{"paper_id":"3560a106-8bab-40e5-ac92-fab960e3574d","body_text":"ORIGINAL ARTICLE\nConservative laparoscopic electrocoagulation adenomyolysis\nfor the management of symptomatic adenomyosis\nHosam Abdel-Fattah1 & Nasser El-Lakkany1 & Adel Saad Helal 1 & Alaa Mosbah1 &\nEl-Said Abdel-Hady1 & Mahmoud Abdel-Shaheed2\nReceived: 23 December 2014 / Accepted: 1 April 2015 / Published online: 6 May 2015\n# Springer-V erlag Berlin Heidelberg 2015\nAbstract The objective of the study was to assess the safety\nand efficacy of conservative laparoscopic electrocoagulation\nadenomyolysis (CLEA) in the management of women with\nsymptomatic adenomyosis. The study design is prospective\nobservational study. The setting was Department of Obstetrics\nand Gynecology, Mansoura University Hospital. Thirty-nine\npremenopausal women, complaining of chronic pelvic pain\nand/or menorrhagia, were diagnosed to have adenomyosis\nby transvaginal ultrasonography (TVS) and/or magnetic reso-\nnance imaging (MRI), between June 2008 and June 2011.\nThey were subjected to laparoscopic multiple uterine unipolar\nelectrocoagulation diathermy punctures aiming at\nadenomyolysis. Women were evaluated before and at 3, 6,\nand 12 months after the procedure. Main outcome is the mag-\nnitude of pain by using the visual analog scale (V AS) and the\noverall patient self satisfaction as assessed by short form 36\n(SF-36) questionnaires; secondary outcome is the uterine vol-\nume as measured by TVS. At 3-, 6-, and 12-month follow-up\nvisits, there was a gradual, yet a significant, reduction in the\nmedian V AS scoring system of pain ( p<0.01), a significant\nimprovement in every scale of the SF-36 (p<0.01), and also a\nsignificant reduction (p<0.01) in the median uterine volume\nas assessed by TVS. Conservative laparoscopic\nelectrocoagulation adenomyolysis may be an effective and\nsafer minimal invasive procedure for the management of\nsymptomatic adenomyosis in premenopausal women.\nKeywords Adenomyosis . Pain . Laparascopy .\nAdenomyolysis\nIntroduction\nAdenomyosis is a benign gynecological disease in which the\nendometrial stroma invades the uterine myometrium.\nAdenomyosis is divided into diffuse and localized forms ac-\ncording to the extent of the lesion. Localized adenomyosis is\nalso known as adenomyoma [1].\nThe incidence of the disease varies between 5 and 70 %.\nGenerally, it occurs in women aged between 40 and 50 years,\nwith a prevalence rate of 70 –80 %. Adenomyosis was found\nin 23 % of uteri that were removed due to fibroids [ 2].\nThe etiology of this disease has not been clearly elucidated.\nHowever, several pathophysiological mechanisms have been\nproposed, such as damage of endometrial-myometrial border\ndue to trauma and high estrogen biosynthesis associated with\nincreased activities of aromatase enzyme [ 3]. The clinical\nmanifestations include dysmenorrhea, chronic pelvic pain,\nand menorrhagia. It is usually combined with pelvic endome-\ntriosis, endometrial cysts of the ovary, uterine fibroids, or oth-\ner estrogen-dependent diseases [4].\nThe diagnosis of adenomyosis was based on clinical symp-\ntoms. In recent years, the development of imaging techniques\nhas made diagnosis more accurate. It has been reported that\nthe sensitivity of diagnosis by vaginal ultrasound was 80 –\n86 % and the specificity was 74 –86 %. The sensitivity of\nmagnetic resonance imaging (MRI) was 80 –86 % and the\nspecificity was 74–86 % [ 5].\nThe myometrium has three distinct sonographic layers: the\nouter, middle, and inner layers. The middle layer is the most\nechogenic and is separated from the outer layer by the arcuate\nvenous and arterial plexus. The inner layer (the\n* Adel Saad Helal\nadelsaadhelal@yahoo.com\n1 Department of Obstetrics and Gynecology,\nMansoura University, Mansoura, Egypt\n2 Department of Diagnostic Radiology,\nMansoura University, Mansoura, Egypt\nGynecol Surg (2015) 12:139–147\nDOI 10.1007/s10397-015-0890-8\nRETRACTED ARTICLE\n\nsubendometrial halo) is composed of longitudinal and circular\nclosely packed smooth muscle fibers. The inner layer\n(archimyometrium or stratum subvasculare, e.g., the\nsubendometrial halo) is hypoechogenic at transvaginal ultra-\nsonography (TVS) but at MRI, it is readily and more distinctly\nseen as a low-signal intensity (SI) band referred to as the JZ\n[6].\nThe sonographic findings of adenomyosis, best obtained\nby transvaginal sonography, include the following [7]:\n1. Uterine enlargement—globular uterine enlargement that\nis generally up to 12 cm in uterine length and that is not\nexplained by the presence of leiomyomata is a character-\nistic finding (Fig. 1).\n2. Cystic anechoic spaces or lakes in the myometrium —the\ncystic anechoic spaces within the myometrium are vari-\nable in size and can occur throughout the myometrium.\nThe cystic changes in the outer myometrium may on oc-\ncasion represent small arcuate veins rather than\nadenomyomas. The application of color Doppler imaging\nat low velocity scales may help in this differentiation\n(Fig. 2).\n3. Uterine wall thickening—the uterine wall thickening can\nshow antero-posterior asymmetry, especially when the\ndisease is focal (Fig. 3).\n4. Subendometrial echogenic linear striations —invasion of\nthe endometrial glands into the subendometrial tissue in-\nduces a hyperplastic reaction, which appears as echogenic\nlinear striations fanning out from three endometrial layer\n(Fig. 4).\n5. Heterogeneous echo texture—there is a lack of homoge-\nneity within the myometrium with evidence of architec-\ntural disturbance (Fig. 5). This finding has been shown to\nbe the most predictive of adenomyosis.\n6. Obscure endometrial/myometrial border—invasion of the\nmyometrium by the glands also obscures the normally\ndistinct endometrial/myometrial border (Fig. 6).\n7. Thickening of the transition zone—this zone is a layer that\nappears as a hypoechoic halo surrounding the endometrial\nlayer. A thickness of 12 mm or greater has been shown to\nbe associated with adenomyosis.\nDoppler sonography may fac ilitate the differentiation\nbetween myomas and adenomyosis (Fig. 7). V essels\naround myomas produce a well-defined rim with a few\nvessels entering the body of the mass. In contrast, in\nadenomyosis, vessels follow their normal perpendicular\ncourse in myometrial areas [ 8].\nAdenomyosis typically presents as either diffuse or focal\nthickening of the inner myometrium or an ill-defined\nmyometrial nodule of low SI on MRI T2-WIs (Figs. 8, 9,\nand 10). In healthy women of reproductive age, the inner\nmyometrium, which is also called the JZ, appears as the band\nof low SI between the endometrium of high SI and the outer\nmyometrium of intermediate SI. Although adenomyosis can\nbe readily suspected when it present as focal thickening of the\nJZ, diffuse thickening of the JZ should be carefully distin-\nguished from physiological change since the thickness of the\nJZ varies considerably during the menstrual cycle [ 9].\nThe JZ is generally widest and most clearly visible in the\nlate secretory phase. Generally, a maximal thickness of the JZ\n(>12 mm) is highly predictive of the presence of adenomyosis,\nwhile a uterus with the JZ (<8 mm) is unlikely to have\nadenomyosis. Since the JZ can frequently show thickness of\n>12 mm during menstruation, especially on cycle days 1 and 2\nin our experience (Fig. 11), MR examination during the men-\nstrual phase should be avoided for evaluating adenomyosis\n[10].\nThe decreased SI on T2-WIs represents smooth muscle\nhyperplasia associated with ectopic endometrium. Occasion-\nally, the islands of ectopic endometrial tissue can be demon-\nstrated as punctate foci of high SI on T2-WIs (Fig.12a). When\nmenstrual hemorrhage occurs within these ectopic endometri-\nal glands, cystically dilated glands are presented as foci of\nhigh SI on T1-WIs (Fig. 12b). Less commonly, benign inva-\nsion of the basal endometrium into the myometrium can man-\nifest as Blinear striations^ of high SI radiating out from the\nFig. 1 Globular uterine enlargement with an obscure\nendometrialmyometrial border (arrow)\nFig. 2 The application of color Doppler imaging at low velocity scales\n140 Gynecol Surg (2015) 12:139–147\nRETRACTED ARTICLE\n\nendometrium on T2-WIs, resulting in Bpseudowidening^ of\nthe endometrium (Fig. 13)[ 11].\nV a r i a t i o ni nM Rf e a t u r e so fa d e n o m y o s i s\nAdenomyoma\nAdenomyoma is a localized and well-circumscribed form of\nadenomyosis. Recognition of this entity is of clinical impor-\ntance because adenomyomas are frequently confused with\nleiomyomas, not only on MRI but also at pathological exam-\nination. On MRI, myometrial adenomyomas typically exhibit\nlow SI on T2-WIs, which may closely simulate leiomyoma.\nWhen the lesion is accompanied by hyperintense foci\nrepresenting ectopic endometrium on T2-WIs, MRI can allow\ncorrect diagnosis of this entity (Fig. 14). Unlike the ordinary\nform of adenomyosis, myometrial adenomyoma can be treat-\ned surgically with myomectomy [12].\nAdenomyomatous polyp (polypoid adenomyoma)\nAdenomyomatous polyp (polypoid adenomyoma) presents as\na pedunculated or sessile polypoid mass in the lower uterine\nendometrium or endocervix, and accounts for about (2 %) of\nall endometrial polyps. It typically affects premenopausal\nwomen, presenting as abnormal genital bleeding. On MRI,\nthe lesion typically presents as a hypointense polypoid mass\nrepresenting myometrial tissue, associated with hyperintense\nfoci on T2-WIs. The recognition of the attachment site of the\npolypoid lesion and the typical signal pattern on MRI may\nallow preoperative diagnosis of polypoid adenomyoma. Atyp-\nical polypoid adenomyoma is a rare variant of a polypoid\nadenomyoma, microscopically characterized by architectural\nand cytologic atypia. MR findings are similar to those an\nordinary polypoid adenomyoma and may reveal a hemorrhag-\nic cyst within the lesion (Fig. 15)[ 10].\nAdenomyotic cyst (cystic adenomyosis)\nAdenomyotic cyst is a rare variant of adenomyosis character-\nized by the presence of a large hemorrhagic cyst resulting\nfrom extensive menstrual bleeding in the ectopic endometrial\ngland. The lesion can be entirely within the myometrial, sub-\nmucosal, or subserosal tissue. On MRI, fluid content exhibits\nhigh SI on T1-WIs, and the surrounding solid wall exhibits a\ndistinct low SI on T2-WIs (Fig. 16). Occasionally, the solid\nwall may consist of an inner zone of low SI that resembles a JZ\nand an outer zone of a relatively increased intensity; an\nadenomyoma with this finding can be called a Bminiature\nuterus^ [10].\nDifferent strategies for the management of adenomyosis\nhave been tried [ 13]; for patients who prefer conservative\nmeasures, medical therapy may be the least invasive and most\nacceptable strategy and includes the use of prostaglandin in-\nhibitors, oral contraceptive pills, progestogens, danazol,\nFig. 3 Uterine wall thickening which shows antero-posterior asymmetry\nFig. 4 Subendometrial echogenic linear striations\nFig. 5 Heterogeneous echo texture\nFig. 6 Obscure endometrial/myometrial border\nGynecol Surg (2015) 12:139–147 141\nRETRACTED ARTICLE\n\ngestrinone, and gonadotropin-releasing hormone (GnRH) ag-\nonists. Unfortunately, the effect of these medical treatments is\noften transient, and the symptoms (especially pain) usually\nreappear after discontinuing medication [14].\nThe surgical approach for preserving the uterus can be con-\nsidered when dysmenorrhea does not respond to drug treat-\nment; these include excision of the myometrial adenomyoma\nthrough a laparotomy. Less invasive conservative surgical ap-\nproaches, including endomyometrial ablation, laparoscopic\nmyometrial electrocoagulation, and laparoscopic surgery,\nhave been attempted [15]. All conservative surgical treatments\nFig. 7 a , b Doppler sonography\nmay facilitate the differentiation\nbetween myomas and\nadenomyosis\nFig. 8 Adenomyosis presenting as diffuse thickening of the JZ. MRI\nSagittal T2-WI shows an enlarged uterus with diffusely thickened JZ\nwhich measures >12 mm in thickness\nFig. 9 Adenomyosis presenting as focal thickening of the JZ. MRI\nSagittal T2-WI shows focal thickening of the JZ in the posterior wall of\nthe uterus (arrows)\n142 Gynecol Surg (2015) 12:139–147\nRETRACTED ARTICLE\n\nhave proven effective in up to 50 % of patients; however, the\nfollow-up assessment periods have been of short duration\n[16].\nThe conventional and definitive management of symptom-\natic adenomyosis is hysterectomy [ 17]. Phillips et al. [ 18]\nstudied laparoscopic bipolar coagulation for conservative\ntreatment of adenomyomata with preoperative GnRH analog\nand concluded that further evaluation of this technique is nec-\nessary to determine its definitive role.\nWood’ss t u d y[ 16] showed that endometrial ablation,\nmyometrial electrocoagulation, or laparoscopic excision were\neffective in >50 % of patients. Laparoscopic resection versus\nmyolysis in the management of symptomatic uterine\nadenomyosis was also studied before [ 2]; no significant dif-\nferences were found in the median reduction of menorrhagia\nand dysmenorrhea scores between the resection and the\nmyolysis groups.\nPatients and methods\nThis study included 39 women admitted to the Department of\nObstetrics and Gynecology, Mansoura University Hospital,\nbetween June 2008 and June 2011. They complained of\nchronic pelvic pain and/or menorrhagia with a provisional\ndiagnosis of adenomyosis. The inclusion criteria included pre-\nmenopausal women (40–50 years), who had completed their\nfamilies and were not willing to undergo hysterectomy; other\npelvic pathology was excluded. Diagnosis of adenomyosis\nwas established by TVS, color Doppler, and MRI. Laparosco-\npy was decided, and the intended procedure was explained; a\nwritten consent was signed by the patient and her husband.\nAlso, the procedure was approved by Mansoura Medical Eth-\nical Committee. Usual preoperative investigations and prepa-\nrations including 400μg prostaglandin E1 analog, misoprostol\n(Misotac Sigma) per rectum were immediately placed before\nlaparoscopy. Laparoscopy was performed under general anes-\nthesia in the neutral-lithotomy position. Patients were cathe-\nterized and vaginally prepared, and uterine manipulator was\ninserted. Pneumo-peritoneum was done with V eress needle\nthrough the umblicus. For the primary puncture, 10-mm port\nwas inserted through the umblical incision with a video lapa-\nroscope introduced. For the second puncture, 5-mm port was\nplaced laterally on Pfannenstiel line for uterine manipulation.\nFor the third puncture, 5-mm port was inserted in the middle\nof Pfannenstiel line for adenomyolysis diathermy needle. A\nunipolar diathermy needle was introduced for puncture and\ncauterization of the anterior and posterior uterine wall, as well\nas the fundus. An average of 6 –10 punctures was placed\nthrough the anterior uterine wall and 4 –6 punctures for the\nfundus; the latter was brought perpendicular to the needle axis\nby extreme anteflexion by an instrument through second port.\nThe posterior wall was approached perpendicularly by the\ndiathermy needle introduced in a 5-mm reducer through the\nprimary port, and the procedure was monitored by 5-mm\nscope through the suprapubic incision (changing entry) and\n6–10 punctures were done in posterior wall. The needle punc-\ntures were 1 –2 cm using 100-W current; the depth of punc-\ntures was about 10 –15 mm; saline wash was done. Finally,\nintaperitoneal drain was left in place for 24 h. Women were\nadvised to use condoms for contraception, to avoid the effects\nof hormonal therapy and the intra uterine device. Patients were\nfollowed up at 3, 6, and 12 months. At each visit, patients were\nevaluated as regards (a) chronic pelvic pain, which was\nassessed by the visual analog score (V AS), (b) quality of life\nscales which was assessed by the short form 36 (SF-36), and\n(c) the uterine volume which was evaluated by TVS.\nFig. 10 Diffuse adenomyosis presenting as an ill-defined myometrial\nmass. MRI Sagittal T2-WI shows a diffusely enlarged uterus with indis-\ntinct zonal anatomy. There is an ill-defined mass of decreased SI in the\nmyometrium of the anterior wall and the fundus\nFig. 11 JZ can frequently show thickness of >12 mm during\nGynecol Surg (2015) 12:139–147 143\nRETRACTED ARTICLE\n\nStatistical analysis used SPSS (version 11) with median\nvalues and SD, and Student ’s t test was used to compare be-\ntween preoperative and follow-up visits. The difference was\nconsidered significant when p value was less than 0.05.\nResults\nThe magnitude of pelvic pain was significantly improved\n(p<0.01), following the procedure and at 3, 6, and 12 months\nas assessed by the visual analog score as given in Table1.T h e\nquality of life scores showed significant improvement as\nassessed by the SF-36 scores. By 12 months following the\nprocedure, a significant improvement was observed in each\nitem of the SF-36 scores ( p<0.01) as given in Table 2.\nThe uterine volume as assessed by transvaginal ultrasound\nshowed a gradual, yet a significant, reduction in the mean\nFig. 12 a The islands of ectopic\nendometrial tissue can be\ndemonstrated as punctate foci of\nhigh SI and b when menstrual\nhaemorrhage occurs within\nectopic endometrial glands,\ncystically dilated glands are\npresented as foci of high SI on\nT1- WIs\nFig. 13 a , b Benign invasion of\nthe basal endometrium into the\nmyometrium can manifest as\nBlinear striations^ of high SI\nradiating out from the\nendometrium on T2-WIs,\nresulting in Bpseudowidening^ of\nthe endometrium\nFig. 14 When the lesion is accompanied by hyperintense foci\nrepresenting ectopic endometrium on T2-WIs, MRI can allow correct\ndiagnosis of this entity\n144 Gynecol Surg (2015) 12:139–147\nRETRACTED ARTICLE\n\nuterine volume with an average reduction of volume by 43 %\nat 12 months following the procedure ( p<0.01) as given in\nTable 3. The procedure was not associated with significant\ncomplication apart from any routine laparoscopic procedure.\nPatients’ requirements for analgesics were comparable to any\nroutine laparoscopic procedure.\nDiscussion\nThis study includes 39 women with symptomatic\nadenomyosis aged between 40 and 50 years who were sub-\njected to conservative laparoscopic adenomyolysis from the\nperiod of June 2008 to June 2011, as shown in Fig. 1.A n d\nthey were followed up for 12 months. Many patients in such\nan age group especially in early 1940s may prefer a rather\nminimally invasive technique to improve their symptoms.\nHysterectomy, as a standard surgical procedure for the\nmanagement of symptomatic adenomyosis, may not be an\naccepted modality option by many premenopausal women.\nSimple random unipolar electrocauterization of adenomyotic\nuteri was tried in this study, assuming that necrosis of\nadenomyotic implants will improve the symptoms.\nMain findings\nA recoded significant improvement at 3-, 6-, and 12-month\nfollow-up include the severity of pain as assessed by the V AS\nas well as the quality of life as assessed by SF-36 scores\nfollowing conservative laparoscopic electrocoagulation\nadenomyolysis (CLEA) procedure as given in Tables 1 and\n2. Also, the assessment of the uterine volume by TVS revealed\na significant reduction, average 43 %, by the end of 1 year as\ngiven in Table 3 as a secondary outcome. There were no re-\ncorded significant complications following the procedure.\nFig. 15 a , b Haemorrhagic cyst\nwithin the lesion\nFig. 16 a , b On MRI, fluid\ncontent exhibits high SI on T1-\nWIs and the surrounding solid\nwall exhibits a distinct low SI on\nT2-WIs\nGynecol Surg (2015) 12:139–147 145\nRETRACTED ARTICLE\n\nStrength and limitations\nSmall sample size represents the main limitation in this study\nas the use of unipolar diathermy was the first trial and also no\npreceding adjuvant medical treatment.\nInterpretation\nThe use of unipolar diathermy needle in our study was\nintended to ensure better speed of current through the\ntissues, rather than the use of bipolar needle. The latter\nwas tried by others [ 2, 18], on a smaller number of\ncases. In these studies, either pre- or postoperative ad-\njuvant GnRH therapy was us ed. In this study, CLEA\nwas attempted only with no added adjuvant medical\ntreatment. Two unplanned pregnancies occurred in this\nseries within the follow-up period. One pregnancy end-\ned in a spontaneous miscarriage at 8 weeks, and the\nother pregnancy continued with no adverse effects up\nto 38 weeks and the baby was born by an elective\ncesarean section; a healthy baby weighing 3 kg was\nborn (data not shown).\nConclusions\nLaparoscopic electrocoagulation adenomyolysis is recom-\nmended as an effective and safer minimal invasive procedure\nfor the management of symptomatic adenomyosis.\nY et, more studies and larger number of patients are recom-\nmended to assess the effectiveness and side effects of this\nprocedure.\nAcknowledgments The authors thank all the staff members in the De-\npartment of Obstetrics and Gynecology, the operating room staff mem-\nbers, and all the patients who shared information and experiences in this\nresearch. This research is approved by local ethical research committee of\nMansoura University, Faculty of Medicine on May 2008.\nConflict of interest There is no conflict of interest in this work.\nFunding None.\nAuthors’ contributions Hossam abd elfatah, Nasser Allakany, and\nAdel Saad Helal made the design and did the operations. Alaa mesbah\nperformed the preoperative and postoperative TVS evaluation of all pa-\ntients. Mahmoud abd elshahied did the preoperative and postoperative\nDoppler study of all patients. Elsaid M. Abd elhady wrote the paper\nand helped in statistical analysis.\nReferences\n1. Ai-jun SUN, Min LUO, Wei W ANG, Rong CHEN, Jing-he LANG\n(2011) Characteristics and efficacy of modified adenomyomectomy\nin the treatment of uterine adenomyoma. Chin Med J 124(9):1322–\n1326\n2. Wachyu H, Dewi Anggraeni T (2006) Laparoscopic resection ver-\nsus myolysis in the management of symptomatic uterine\nadenomyosis: alternatives to conventional treatment. Med J\nIndones 15(1):9–17\n3. Ota H, Igarashi S, Hatazawa J, Tanaka T (1998) Is adenomyosis an\nimmune disease? Hum Reprod Update 4:360–367\n4. Reinhold C, McCarthy S, Bret PM (1996) Diffuse adenomyosis:\ncomparison of endovaginal UA and MR imaging with histopatho-\nlogic correlation. Radiology 199:151–158\n5. Ascher SM, Arnold LL, Patt RH (1994) Adenomyosis: prospective\ncomparison of MR imaging and transvaginal sonography.\nRadiology 190:803–806\n6. Gilks CB, Clement PB, Hart WR et al (2000) Uterine\nadenomyomas excluding atypical polypoid adenomyomas and\nTable 2 Assessment of quality of life scales by short form (SF-36\nscores): there was a gradual improvement in each item of the SF-36 scores\nand by 12 months following the procedure; a significant improvement\nwas observed in each item of the SF-36 scores ( p<0.01)\nScale Pre 12 months p value\nPhysical functioning 13±1.6 39±14 <0.01\nRole limitations due to physical health 27±16 48±24 <0.01\nRole limitations due to emotional\nproblems\n36.3±21.8 36.5±22.1 <0.01\nEnergy/fatigue 39±4.9 54±13 <0.01\nEmotional well-being 58±6.7 69±12 <0.01\nSocial functioning 28±5.6 52±16.5 <0.01\nPain 30±3.7 62±18.8 <0.01\nGeneral health 31±5.3 59±15.9 <0.01\nTable 3 Assessment of the uterine volume by TVS: there was a\ngradual, yet a significant, reduction in the mean uterine volume as\nassessed by TVS, by an average of 43 % at 12 months following the\nprocedure (p<0.01)\nPreoperative\n(mean) (cm3)\nPostoperative (mean) (cm3)\n3 months 6 months 12 months\nUterine volume 435.3 262.5 247.4 247.5\np 0.01 0.01 0.01\nTVS transvaginal ultrasonography\nTable 1 Assessment of pain by V AS: visual analog score was\nsignificantly improved at 3, 6, and 12 months after the procedure\n(p<0. 01 )\nVA S N Median± SD p value\nPreoperative 39 69.0000 6.6176\n3 months 36 59.6667 9.8027 <0.01\n6 months 30 41.0000 14.7040 <0.01\n12 months 30 40.0333 14.7028 <0.01\nVAS visual analog scale\n146 Gynecol Surg (2015) 12:139–147\nRETRACTED ARTICLE\n\nadenomyomas of endocervical type: a clinicopathologic study of\n30 cases of an underemphasized lesion that may cause diagnostic\nproblems with brief consideration of adenomyomas of other female\ngenital tract sites. 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Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS (1996)\nLaparoscopic bipolar coagulation for the conservative treatment\nof adenomyomata. J Am Assoc Gynecol Laparosc 4(1):19–24\nGynecol Surg (2015) 12:139–147 147\nRETRACTED ARTICLE","source_license":"CC0","license_restricted":false}