{"paper_id":"1ec1e50b-9014-4103-a928-ece66b50afe2","body_text":"R E S E A R C H A R T I C L E Open Access\nEfficacy of laparoscopic adenomyomectomy\nusing double-flap method for diffuse uterine\nadenomyosis\nXiufeng Huang, Qiongshi Huang, Shuyi Chen, Jing Zhang, Kaiqing Lin and Xinmei Zhang *\nAbstract\nBackground: Adenomyomectomy has recently been considered the priority option for the treatment of\nadenomyosis, however, the surgical efficacy and modes are still debated. We aimed to evaluate the efficacy of\nlaparoscopic adenomyomectomy using a double-flap method for the treatment of uterine diffuse adenomyosis\nwhen compared with conventional laparoscopic adenomyomectomy.\nMethods: Laparoscopic adenomyomectomy using the conventional method (group A, n= 48) and the double-flap\nmethod (group B, n= 46) to treat diffuse uterine adenomyosis, respectively. Visual analog scale (VAS), menstrual\namount, serum CA125 levels, and uterine volume were comparatively analyzed in both groups.\nResults: The VAS scores, menstrual amount, serum CA125 levels, and uterine volume at 12 or 24 months after\nsurgery significantly reduced in group B than in group A (P < 0.05); these parameters were statistically decreased in\nboth groups after surgery compared with those obtained before surgery (P < 0.001). Moreover, serum CA125 levels\nand uterine volume at six months of follow up were significantly lower in group B than in group A (P < 0.01). In\naddition, blood loss during surgery was similar in groups A and B (P > 0.05), although the operative time was\nsignificantly longer in group B than that in group A (P < 0.05).\nConclusions: Laparoscopic adenomyomectomy using the double-flap method may be an effective technique to\ntreat uterine diffuse adenomyosis.\nKeywords: Adenomyosis, Adenomyomectomy, Dysmenorrhea, Double flap method, Surgery\nBackground\nAdenomyosis is a benign gynecologic disorder charac-\nterized by the invasion of endometrial glands and\nstroma in the uterine myometrium, resulting in dys-\nmenorrhea, hypermenorrhea, and infertility [1]. Al-\nthough adenomyosis may be treated with several\nmethods, such as hysterectomy, conservative surgery,\ndrug therapy such as gonadotropin-releasing hormone\nagonist therapy (GnRHa), and uterine artery embolization,\ncomplete hysterectomy can thoroughly treat this disease\n[2-9]. However, total hysterectomy is not suitable for\nwomen with adenomyosis who want to preserve their\nuteri and/or require fertility in the future. As such, these\nwomen prefer uterus-sparing surgery.\nAlthough many uterus-sparing surgical techniques\nhave been developed to treat adenomyosis, adenomyo-\nmectomy is considered as the most feasible and effica-\ncious; adenomyomectomy has also been considered as\nthe first-line approach to treat adenomyosis, particularly\nfocal adenomyosis [10]. Partial adenomyomectomy in-\ncluding wedge resection of the uterine wall, transverse H\nincision technique, and asymmetric dissection of uterus\nto treat diffuse adenomyosis, can improve clinical symp-\ntoms; however, these techniques are frequently associ-\nated with adenomyosis recurrence and spontaneous\nuterine rupture in pregnancy [2,11-14]. The complete\nexcision of adenomyosis by employing several tech-\nniques, such as overlapping flaps and triple-flap method\nto treat diffuse adenomyosis, can achieve good results;\nnevertheless, these techniques are difficult to implement,\nparticularly laparoscopy [15-17]. These findings suggest\n* Correspondence: zxm20130729@163.com\nThe Department of Gynecology, Women ’s Hospital, Zhejiang University\nSchool of Medicine, 1 Xueshi Road, Hangzhou, Zhejiang 310006, P. R. China\n© 2015 Huang et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative\nCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and\nreproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain\nDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,\nunless otherwise stated.\nHuang et al. BMC Women's Health  (2015) 15:24 \nDOI 10.1186/s12905-015-0182-5\n\nthat the development of a new surgical technique is a\nmajor concern to improve the convenience of laparo-\nscopic conservative surgery to treat diffuse adenomyosis;\nwith these novel techniques, adenomyotic lesions should\nbe excised during surgery and uterine wall integrity\nshould be retained.\nTherefore, this study aimed to modify the technique\nof Osada et al. to perform laparoscopic adenomyomect-\nomy by using a double-flap method for the treatment\nof uterine diffuse adenomyosis [16]. This study was also\ndesigned to evaluate the surgical efficacy of laparo-\nscopic adenomyomectomy with the modified double-\nflap method for women with uterine diffuse adenomyosis,\nparticularly those who manifested severe clinical symp-\ntoms and wished to preserve their uteri, but their repro-\nductive capacity was not a priority request, compared with\nconventional laparoscopic adenomyomectomy.\nMethods\nPatients\nThe Ethics Committee of the Women ’s Hospital, Zhejiang\nUniversity School of Medicine approved this study. Writ-\nten informed consent for participation in the study was\nobtained from participants.\nA total of 129 patients who were referred to our hos-\npital and underwent laparoscopic adenomyomectomy\nfor uterine diffuse adenomyosis between March 2011\nand February 2014 were recruited in this study. The inclu-\nsion criteria were listed as follows: ①women had severe\ndysmenorrhea with and without menorrhagia (hyperme-\nnorrhea), but failed to undergo drug therapy, including\nGnRHa, Mirena and oral contraceptives; ②women wished\nto preserve their uteri, but their reproductive capacity was\nnot a priority request; ③Pure adenomyosis for all the\nstudy subjects was preoperatively verified by ultrasound\nand magnetic resonance imaging according to the previ-\nous reported diagnostic criteria [16-26], and affected more\nthan 70% of the anterior and/or posterior wall of the\nuterus with an enlargement of >5 cm in thickness. The ex-\nclusion criteria were listed as follows: women presenting\nwith a contraindication to laparoscopy because of severe\nmedical illness. The patients who were recruited in this\nstudy were all interviewed by Dr. Huang. During her inter-\nview, each patient was in detail told about the advantage\nand disadvantage of the conventional method and the\ndouble-flap method (for example, less time and blood loss\nbut less adenomyotic lesions excised may be in the former,\nwhereas more time and blood loss but more adenomyotic\nlesions excised may be in the latter), and decide whether\nto participate in the study, and which method to take.\nConsquently, thirty-five among 129 patients who were in-\nvited to participate refused treatment. The 94 remaining\npatients with diffuse adenomyosis who were included in\nthis study were assigned to undergo laparoscopic\nadenomyomectomy by using the conventional method\n(group A, n = 4 8 )a n dt h ed o u b l e - f l a pm e t h o d( g r o u pB ,\nn= 4 6 )b a s e do np a t i e n tr e q u i r e m e n t s .A f t e rs u r g e r y\nwas completed, all of the patients received GnRHa for\nsix months. None of the study patients revoked their\nconsent, failed to undergo follow up, or received sex-\nhormone therapy six months before surgery.\nSurgical procedure\nAll surgical procedures were performed under general\nanesthesia in the Trendelenbu rg position with four-port\nlaparoscopy. One 10 mm port was inserted through the\numbilicus for the zero-degree laparoscope, and two lat-\neral 5 mm ports were inserted above and medial to\neach anterior superior iliac spine. A second left sided\n5 mm port was inserted between the left lateral port\nand the umbilical port. The surgeon (XZ and XH) used\nthe two left sided ports to perform most of the surgical\nprocedures.\nThe technique of resection of adenomyotic lesions\nusing the double-flap method was previously described\nby Osada et al. [16]. In brief, 12 units of pituitrin (di-\nluted in 100 ml of normal saline) were injected. An inci-\nsion was made in the midline of the serosal surface of\nthe fundus by using scissors (or monopolar) and contin-\nued along the sagittal direction until the uterine cavity\nwas reached. The incision was further continued along\nthe posterior and anterior walls of the uterus to the level\nof the internal os of the cervix. Afterward, adenomyoma-\ntous tissues were grasped with forceps, identified, and\nexcised from the surrounding myometrium. This pro-\ncedure was performed with care to avoid damaging the\nendometrium and the serosal surface of the uterus. If\nthe myometrium appeared normal, this part was spared\nas much as possible. In general, a myometrial thickness\nof 1 cm below the serosa or above the endometrium was\nleft. In addition, this procedure was performed with care\nto avoid damaging the interstitial portion of the fallopian\ntube, particularly in patients who desired to have future\npregnancies.\nAfter adenomyotic lesions were removed (Figure 1A\nand E), the endometrial lining was approximated with\ninterrupted sutures of 3 –0 Vicryl (Figure 1B and F). The\nmyometrium and serosa of the bisected uterus were su-\ntured with 2 –0 Vicryl by using the double-flap method\ndescribed by Kim et al. [17], but not by using the triple-\nflap method proposed by Osada et al. [16]. Namely, the\nfirst flap in one side wall of the uterus (including the ser-\nosa and the myometrium) was brought into the second\nflap in another side of the uterine wall (including the\nendometrium and the myometrium) such that the other\nside wall of the uterus (including the endometrium and\nthe myometrium) was covered (Figure 1C and G). Next,\nthe second flap in another side of the uterine wall was\nHuang et al. BMC Women's Health  (2015) 15:24 Page 2 of 8\n\nbrought to cover the first flap in one side wall of the\nuterus (Figure 1D and H). Before overlapping occurred,\nthe serosal surface of the underlying flaps was stripped\nto ensure that only myometrial tissue flaps overlapped.\nDuring the suture procedure, dead space or hematoma\nbetween the tissues was avoided. The conventional sur-\ngical procedure was similar to that of myomectomy and\ncompletely different from the new surgical procedure\n(Figure 2). After the surgical procedure, we used INTER-\nCEED (an anti adhesion membrane, Johnson company)\nto prevent postoperative adhesion. All excised adeno-\nmyotic tissues were confirmed by histopathology after\nsurgery.\nFollow up\nSurgical efficacy was evaluated by rating the levels of\nserum CA125, the size of the uterus, and the severity of\ndysmenorrhea and hypermenorrhea before and after sur-\ngery as well as the presence of pregnancy after surgery\nin the two groups. The severity of dysmenorrhea was\ndocumented using a standardized questionnaire with a\nvisual analog scale (VAS). The pain scale was subdivided\ninto ten grades. “No pain ” was indicated at the left side\nof the scale and “the maximum pain you could imagine ”\nwas designated at the right side of the scale. The size of\nthe uterus was measured by ultrasonography [uterine\nvolume = A × B × C × 0.5233 (where A, B, and C are the\nuterine length, width, and thickness, respectively)].\nSerum CA125 levels were determined by enzyme-linked\nimmunosorbent assay (ELISA) with a human CA125\nELISA kit (HM10776, Bio-swamp) according to the\nmanufacturer’s instructions (the normal range was ≤35\nkU/L). The menstrual product use of ≥5 pads/day was\ndefined as menorrhagia in this study; as such, the sever-\nity of menorrhagia was arbitrarily graded as mild (5 to 7\npads/day), moderate (7 to 9 pads/day), and severe (>9\npads/day) [27].\nAll of the patients were followed up one, three, and six\nmonths after surgery and subsequently every six months\nafter surgery. Considering that these patients were\ntreated with GnRHa for six months after surgery, we fo-\ncused on two endpoints to determine short- and long-\nterm surgical treatment efficacies. As such, the results of\nthe preoperative visit were compared with those of the\n12-month follow up and those of the 24-month follow\nup to observe the short- and long-term efficacies after\nFigure 1 Schematic (A, B, C, and D) and surgical view (E, F, G, and H) of laparoscopic adenomyomectomy using the double-flap\nmethod. (A and E) after complete removal of adenomyotic lesions using the resection technique of Osada et al. (B and F) closure and\nreconstruction of the uterine cavity using 3 –0 absorbable suture. (C and G) the first flap in one side wall of the uterus is brought into the second\nflap in another side of the uterine wall such that the other side wall of the uterus is covered. (D and H) the second flap in another side of the\nuterine wall is brought to cover the first flap in one side wall of the uterus (before overlapping occurs, the serosal surface of the underlying flaps\nis stripped to ensure that only myometrial tissue flaps are overlapped).\nHuang et al. BMC Women's Health  (2015) 15:24 Page 3 of 8\n\nlaparoscopic adenomyomectomy was performed using\nthe double-flap method and the conventional method to\ntreat uterine diffuse adenomyosis.\nStatistical analysis\nWe used SPSS version 17.0 (SPSS, IBM, Chicago, IL, USA)\nto perform statistical analyses. Results were expressed as\nthe mean value ± standard derivation (SD), although the\nmeasured values of the variables were not normally distrib-\nuted. Mann –Whitney U test was performed to compare\nnon-parametric data, and chi-square test was conducted to\ncompare the frequency between groups. Differences were\nconsidered significant at P < 0.05.\nResults\nNo significant differences in age, gravidity, parity, abor-\ntion, hemoglobin levels, uterine volume, VAS score,\nmenorrhagia, and serum CA125 levels were found be-\ntween the two groups (P > 0.05, Table 1). Six months\nafter surgery, five patients (5/48, 10.4%) in group A and\ntwo patients (2/46, 4.3%) in group B still exhibited pain\nsymptoms with VAS scores of ≤2. The VAS scores at six-\nmonth follow-up period in group A or B significantly de-\ncreased compared with those before surgery (P <0.0001),\nbut no statistically significant differences were found be-\ntween groups A and B (P > 0.05, Table 2, Figure 3). Uter-\nine size and serum CA125 levels six months after\nsurgery were significantly higher in group A than in\ngroup B (P < 0.0001), although both parameters in each\ngroup were statistically decreased compared with those\nobtained before surgery (P <0.0001, Table 2, Figure 3).\nTwelve months after surgery, nine patients (9/31,\n29.0%) in group A and three patients (3/27, 11.1%) in\ngroup B manifested pain symptoms, and the VAS scores\nFigure 2 Comparisons of surgical view and schematic of laparoscopic adneomyomectomy using the double-flap method and the\nconventional method. (A, C) Conventional method; (B, D) double-flap method.\nTable 1 Patients ’ characteristics (Mean ± SD)\nParameters Group A* ( n= 48) Group B ( n= 46) P value\nAge at operation(years) 36.6 ± 5.9 37.1 ± 6.6 0.187\nParity 1.1 ± 0.1 1.1 ± 0.1 0.321\nGravidity 3.4 ± 0.2 3.5 ± 0.2 0.165\nAbortion 2.3 ± 0.2 2.4 ± 0.2 0.245\nHemoglobin (g/dl) 10.6 ± 2.2 10.8 ± 2.3 0.209\nCA125 (kU/L) 108.7 ± 168.9 106.5 ± 199.5 0.654\nVAS score 8.1 ± 1.6 8.2 ± 1.5 0.197\nUterine volume (cm 3) 198.5 ± 82.6 209.1 ± 117.5 0.346\nMenorrhagia (pads) 8.2 ± 1.5 8.1 ± 1.3 0.278\n*Group A = Conventional method, Group B = Double-flap method.\nHuang et al. BMC Women's Health  (2015) 15:24 Page 4 of 8\n\nwere ≤3.0. In group A, the VAS scores increased at\n12 months after surgery compared with those at 6 months\nafter surgery (P <0.01); the VAS scores increased at\n24 months after surgery compared with those at\n12 months after surgery (P <0.05). In group B, the VAS\nscores were similar between 12 and 6 months after surgery\nand between 24 and 12 months after surgery (P > 0.05).\nThe VAS scores at 12 and 24 months after surgery were\nsignificantly higher in group A than in group B (P <\n0.05); these scores in each group were significantly\nlower compared with those before surgery (P < 0.0001,\nTable 2, Figure 3). Twenty-four months after surgery,\nnine patients (9/15, 60.0%) in group A reported pain,\nand their highest VAS score was 5.5; by contrast, three\npatients (3/13, 23.1%) in group B reported pain, and\ntheir VAS scores were ≤2.5.\nUterine volume significantly increased at 12 months\nafter surgery compared with those at 6 months after\nsurgery (P < 0.0001). Furthermore, the uterine volume\nof the two groups significantly increased at 24 months\nafter surgery compared with those at 12 months after\nsurgery (P < 0.01, Table 2, Figure 3). Uterine sizes at 12\nand 24 months after surgery w ere statistically higher in\ngroup A than in group B (P < 0.0001); uterine size in\neach group was significantly decreased after surgery\ncompared with that before surgery (P < 0.0001, T able 2,\nFigure 3). Similar to uterine size, serum CA125 levels at\n12 and 24 months after surgery were significantly\nhigher in group A than in group B (P < 0.05); serum\nCA125 levels were also statistically lower than those be-\nfore surgery (P = <0.0001, Tables 1 and 2). Differences\nin serum CA125 levels between 6 and 12 months and\nTable 2 Changes in serum CA125 levels, uterine size, pain scores, and menorrhagia after surgery in groups A and B\nParameters Serum CA125 Pain\nscores\nUterine size Menorrhagia\n(kU/L) (cm 3) (pads)\nGroup A* ( n= 48)\n6 months* ( n= 48) 20.3 ± 6.9 0.2 ± 0.5 43.0 ± 12.1 ————\n12 months ( n= 31) 29.4 ± 18.3 0.8 ± 1.1 59.7 ± 24.1 4.2 ± 0.9\n24 months ( n= 15) 43.8 ± 20.7 2.0 ± 2.1 74.0 ± 30.6 4.6 ± 1.1\nGroup B ( n= 46)\n6 months ( n= 46) 13.3 ± 3.9 0.1 ± 0.3 37.6 ± 4.6 ————\n12 months ( n= 27) 19.7 ± 6.2 0.2 ± 0.6 45.8 ± 4.9 3.7 ± 0.6\n24 months ( n= 13) 25.6 ± 6.7 0.4 ± 0.9 48.1 ± 5.1 3.8 ± 0.6\n*Group A = Conventional method, Group B = Double-flap method.\nFigure 3 Changes of serum CA125 levels, uterine size, pain scores, and menorrhagia before and after surgery in groups A and B.\nGroup A = Conventional method, Group B = Double-flap method.\nHuang et al. BMC Women's Health  (2015) 15:24 Page 5 of 8\n\nbetween 12 and 24 months after surgery were significantly\ndifferent in both groups A and group B (P <0.05). In group\nB, all of the patients revealed normal serum CA125 levels\nat any month after surgery; by contrast, the serum\nCA125 levels of six (19.4%) patients in group A at\n12 months and seven (46.7%) patients at 24 months\nafter surgery were >35 kU/L.\nThe numbers of healthy pads used during menstruation\nat 12 and 24 months after surgery were significantly\nhigher in group A than in group B (P <0.05), but the num-\nber of pads in each group was significantly lower than that\nbefore surgery (P < 0.0001, T able 2, Figure 3). The differ-\nences in menstrual flow between 12 and 24 months after\nsurgery were not statistically significant in either of the\ngroups (P > 0.05), although the menstrual flow at\n24 months after surgery increased compared with that at\n12 months after surgery in both groups (T able 2, Figure 3).\nIn group B, all of the patients experienced normal men-\nstruation after surgery. In group A, six (19.4%) patients at\n12 months and five (33.3%) patients at 24 months after\nsurgery suffered from menorrhagia, but the number of\npads used was ≤7.\nThe amount of blood loss during surgery was similar\nin groups A and B (137.5 ± 54.6 ml vs. 145.6 ± 61.6 ml,\nP > 0.05). Accordingly, the amount of hemoglobin loss\nbetween before and after surgery was also similar in\ngroups A and B (0.5 ± 0.26 g/dl vs. 0.6 ± 0.37 g/dl, P >\n0.05). The operative time was much more in group B\n(152.5 ± 106.9 min) than that in group A (116.7 ±\n53.8 min, P < 0.05). Next, the weight of the excised tis-\nsues was heavier in group B than that in group A (177 ±\n155 g vs. 235.7 ± 201.3 g, P < 0.05). Furthermore, no in-\ntraoperative or postoperative complications were found\nin groups A and B. In addition, ten patients after surgery\nin this study (group A = 6, group B = 4) who wished to\nhave future pregnancies did not want to have a preg-\nnancy so far, because they have had children.\nDiscussion\nThe present results showed that all of the study patients\nexhibited a significant reduction in pain symptoms,\nmenorrhagia, serum CA125 levels and uterine size after\nsurgery. Dysmenorrhea and menorrhagia are the charac-\nteristic symptoms of adenomyosis, and directly related\nto the surgical efficacy of laparoscopic adenomyomect-\nomy [9,28,29]. Serum CA125 levels are considered as a\ngood biomarker to diagnose and monitor the therapeutic\nefficacy and recurrence of adenomyosis [30,31]. An en-\nlarged uterus is also a major symptom of adenomyosis,\nand a reduction in uterine size is also directly associated\nwith therapeutic efficacy [32,33]. It is apparent that lap-\naroscopic adenomyomectomy can treat diffuse uterine\nadenomyosis effectively [4,10,34-36]. However, menor-\nrhagia, serum CA125 levels and uterine size were\nincreased after surgery when postoperative follow up\nwas prolonged even if we used GnRHa therapy for six\nmonths after operation. It is indicated that the surgical\nefficacy of laparoscopic adenomyomectomy for the treat-\nment of diffuse uterine adenomyosis can decrease over\ntime. Therefore, long-term drug therapy such as Mirena\n(or oral contraceptives) is recommeneded after adeno-\nmyomectomy for the treatment of diffuse uterine adeno-\nmyosis [17,37].\nIn fact, the surgical efficacy of adenomyomectomy is\ndependent on the type and extent of adenomyosis as\nwell as the modes of surgery [10,37,38]. Theoretically,\nadenomyomectomy can achieve good results for focal\nadenomyosis (or adenomyoma), but not for diffuse ade-\nnomyosis. Complete resection of adenomyotic lesions\n(type I) can have more surgical efficacy compared with\ncytoreductive surgery of adenomyosis (type II) [10,37].\nIn our study, the triple-flap method was modified by\nchanging the mode of surgery and the suturing method,\nbut the resection method was retained [16]. Obviously,\nthe double-flap method is classified as type I, while the\nconventional method is classified as type II [10,37]. Our\nresults showed that the VAS scores, the number of\nhealthy pads, serum CA125 levels and uterine volume at\n12 or 24 months after surgery were all significantly lower\nwhen the double-flap method was used than when the\nconventional method was used. Moreover, all of the pa-\ntients experienced normal CA125 levels and menstru-\nation, and the VAS scores were similar after surgery\nwhen the double-flap method was used. By contrast,\n25% patients still suffered from menorrhagia, about half\nof patients showed high serum CA125 levels, and the\nVAS scores increased after surgery when the conventional\nmethod was used as follow up time was prolonged. These\nresults indicate that laparoscopic adenomyomectomy\nusing the double-flap method was more effective to treat\nuterine diffuse adenomyosis than conventional laparo-\nscopic adenomyomectomy, which are similar to the previ-\nous reports [10,37].\nRecently, Saremi et al. performed open wedge-shaped\nadenomyomectomy for 103 patients with adenomyosis,\nand 21 (30%) out of 70 patients who attempted preg-\nnancy achieved a clinical pregnancy [39]. Kishi et al.\ntreated 102 patients with adenomyosis who had a desire\nfor pregnancy by laparoscopic adenomyomectomy using\nthe conventional method, and the clinical pregnancy\nrates in women with age ≤39 years and ≥ 40 year were\n41.3% and 3.7%, respectively [40]. In our study, 10 pa-\ntients who wished to conceive after surgery did not want\nto have a pregnancy so far, because their age were rela-\ntively older, and they have had children, which is in\nagreement with the study of Kim et al. [17]. Actually,\nour study and the study of Kim et al. contain less infer-\ntility patients compared with the studies of Kishi et al.\nHuang et al. BMC Women's Health  (2015) 15:24 Page 6 of 8\n\nand Saremi et al. [17,39,40]. Moreover, patients with\nage >40 years do not show a clear benefit of the surgery\non fertility outcomes after adenomyomectomy for the\ntreatment of adenomyosis [39]. Furthermore, in patients\nwith extremely severe diffuse adenomyosis, it is quite diffi-\ncult to maintain the intact morphological and functional\nreconstruction after complete removal of adenomyotic le-\nsions. In such cases, it is hard to tell patients whether they\nhave a future pregnancy [39]. Therefore, the fear of future\npregnant uterine rupture may also be a factor for our pa-\ntients with severe diffuse adenomyosis who do not want\nto have a pregnancy at present [41].\nAlthough Kim et al. reconstructed the uterine wall using\nthe double flap method after laparoscopic-assisted adeno-\nmyomectomy, yet, their resection method quite differs\nfrom our resection method [17]. As matter of fact, we ini-\ntially try to perform open adenomyomectomy by using the\ntechnique of Osada et al. [16]. When we find it is ex-\ntremely difficult to reconstruct the uterine wall using the\ntriple-flap method in despite of a new absorbable barbed\nsuture (v-loc) [16,37], then we try to suture using the\ndouble flap method. After we have mastered the technique\nof the double flap method, we perform a laparoscopic sur-\ngery. During the surgical procedure, a diluted solution of\npituitrin was first injected until the uterus became white\ncolour, and then the remained pituitrin solution was con-\ntinually used when it was needed. In the meantime, a\ndrainage tube used as a tourniquet for transient occlusion\nof uterine arteries was placed into the abdominal cavity in\ncase of massive bleeding during the procedure [42]. More-\nover, the uterine cavity was opened so that the entire ex-\ntent of the adenomyosis, the crucial landmarks of the\nendometrium and the serosal surface are clearly visible\n[16]. We found no patients required conversion to open\nsurgery, and the blood loss was similar in the two\nmethods, although the double-flap method had more op-\nerative time compared with the conventional method.\nInterestingly, the amount of the blood loss in our study\n(145.6 ml) is less compared with the study of Kim et al.\n(383.3 ml), while the operative time is a little longer in our\nstudy (152.5 min) in comparison with the study of Kim\net al. (130.6 min) [17]. Moreover, no intraoperative or\npostoperative complications were observed in all of the\nstudy patients. In addition, complete removal of the ade-\nnomyotic lesions may create better uterine conditions for\npregnancy [16]. Therefore, the double-flap method could\nbe safe and effective to treat uterine diffuse adenomyosis,\nalthough future follow-up observation is needed for post-\noperative pregnancy and childbirth in order to verify the\nrobustness of the uterine reconstruction.\nConclusions\nOur results showed that women with diffuse adenomyo-\nsis exhibited a significant reduction in serum CA125\nlevels, uterine size, hypermenorrhea, and dysmenorrhea\nafter laparoscopic adenomyomectomy was performed\nusing the double-flap method. These results suggest\nthat adenomyomectomy with the double-flap method\nmay be a good therapeutic option for women with diffuse\nuterine adenomyosis and wish to avoid hysterectomy.\nNevertheless, further studies should be conducted to ver-\nify these results.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthors’ contributions\nXFH designed the study protocol, collected the data, performed the\nstatistical analysis, and drafted the manuscript. QSH aided to collect the data\nand draft the manuscript. SC helped to perform the statistical analysis and\ninterpreted the data. JZ and KQL both helped to collect the data. XMZ\nconceived the study concept, designed the study protocol and co-ordinate\nthe whole research procedure, helped to do data analysis and finalising the\nmanuscript. All authors read and approved the final manuscript.\nAcknowledgments\nWe appreciate the financial support of the National Nature Science\nFoundation of China (Grant Nos. 81270672 and 81471433), the Nature\nScience Foundation of Zhejiang Province (Grant Nos. Y2110181 and\nY2110128), the Science and Technology Fund of Zhejiang Province\n(Grant Nos. 2011C13028-1 and 2013C33149), and the Key Medical Science\n(Innovation) Project of Zhejiang Province.\nReceived: 2 November 2014 Accepted: 24 February 2015\nReferences\n1. Zhang X, Yuan H, Deng L, Hu F, Ma J, Lin J. Evaluation of the efficacy of a\ndanazol-loaded intrauterine contraceptive device on adenomyosis in an ICR\nmouse model. Hum Reprod. 2008;23:2024 –30.\n2. Nishida M, Takano K, Arai Y, Ozone H, Ichikawa R. Conservative surgical\nmanagement for diffuse uterine adenomyosis. Fertil Steril. 2010;94:715 –9.\n3. 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[Epub ahead of print].\nSubmit your next manuscript to BioMed Central\nand take full advantage of: \n• Convenient online submission\n• Thorough peer review\n• No space constraints or color figure charges\n• Immediate publication on acceptance\n• Inclusion in PubMed, CAS, Scopus and Google Scholar\n• Research which is freely available for redistribution\nSubmit your manuscript at \nwww.biomedcentral.com/submit\nHuang et al. BMC Women's Health  (2015) 15:24 Page 8 of 8","source_license":"CC0","license_restricted":false}