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Pecorella G, Nigdelis MP, Sparic R, Morciano A, Tinelli A. Adenomyosis and fertility-sparing surgery: A literature appraisal. Int J Gynaecol Obstet 2024; 166:512-526. [PMID: 38287707 DOI: 10.1002/ijgo.15389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 01/31/2024]
Abstract
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.
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Affiliation(s)
- Giovanni Pecorella
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Meletios P Nigdelis
- Department of Gynecology, Obstetrics and Reproduction Medicine, Saarland University, Homburg, Germany
| | - Radmila Sparic
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andrea Morciano
- Department of Gynecology and Obstetrics, Pia Fondazione "Card. G. Panico", Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Lecce, Italy
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Liu L, Tian H, Lin D, Zhao L, Wang H, Hao Y. Risk of Recurrence and Reintervention After Uterine-Sparing Interventions for Symptomatic Adenomyosis: A Systematic Review and Meta-Analysis. Obstet Gynecol 2023; 141:711-723. [PMID: 36897132 PMCID: PMC10026977 DOI: 10.1097/aog.0000000000005080] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/17/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate the risk of recurrence and reintervention after uterine-sparing treatment options for symptomatic adenomyosis, including adenomyomectomy, uterine artery embolization (UAE), and image-guided thermal ablation. DATA SOURCES We searched electronic databases such as Web of Science, MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, and Google Scholar from January 2000 to January 2022. The search was conducted using the following search terms: "adenomyosis," "recurrence," "reintervention," "relapse," and "recur." METHODS OF STUDY SELECTION All studies that described the risk of recurrence or reintervention after uterine-sparing interventions for symptomatic adenomyosis were reviewed and screened according to the eligibility criteria. Recurrence was defined as the reappearance of symptoms (painful menses or heavy menstrual bleeding) after significant or complete remission, or the reappearance of adenomyotic lesions confirmed by ultrasonography or magnetic resonance imaging. TABULATION, INTEGRATION, AND RESULTS The outcome measures were presented as the frequency with percentage and pooled with 95% CI. A total of 42 studies (single-arm retrospective and prospective studies) that represented 5,877 patients were included. The recurrence rates after adenomyomectomy, UAE, and image-guided thermal ablation were 12.6% (95% CI 8.9-16.4%), 29.5% (95% CI 17.4-41.5%), and 10.0% (95% CI 5.6-14.4%), respectively. The reintervention rates were 2.6% (95% CI 0.9-4.3%), 12.8% (95% CI 7.2-18.4%), and 8.2% (95% CI 4.6-11.9%) after adenomyomectomy, UAE, and image-guided thermal ablation, respectively. Subgroup analysis and sensitivity analysis were performed, and the heterogeneity was reduced in several analyses. CONCLUSION Uterine-sparing techniques were successful in treating adenomyosis with low reintervention rates. Uterine artery embolization had higher recurrence and reintervention rates than other techniques; however, patients treated with UAE had larger uteri and larger adenomyosis, indicating that selection bias may influence these results. More randomized controlled trials with a larger population are needed in the future. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021261289.
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Affiliation(s)
- Lu Liu
- Department of Ultrasound Medicine, South China Hospital, Medical School, Shenzhen University, Shenzhen, China
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Kwack JY, Seo M, Hong JS, Im KS, Kwon YS. Advanced Laparoscopic Adenomyomectomy Technique for Focal Uterine Adenomyosis by Three-step Approach. JSLS 2022; 26:JSLS.2022.00055. [PMID: 36452905 PMCID: PMC9680819 DOI: 10.4293/jsls.2022.00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Jae Young Kwack
- Department of Obstetrics and Gynecology, Nowon Eulji Medical Center, Eulji University, College of Medicine. Seoul, South Korea
| | - Minji Seo
- Department of Obstetrics and Gynecology, Nowon Eulji Medical Center, Eulji University, College of Medicine. Seoul, South Korea
| | - Ji su Hong
- Department of Obstetrics and Gynecology, Nowon Eulji Medical Center, Eulji University, College of Medicine. Seoul, South Korea
| | - Kyong Shil Im
- Department of Anesthesiology and Pain Medicine, Uijeongbu St Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Yong-Soon Kwon
- Department of Obstetrics and Gynecology, Nowon Eulji Medical Center, Eulji University, College of Medicine. Seoul, South Korea
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Kwack JY, Lee SJ, Kwon YS. Pregnancy and delivery outcomes in the women who have received adenomyomectomy: Performed by a single surgeon by a uniform surgical technique. Taiwan J Obstet Gynecol 2021; 60:99-102. [PMID: 33495018 DOI: 10.1016/j.tjog.2020.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Although adenomyomectomy for fertility-sparing is an expanding procedure worldwide, there is no guideline or consensus about how to manage the pregnant women who have previously received conservative surgery for adenomyosis. The aim of this study is to evaluate antenatal care and delivery outcomes in pregnant women after adenomyomectomy. MATERIALS AND METHODS Between May 2011 and May 2019, the medical record was reviewed in all delivery of pregnant women received adenomyomectomy performed by a single surgeon by a uniform surgical technique. The evaluating parameters consisted of antenatal care outcomes, delivery outcomes, intrapartum outcome, and neonatal outcomes. RESULTS Twenty-two patients were evaluated to monitor pregnancy and delivery outcomes after the adenomyomectomy. Mean age of delivery was 37.0 years old (SD = 3.1, range 32-45, median 37). All were delivered by cesarean section. Mean gestational age was 36.2 weeks (SD = 3.6, range 27.4-39.4, median 37.3). The mean birth weight was 2560.9 g (SD = 771.8, range 1100-3920, median 2550) and the number of preterm births admitted for prematurity care was seven (31.8%, 7/22). Placental abnormality was found in the four cases, which included two placenta accreta and two previa. However, there were no cases of hysterectomy or intervention. We identified one case of uterine rupture during pregnancy (4.5%, 1/22) at 27 weeks of gestation. Except for preterm birth, adverse neonatal outcomes were not found in this study. CONCLUSION Delivery of pregnant women who received adenomyomectomy can obtain safe perinatal outcomes under close monitoring of preterm labor and surveillance of catastrophic pregnancy related complications.
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Affiliation(s)
- Jae-Young Kwack
- Department of Obstetrics and Gynecology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Soo-Jeong Lee
- Department of Obstetrics and Gynaecology, Ulsan University Hospital, University of Ulsan College of Medicine, South Korea
| | - Yong-Soon Kwon
- Department of Obstetrics and Gynecology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea.
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King NR, Lin E, Yeh C, Wong JMK, Friedman J, Traylor J, Tsai S, Chaudhari A, Milad MP. Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review. Obstet Gynecol 2021; 137:434-442. [PMID: 33543898 DOI: 10.1097/aog.0000000000004280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications. DATA SOURCES A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted. METHODS OF STUDY SELECTION One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts. TABULATION, INTEGRATION, AND RESULTS Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004). CONCLUSION The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.
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Affiliation(s)
- Nathan R King
- Department of Obstetrics and Gynecology and the Division of Biostatistics, Department of Preventive Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois; and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Chen J, Porter AE, Kho KA. Current and Future Surgical and Interventional Management Options for Adenomyosis. Semin Reprod Med 2020; 38:157-167. [PMID: 33152768 DOI: 10.1055/s-0040-1718921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Joseph Chen
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anne E Porter
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Kimberly A Kho
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
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Shim JI, Jo EH, Kim M, Kim MK, Kim ML, Yun BS, Seong SJ, Jung YW. A comparison of surgical outcomes between robot and laparoscopy-assisted adenomyomectomy. Medicine (Baltimore) 2019; 98:e15466. [PMID: 31045825 PMCID: PMC6504297 DOI: 10.1097/md.0000000000015466] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Keserci B, Duc NM. Magnetic resonance imaging features influencing high-intensity focused ultrasound ablation of adenomyosis with a nonperfused volume ratio of ≥90% as a measure of clinical treatment success: retrospective multivariate analysis. Int J Hyperthermia 2018; 35:626-636. [DOI: 10.1080/02656736.2018.1516301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Bilgin Keserci
- Department of Radiology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, USM 16150 Kubang Kerian, Kelantan, Malaysia
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
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