an inadequate option for women who want to preserve fertility or avoid more extensive surgery. To summarize the medicine and conservative surgery treatment for adenomyosis. An extensive literature search was performed using PubMed, Web of Science, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure (CNKI) without language restriction. The search terms were as follows: adenomyomas, adenomyosis, conservative therapy; combined therapy; medicine; surgery. The search included all titles and abstracts assessing conservative treatment for adenomyosis including medical and surgical therapy. All published papers were analyzed if considered relevant. Increasing current conservative treatments will not only improve the quality of life of the patients but also preserve fertility. Therefore, conservative treatment is extremely important for patients with fertility requirements or a strong desire to retain the uterus. Conservative treatment for adenomyosis may become a future trend in the field of gynecology.

Heat can treat: long-term follow-up results after uterine-sparing treatment of adenomyosis with radiofrequency thermal ablation in 60 hysterectomy candidate patients

BACKGROUND

Adenomyosis may induce pelvic pain, abnormal uterine bleeding or bulk symptoms. If hormonal treatment proves ineffective or contraindicated, hysterectomy may be necessary. For patients who desire to conserve the uterus despite severe symptomatology, uterine-sparing techniques have been introduced. Radiofrequency thermal ablation (RFA) consists of the local application of high temperature to eliminate diseased tissue, applied recently for adenomyosis treatment. The objective of the study was to analyze the efficacy of RFA for avoiding hysterectomy in patients with adenomyosis-related symptoms.

METHODS

This is a single-center, retrospective cohort study performed in a referral center for endometriosis. The study population consisted of all consecutive patients who underwent Radiofrequency thermal ablation (RFA) treatment as an alternative to hysterectomy for adenomyosis between March 2011 and June 2019 in our institution. RFA was performed using laparoscopic access. To evaluate the impact of RFA treatment on symptoms, follow-up findings were compared to preoperative symptomatology using the ten-point visual analog scale (VAS) for pain assessment.

RESULTS

Sixty patients were included in the study, 39 of them (65%), underwent a concomitant surgery for endometriosis in association to RFA. On a long-term follow-up (mean 56 months (range 10-115, SD 29), hysterectomy was performed in 8 patients (13%). The mean VAS score before vs after surgery was 7.4 vs 3.3 for dysmenorrhea, 3.7 vs 0.3 for dyschezia, 4.7 vs 0.7 for dyspareunia, and 4.0 vs 1.4 for chronic pelvic pain, being significantly reduced after RFA for all these pain components (p < 0.0001 in every case). Thirty-one patients (52%) suffered from AUB before RFA, this symptom persisted in 10 patients (16%) during follow-up (p < 0.001). Bulk symptoms were present in 16 patients (27%) and disappeared after RFA in all cases.

CONCLUSIONS

RFA allows for hysterectomy avoidance in most cases. It leads to marked improvements in pain symptomatology, uterine bleeding and bulk symptoms.

Laparoscopic "Shaving" for Infiltrative External Adenomyosis of Bowel Muscularis and Concomitant Deep Infiltrating Endometriosis

Deep infiltrating endometriosis (DIE) is a common finding in patients diagnosed with adenomyosis. Women commonly present with severe, incapacitating dysmenorrhea. We report a case of severe dysmenorrhea and lower abdominal tightness for 4 years, diagnosed with posterior adenomyosis. The patient underwent surgery and DIE involving the rectosigmoid and coexisting uterocervical adenomyosis infiltrating bowel muscularis successfully diagnosed and treated using laparoscopic “shaving” technique. Dysmenorrhea significantly resolved after surgery. Laparoscopic surgical “shaving” technique for external adenomyosis infiltrating Rectosigmoid muscularis is feasible, where uterine preservation is desired.

Ultrasound-guided transvaginal radiofrequency ablation combined with levonorgestrel-releasing intrauterine system for symptomatic uterine adenomyosis treatment

OBJECTIVE

To evaluate the clinical outcomes of transvaginal ultrasound-guided radiofrequency ablation (RFA) combined with a levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of symptomatic uterine adenomyosis.

METHODS

Patients with symptomatic uterine adenomyosis treated with ultrasound-guided RFA in combined with an LNG-IUS from January 2013 to January 2016 and followed up for 3 years after treatment were selected. Assessment endpoints included the uterine volume reduction rate, dysmenorrheal score, symptom severity score and adverse events.

RESULTS

Among the 72 patients, 64 completed the 3-year follow-up evaluations after treatment. No LNG-IUS expulsion was reported. Dysmenorrhea and symptom severity scores statistically significantly declined after the combined treatment of RFA and LNG-IUS was administered. The uterine volume significantly decreased, and the average reduction rate was 55%.

CONCLUSION

Ultrasound-guided RFA combined with an LNG-IUS might be a simple, safe and effective alternative for the treatment of symptomatic adenomyosis.

Long-term durability of uterine artery embolisation for treatment of symptomatic adenomyosis

BACKGROUND

Failing conservative therapies, uterine artery embolisation (UAE) has been proposed as a uterine-sparing option for treatment of symptomatic adenomyosis. UAE appears effective at short-term; however long-term durability is less well established.

AIMS

To evaluate the long-term clinical efficacy of UAE for treatment of adenomyosis.

MATERIALS AND METHODS

One hundred and four women with initial clinical success following UAE for adenomyosis (results previously published) were further followed with a two-part online survey. Part one inquired about menopause, symptom recurrence, need for further intervention and overall satisfaction. Part two comprised the Uterine Fibroid Symptom and health-related Quality of Life (UFS-QOL) questionnaire. Maintenance of clinical success was defined as remaining 'happy' or 'very happy' with overall outcome, no recurrence of symptoms, or need for further intervention.

RESULTS

Of those women with initial success, 91/104 (88%) participated in this long-term study at mean 52 months following UAE. Maintenance of clinical success was demonstrated in 82/91 (90%) women. For the remaining 9/91 (10%) women, mean time to failure was 31 months. There were 53/91 (58%) women who reached menopause at mean age of 51.5 years, occurring at mean 30 months post-UAE. UFS-QOL demonstrated significant decrease in symptom severity from 58.9 to 20.0 (P < 0.001); and significant increase in QOL from 40.3 to 86.3 (P < 0.001).

CONCLUSIONS

Long-term durability of UAE for treatment of adenomyosis was demonstrated, with cumulative success rate of 80% at mean 52 months. UAE did not appear to bring forward menopause. UAE should be considered as an alternative to hysterectomy to treat adenomyosis.

Significance of changes in inflammatory parameters following uterine artery embolization in pre-menopausal females

The purpose of the present study was to describe the course of changes in laboratory inflammatory markers following bilateral uterine artery embolization (UAE) as a treatment for leiomyomas and adenomyosis. The body temperature was measured and blood samples were collected to determine white blood cell (WBC) count and C-reactive protein (CRP) levels in 270 patients on the day prior to UAE and for up to 4 days post-embolization. Aside from a single case with a non-inflammatory complication, none of the other cases had any complications. Post-UAE leukocytosis with a mean maximum value of 10.8±3.5x10⁹/l (range, 5.9-18.6x10⁹/l) was observed one-year post-intervention. The mean leukocyte numbers were indicated to be higher on day 3 post-UAE. The CRP level was also increased post-UAE, with a mean maximum value of 7.75±3.5 mg/dl. Maximum levels were reached in 8 patients on the 2nd and in 11 patients on the 3rd post-operative day. The maximum pain score was ~5.5 and reached its lowest level at the end of the 12th week post-intervention. The present study did not consider an association between the embolic material used or uterus size with the level of treatment success. No complications were observed post-UAE; however, a significant increase in the WBC count was observed within the first 3 days, indicating mild leukocytosis.

Gynecological associated disorders and management

BACKGROUND

Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management.

METHODS

An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed.

RESULTS

Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery.

CONCLUSION

Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.