Update on the surgical management of adenomyosis

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.

Shi Xiao San ameliorates the development of adenomyosis in an ICR mouse model

The use of Shi Xiao San (SXS), composed of Pollen Typhae Angustifoliae and Faeces Trogopterori, can be traced back to the Song dynasty. Traditionally, SXS has been used to treat irregular menstruation, pelvic pain, progressive dysmenorrhea, and postpartum lochiorrhea. The management of adenomyosis (AM) is challenging and to the best of our knowledge there are currently no effective therapeutic strategies. Therefore, the aim of the present study was to investigate the effect of SXS on the development of adenomyosis in a mouse model. AM was induced in 60 neonatal female ICR mice by administering tamoxifen; 10 randomly selected mice were used for model identification via histopathological examination and 10 mice treated with the solvent alone were used as the normal controls. A total of sixty days after birth, the mice treated with AM were randomly divided into four groups and administered one of the following treatments: Low-dose SXS (55 mg/kg); high-dose SXS (110 mg/kg); danazol (1 mg/20 g body weight); or no treatment (model group); at the same time, the normal control group received no treatment. After 2 months of treatment, hotplate and tail-flick tests were used to assess the response to noxious thermal stimuli in the mice, and plasma samples were collected to measure corticosterone levels. Hematoxylin and eosin staining scores of myometrial infiltration and the number of AM nodules were evaluated. Furthermore, the expression of genes associated with AM-related pain was also analyzed. The results from the present study indicated that treatment with SXS decreased myometrial infiltration, alleviated generalized hyperalgesia, and lowered plasma corticosterone levels in mice with induced AM. These findings suggest that SXS effectively attenuated the development of AM, and may serve as a promising treatment approach for AM treatment.

Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.

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.

Treatment options and reproductive outcome for adenomyosis-associated infertility

PURPOSE

Adenomyosis is a benign gynecological disease mostly diagnosed in the forth and fifth decades. The recent improvement of the diagnostic tools and a better understanding of the pathology allowed clinicians to postulate a possible relationship between adenomyosis and infertility and to diagnose it in younger asymptomatic women during infertility work-up. Purpose of this article is to review the different theories regarding the possible correlation between adenomyosis and infertility and to discuss the treatment options and the final reproductive outcome after the treatment.

MATERIALS AND METHODS

We search Pubmed for articles published in the English language with the use of the following MeSH search terms: "adenomyosis" combined with "treatment" and "fertility outcome" with the restriction to the human species. A manual search of review articles and cross-references completed the search. All selected articles were assessed for study design, patients characteristic, diagnosis of adenomyosis, type of treatment, post-treatment rates of conception, full-term pregnancy and completeness of information of the data sets.

RESULTS

Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and the only ones published are retrospective evaluations or small case series.

CONCLUSIONS

Adenomyosis represents a common gynecological disorder with a negative impact on fertility. However, it remains challenging to establish if adenomyosis is the only cause of the infertility or not, because patients, in both case and control groups, may be affected by concomitant endometriosis. Further studies are required to determine the reason of implantation failure in women with adenomyosis and the impact of adenomyosis on infertile women with or without endometriosis.

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.

Abnormal uterine bleeding

INTRODUCTION

It is not uncommon for a woman to suffer from abnormal uterine bleeding (AUB) or heavy menstrual bleeding (HMB) at some point during her lifetime. Once pathology is excluded, in practice, management needs to be individualised, taking into account the improvement of the woman's symptoms and quality of life.

SOURCES OF DATA

Peer-reviewed journals, governmental and professional society publications.

AREAS OF AGREEMENT

There is now agreement on a structured, universal approach to the diagnosis of AUB, with the aide memoirs PALM (polyps, adenomyosis, leiomyoma, malignancy) and COEIN (coagulopathies, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified). Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option, with surgery, including endometrial ablation and hysterectomy, offered when medical management has failed to resolve symptoms and fertility is no longer desired.

AREAS OF CONTROVERSY

There remains controversy around the management of the types and subtypes of adenomyosis and leiomyoma, and understanding their impact on clinical reproductive outcomes.

AREAS CURRENTLY UNDER DEVELOPMENT

Standardised assessment tools for measuring outcomes of AUB are being developed.

AREAS TIMELY FOR DEVELOPING RESEARCH

Novel diagnostic and monitoring tools should be developed to help stratify treatment for women with AUB, particularly relating to 'unclassified' and 'endometrial' causes.

Robot-Assisted Laparoscopic Adenomyomectomy for Patients Who Want to Preserve Fertility

An adenomyomectomy is a conservative-surgical option for preserving fertility. Conventional laparoscopic adenomyomectomies present difficulties in adenomyoma removal and suturing of the remaining myometrium. Robot-assisted laparoscopic surgery could overcome the limitations of conventional laparoscopic surgery. Four patients with severe secondary dysmenorrhea and pelvic pain visited Seoul St. Mary's Hospital and were diagnosed with adenomyosis by pelvic ultrasonography and pelvic magnetic resonance imaging (MRI). The four patients were unmarried, nulliparous women, who desired a fertility-preserving treatment. We performed robot-assisted laparoscopic adenomyomectomies. The dysmenorrhea and pelvic pain of the patients nearly disappeared after surgery. No residual adenomyosis was observed on the follow-up pelvic MRI. A robot-assisted laparoscopic adenomyomectomy was feasible, and could be a minimally invasive surgical option for fertility-sparing treatment in patients with adenomyosis.

The effect of adenomyosis on the outcomes of laparoscopic hysterectomy

OBJECTIVE

The presence of adenomyosis (ADS) may increase complication rates associated with laparoscopic hysterectomy (LH) due to an increased weight of the uterus, increased vascularization of the uterus, impaired myometrial tissue, and presence of additional gynecological pathologies such as leiomyoma or endometriosis. The aim of the present study was to evaluate perioperative and early postoperative parameters in patients with or without adenomyotic lesions.

MATERIAL AND METHODS

The study included patients who underwent LH in a university hospital. Patient data were retrieved from the hospital records and reviewed retrospectively. Sixty-one patients (85.9%) without adenomyotic lesions comprised the control group. Ten patients with adenomyotic lesions (14.1%) were regarded as the study group.

RESULTS

In this study, the mean age of the patients was 50.93±9.39 years. The mean uterus size was significantly higher in patients with ADS (p=0.02). There was no statistically significant difference in perioperative variables such as delta hemoglobin (Hb), insertion of pelvic drainage catheter, and invasive assessment of the urinary tract between both the groups (p=0.27, p=1.0, and p=0.67, respectively). The difference between the groups in terms of postoperative blood transfusion was not statistically significant (p=0.25). There was no statistically significant difference in the postoperative maximum body temperature, length of hospital stay, and duration of urinary catheterization between both the groups (p=0.77, p=0.36, and p=0.75, respectively).

CONCLUSION

LH appears to be a safe alternative for patients with ADS. Large-scale, prospective, and randomized trials are required in order to suggest the routine use of LH in patients preoperatively diagnosed with ADS.

Endometriosis-associated Maternal Pregnancy Complications - Case Report and Literature Review

The incidence of endometriosis is increasing. Particularly during pregnancy and labour, clinicians should be alert to possible endometriosis-associated complications or complications of previous endometriosis treatment, despite a low relative risk. In addition to an increased rate of early miscarriage, complications such as spontaneous bowel perforation, rupture of ovarian cysts, uterine rupture and intraabdominal bleeding from decidualised endometriosis lesions or previous surgery are described in the literature. Unfavourable neonatal outcomes have also been discussed. We report on an irreducible ovarian torsion in the 16th week of pregnancy following extensive endometriosis surgery, and an intraabdominal haemorrhage due to endometriosis of the bowel in the 29th week of pregnancy.

Regression of Adenomyosis on Magnetic Resonance Imaging after a Course of Hormonal Suppression in Adolescents: A Case Series

STUDY OBJECTIVE

To demonstrate that adenomyosis is a rare cause of dysmenorrhea or chronic pelvic pain (CPP) in the adolescent population that can be identified with magnetic resonance imaging (MRI) and to report resolution of adenomyosis by MRI after a course of hormonal suppression in 4 adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case series of 4 adolescents with adenomyosis on pelvic MRI at Texas Children's Hospital.

INTERVENTIONS

Continuous oral contraceptive (COC) therapy or leuprolide acetate.

MAIN OUTCOME MEASURES

Lesions on pelvic MRI after treatment.

METHODS

We reviewed medical records of 4 adolescents with CPP and adenomyosis on T2-weighted pelvic MRI. All patients had initial diagnostic pelvic MRI and then definitive hormonal intervention. Repeat imaging was obtained after a symptom-free interval.

RESULTS

Patient ages ranged from 12 to 16 years. One patient had resolution of symptoms with COC therapy. MRI performed 3 years later showed no adenomyosis. Three patients failed COC therapy. All were symptomatically improved after therapy with a gonadotropin-releasing hormone agonist. Follow-up MRI performed at intervals between 6 months and 3 years showed resolution of adenomyosis.

CONCLUSION

MRI can raise suspicion for the diagnosis of adenomyosis in adolescents with refractory CPP. Subsequent MRI can show regression of lesions after symptom resolution with hormonal therapy.

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

Background

Adenomyomectomy has recently been considered the priority option for the treatment of adenomyosis, however, the surgical efficacy and modes are still debated. We aimed to evaluate the efficacy of laparoscopic adenomyomectomy using a double-flap method for the treatment of uterine diffuse adenomyosis when compared with conventional laparoscopic adenomyomectomy.

Methods

Laparoscopic adenomyomectomy using the conventional method (group A, n = 48) and the double-flap method (group B, n = 46) to treat diffuse uterine adenomyosis, respectively. Visual analog scale (VAS), menstrual amount, serum CA125 levels, and uterine volume were comparatively analyzed in both groups.

Results

The VAS scores, menstrual amount, serum CA125 levels, and uterine volume at 12 or 24 months after surgery significantly reduced in group B than in group A (P < 0.05); these parameters were statistically decreased in both groups after surgery compared with those obtained before surgery (P < 0.001). Moreover, serum CA125 levels and uterine volume at six months of follow up were significantly lower in group B than in group A (P < 0.01). In addition, blood loss during surgery was similar in groups A and B (P > 0.05), although the operative time was significantly longer in group B than that in group A (P < 0.05).

Conclusions

Laparoscopic adenomyomectomy using the double-flap method may be an effective technique to treat uterine diffuse adenomyosis.

Usefulness of CA125 in the differential diagnosis of uterine adenomyosis and myoma

OBJECTIVES

To evaluate the usefulness of CA125 levels in the differential diagnosis of adenomyosis and myoma. This has been addressed by few, if any, previous studies.

STUDY DESIGN

Preoperative serum CA125 levels were measured in 2149 women who were diagnosed at total hysterectomy as having adenomyosis, myoma, endometriosis, and/or normal pelvis. Their medical records were retrieved and reviewed.

RESULTS

The mean serum CA125 level in the adenomyosis patients was significantly greater than that in the patients diagnosed with myoma (65.21±96.60 U/mL vs.12.86±14.23 U/mL, respectively; P<0.001). In the differential diagnosis of adenomyosis and myoma, the cut-off serum CA125 level with the highest accuracy (78.8%) and highest diagnostic value (61.2%) was 19 U/mL. Using this cut-off value, the negative predictive value was 69.5%, and the positive predictive value was 76.5%. These results are clearly superior to those of the empirical single cut-off value of 35 U/mL. Receiver operating characteristic curve analysis revealed the area under the curve for differentiating adenomyosis from myoma was 0.776, indicating good diagnostic performance.

CONCLUSION

In the differential diagnosis of adenomyosis and myoma, cut-off values for CA125, particularly the cut-off value of 19 U/mL, provide improved diagnostic performance. Serum CA125 testing can be performed during the initial screening of women with possible adenomyosis to differentiate this condition from myoma, although the diagnostic accuracy of using CA125 testing alone is limited.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Adenomyosis is an important clinical challenge in gynecology and healthcare economics; in its fully developed form, hysterectomy is often used to treat it in premenopausal and perimenopausal women. Symptoms of adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. Moreover, adenomyosis and leiomyomas commonly coexist in the same uterus, and differentiating the symptoms for each pathological process can be problematic. Although it has been recognized for over a century, reliable epidemiological studies on this condition are limited, because only postoperative diagnoses were possible in the past. Minimally invasive surgical techniques (endometrial ablation/resection, myometrial excision/reduction, myometrial electrocoagulation, uterine artery ligation) have had limited success in the treatment of adenomyosis, and the reported data for these procedures have been obtained from case reports or small case series with only short follow-up times. However, newer techniques including uterine artery embolization (UAE) and magnetic resonance imaging guided focused ultrasound (MRgFUS) show promise in treating adenomyosis. The data is strongest for UAE; these studies have the largest patient cohorts. However, none of the UAE studies were randomized or controlled. Thus, despite the clinical importance of adenomyosis, there is little evidence on which to base treatment decisions. The objective of this review is to summarize the epidemiology, risk factors, clinical phenotype and to evaluate the accrued experience with surgical and interventional alternatives to hysterectomy.