{"paper_id":"6e3011f5-c5ba-4ba4-a4b9-b0d2097b5163","body_text":"Page 1 of 5\nExperience of Surgical Treatment of Adenomyosis and \nReproductive Outcomes\nRukhliada Nikolai N1,2 *\n1Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Russia\n2Dzhanelidze Saint Petersburg Research Institute of Emergence Care, Russia\n*Corresponding author: Rukhliada Nikolai N, Chief researcher of the Department \nof Gynecology, Dzhanelidze Saint Petersburg Research Institute of Emergence Care \nand Chief specialist, Saint Petersburg State Pediatric Medical University, Ministry \nof Health of Russia, Russia.\nReceived Date: February 06, 2020\nPublished Date: February 18, 2020\nISSN: 2641-6247                                                                                                                           DOI: 10.33552/WJGWH.2020.03.000564\nWorld Journal of \nGynecology & Women’s Health\nReview Article Copyright © All rights are reserved by Rukhliada Nikolai N\nThis work is licensed under Creative Commons Attribution 4.0 License  WJGWH.MS.ID.000564.\nIntroduction\nAdenomyosis is a benign tumor process of the uterus, one of the \nforms of endometrioid disease. Surgical treatment of adenomyosis \nto this day is the subject of discussion by many authors, but the \nprinciple of surgical interventions remains the same - excision of the \nmyometrium affected by glandular invasion. The article discusses \nthe main methods of adenomyomectomy, the results of surgical \ninterventions in terms of the reproductive function of women. In \naddition, its own original technique for suturing the uterus after \nsurgical interventions is given.\nAdenomyosis, being one of the frequent diseases that cause \nuterine bleeding, algomenorrhea, infertility, is an indication for \nprolonged hormone therapy or hysterectomy [1-4]. The use of \norgan-saving methods of surgical treatment for adenomyosis in \norder to maintain fertility and eliminate symptoms is an important \nmodern aspect of therapy [5,6]. Among all the causes of female \ninfertility, adenomyosis accounts for about 20% [7].\nMany authors point to a steady increase in the detection of \nadenomyosis in all age groups, including a tendency to increase \nthe incidence of adenomyosis in young women who did not \nrealize reproductive function. The frequency of its detection in the \npopulation, according to various authors, varies from 10 to 61% \n[8-12]. After hysterectomies in the preparations, the frequency of \ndetection of adenomyosis reaches 46–70% in the population [13]. \nThe lack of effect of conservative treatment methods leads to an \nincrease in the number of radical surgical interventions in young \nwomen [14].\nAt the same time, a review of the medical literature shows \nthat since 1990 at least 2,300 adenomyomectomies have been  \n \nperformed, including 2,123 (89.8%) in Japan. 397 pregnancies \nwere reported after organ-saving surgeries. In 337 (84.89%) \npregnancies ended in childbirth, while 23 pregnancies were \ncomplicated by uterine ruptures [15-17].\nAdenomyomectomy is a recognized method of treatment \nof manifest adenomyosis in combination with uterine myoma, \nmanifested by dysmenorrhea, menorrhagia and infertility. However, \npregnant women after adenomyomectomy have a higher risk of \nspontaneous abortion, uterine scar failure or spontaneous uterine \nrupture during pregnancy and childbirth, says Ota Y, et. al. [18]. \nThe impact of surgical energies during uterine surgery increases \nthe risk of uterine rupture [15,16]. Various surgical treatments for \nadenomyosis are currently being tested. Indications for surgery \nare dysmenorrhea and hypermenorrhea, resistant to conservative \ntherapy, infertility, habitual miscarriage, and the desire to maintain \nfertility or menstrual function with a significant increase in the size \nof the uterus.\nSurgical Treatment\nOrgan-preserving surgical treatment of adenomyosis in young \nwomen was first described by Van Praagh in 1952 [19]. Then \nthe technique of wedge-shaped resection of the myometrium \nwas adopted. In 1991, the results of resection of the affected \nmyometrium in 37 patients were presented. In the described cases, \nmicrosurgical resection of the affected myometrium by laparotomy \naccess was performed. As a result, 6 women became pregnant after \nthe operation, and all pregnancies ended in childbirth [20]. It was \nreported that in 1993 a series of operations of this modification \nwas performed with partial removal of adenomyoma in 28 patients. \nOf the 18 women trying to get pregnant, 13 achieved the desired \n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 3-Issue 3\nCitation: Rukhliada Nikolai N. Experience of Surgical Treatment of Adenomyosis and Reproductive Outcomes. W J Gynecol Women’s Health. \n3(3): 2020. WJGWH.MS.ID.000564.  DOI: 10.33552/WJGWH.2020.03.000564.\nPage 2 of 5\nresult. As a result, there were 9 (50.5%) live births and 7 (38.8%) \nmiscarriages, according to Fedele L, et. al [21].\nInteresting experience in performing Fujishita A, et. al. [22] \nlaparotomic modification of adenomyomectomy with an H-shaped \nincision in the bottom of the uterus with a wide separation of the \nserous part [6]. The altered myometrial tissue was dissected using \nan electrosurgical scalpel or scissors. The uterine wall was restored \nwith a two-row suture. The first row of sutures (muscular-muscular) \nrestored the uterine wall, while the suture was also hemostatic. \nBilateral serous flaps that appear after a vertical incision, as well \nas upper and lower flaps resulting from a transverse incision, were \nsutured with nodular gray-serous sutures.\nBased on the data collected before 2010, in 41 patients \nundergoing the H-section method, 31 attempted to become \npregnant; 12 (38.7%) reached clinical pregnancy, 5 (16.1%) \nmiscarriages and 7 (22.5%) reported live births [22]. In another \nstudy, Nishimoto M, et. al. 14 women were registered who \nperformed this technique [23]. At the same time, all women after \nthe operation planned a pregnancy, 3 (21.4%) reached pregnancy, \nand all had healthy children.\nIn a recent study by Saremi AT , et al. [24] a wedge-shaped \nresection of the uterine wall was reported up to the endometrium \nafter a sagittal section of the uterus [24]. Reconstruction of the \nuterine wall is performed by a continuous horizontal mattress \nsuture. A screw-on gray-serous suture is then applied to reduce the \nrisk of adhesions. Of the 103 patients operated on, 70 attempted \nto become pregnant during the study period, of which 21 (30%) \nreached clinical pregnancies. In 16 (22.8%) pregnancies ended in \nsuccessful live births.\nThe methods of complete excision of adenomyosis include the \ntriple flap method. This adenomyomectomy technique is based on \na completely new idea that differs from standard surgical methods \n[25]. The method involves reconstruction of a defect in the uterine \nwall using the remaining normal uterine muscle. In a study by \nOsada H, et al. 2017 [16], in which 113 women were evaluated after \nsurgery using this method, it was shown that within 6 months the \nblood flow in the area of action returned to normal in almost all \ncases (92/113, 81.4 %). Of the 62 women planning a pregnancy, \n46 became pregnant and 32 gave birth to a healthy baby through \na planned cesarean section. There were no cases of uterine \nrupture. During the study period (27 years), only 4 cases (3.5%) \nof relapses requiring repeated surgical treatment were recorded. \nIn cases where the resection of uterine adenomyosis is performed \nwithout opening the uterine cavity, and the uterine wall is formed \nby a serous-muscular flap, the operation is called the double flap \nmethod [15].\nLaparoscopic Surgery for Adenomyosis\nIn the first report on laparoscopic adenomyomectomy, the \nuterine defect after removal of adenomyosis was restored using \nthe method of cross flaps [26]. A total of 14 patients with focal \nadenomyosis (up to 30mm in diameter) diagnosed with MRI \nperformed resection of adenomyosis, which included transverse \nincisions in the uterus with a monopolar electrode. The flaps \nwere superimposed on each other in an oblique direction to \ncompensate for the lost muscle layer. If the uterine cavity is \nopened intraoperatively, then with such an operation it is closed \nby suturing. Pregnancy after surgery was achieved in 2 patients. \nBy 2017, this method was completed by Kitade M, et al. [15] in 74 \npatients. 31 patients planned pregnancy, 13 (41.9%) pregnancy \noccurred: 4 miscarriages and 9 (29.0%) ended in live births. In this \ncase, cases of uterine ruptures were not recorded.\nKodama, et al [27] reported 71 cases in which an \nadenomyomectomy was performed with good results. Of all the \npatients who underwent this operation, 32 (45.1%) planned a \npregnancy; 16 women reached clinical pregnancy, including 3 \n(18.7%), miscarriage and 13 cases of live births (40.6%). One case \nof uterine rupture was also recorded.\nFertility Rates after Surgical Treatment of Women with Adenomyosis\nTable 1: Fertility indicators after performed adenomyomectomies (% calculated from the number of pregnancies).\nАuthors, year Number of \ncases Approach s Pregnancy has \ncome Miscarriage Childbirth Uterine rupture\nKawamura, et al. [20] 29 LT 29 9 2(22,2%) 7(77,8%) 0\nKikuchi, et al. [17] 24 LT 16 7 2(28,6%) 5(71,4%) 0\nYosiki, et al. [34] 67 LT 40 8 1(12,5%) 7(87,5%) 1(12,5%)\nSuginami, et al. [32] 138 LT 74 24 - 24(100%) 2(8,3%)\nHonda, et al. [35] 51 LT 51 22 7(31,8%) 15(68,2%) 0\nFujishita, et al. [36] 41 LT 31 12 5(41,7%) 7(58,3%) 0\nNishimoto, et al. [23] 14 LT 14 3 0 3 0\nKishi, et al. [37] 141 LS 102 42 10(23,8%) 32(76,2%) 1(2,4%)\nTanaka, et al. [38] 11 LS 11 11 3(27,3%) 8(72,7%) 1(9,1%)\nKodama, et al. [27] 71 LS 32 16 3(18,7%) 13(81,3%) 1(6,3%)\nNishida, et al. [39] 1349 LT No data 221 45(20,3%) 176(79,6%) 5(2,3%)\n\nCitation: Rukhliada Nikolai N. Experience of Surgical Treatment of Adenomyosis and Reproductive Outcomes. W J Gynecol Women’s Health. \n3(3): 2020. WJGWH.MS.ID.000564.  DOI: 10.33552/WJGWH.2020.03.000564.\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 3-Issue 3\nPage 3 of 5\nKitade, et al. [15] 74 LS 31 13 4(30,8%) 9(69,2%) 0\nOsada, et a1. [16] 113 LS + LT 62 46 14(30,4%) 32(69,6%) 0\nFedele, et al. [21] 28 LT 18 18 8(44,4%) 10(55,6%) 0\nGrimbizis, et al. [40] 6 LT 2 0 0 0 0\nKim, et al. [41] 11 LS + LT 5 No data No data 0 0\nSaremi, et al. [24] 103 LT 70 21 4(19,1%) 17(81%) 2(9,5%)\nHuang, et al. [42] 94 LS + LT 10 0 0 0 0\nRukhliada NN, et al. [29] 203 LT 82 39 8(20,5%) 26 (66,7%) 1 (placental \ngrowth)\nMakarenko, et al. [43] 18 LT 12 2 - 2 -\nTotal 2586 - - 490 116 393 13\nThe frequency of pregnancy after various modifications of the \nsurgical treatment of adenomyosis ranges from 17.5 to 72.7%. \nHowever, assisted reproductive technologies contribute to the \nrelatively high pregnancy rate. In total, by 2016, 2365 uterine \nadenomyomectomies were performed according to reports from \n19 institutions (table). Of these, 2112 procedures were performed \nin 13 institutions in Japan, representing 89.8% of the total. Among \nthem, 449 pregnancies were confirmed and 363 (80.8%) led to \nchildbirth, including 2 cases of antenatal fetal death. There were 13 \n(3.6%) cases of uterine rupture (Table 1).\nRisk of Uterine Rupture\nThe rupture rate of the non-operated uterus is 0.005%, Ofir K, \net al.[28]. Report, but increases to 0.04-0.02% in women with scars \non the uterus [28]; natural birth after cesarean section increases \nthe risk of rupture to 0.27–0.7% [29]. In labor, women who have \nundergone an adenomyomectomy have a significantly higher risk \nof spontaneous uterine rupture than with an unoperated uterus. \nIn pregnancy after surgical removal of adenomyosis, the frequency \nof uterine rupture is also significantly higher [16]. Morimatsu Y, et \nal, [30] in 2007 showed that the risk of uterine rupture after these \noperations is 6.0%. Thus, the risk of uterine rupture is higher after \nsurgery for adenomyosis than with uterine fibroids (6 and 0.26%, \nrespectively).\nAccording to a 1986 Azziz R [31] survey, there were only 29 \ncases of obstetric complications due to severe uterine adenomyosis \nin the previous 80 years. Thus, we can conclude that such \ncomplications were considered rare. We studied the literature for \n1990 for information on uterine ruptures during pregnancy in \nwomen who underwent removal of adenomyosis and found a total \nof 24 cases in 18 institutions. Further analysis showed that these \nuterine ruptures occurred after laparotomic adenomyomectomy \nin 13 cases, after laparoscopic surgery in 11 cases; 3 observations \nended with a hysterectomy due to bleeding.\nAccording to the 2008 work, Suginami et al., The authors \nperformed adenomyomectomy in 138 cases [32]. Of the 74 \npreviously infertile women, 24 became pregnant, including 2 \n(8.3%) who suffered uterine ruptures. In 2016, Nishida et al. \nreported 5 cases of uterine rupture. To date, they have performed \n1,349 adenomyomectomies. Of 221 patients who were planning a \npregnancy, 176 had a pregnancy, and uterine rupture occurred in 5 \nwomen at 31, 27, 30, 16 and 19 weeks of pregnancy. The frequency \nof uterine rupture was 2.3% of the total number of pregnancies; \nin all cases, the uterine cavity was opened intraoperatively with \nadenomyomectomy. The placenta was implanted in the sutured \npart of the endometrium in 5 cases, in 2 cases the true increment of \nthe placenta was diagnosed.\nIn 2014, Saremi, et al. [24] reported cases of adenomyomectomy \nby a wedge-shaped technique for removing the uterine wall in 103 \nwomen, including 57 infertile patients. Postoperative complications \nwere observed in 6 patients, in 4 - Asherman’s syndrome; 2 - \nspontaneous uterine rupture (at 32 and 37 weeks of gestation); 1 \n- antenatal death at 37 weeks and 1 - preterm birth.\nThe first report of uterine rupture in pregnancy after \nlaparoscopic adenomyomectomy was described by Wada S, et al. \n[33] in 2006 and is associated with twin pregnancy. Laparoscopic \nadenomyomectomy of focal adenomyosis was performed using \nmonopolar excision, and the remaining myometrium was sutured \nwith 1–0 polyglecapron (in two layers). The patient became \npregnant 10 months after an adenomyomectomy, but there was a \nspontaneous rupture of the uterus along the scar at the 30 th week \nof pregnancy. Despite this, two babies, weighing 1,585g and 1,545g, \nwere born by Caesarean section, and in both of them the Apgar score \nwas 5 out of 9. A 7cm uterine wall rupture was successfully restored \nafter 2600 ml of blood loss was reimbursed. The postoperative \nperiod was uneventful, and the children developed normally [33].\nIn 2015, Kodama et al. reported pregnancy outcomes after \n71 laparoscopic adenomyomectomies, which included one case \nof uterine rupture. Among 71 patients, 32 planned pregnancy; 14 \n(43.8%) had a pregnancy, while 3 (18.7%) had a miscarriage and \n13 (40.6%) had a birth. 1 case of uterine rupture was recorded. In \nthis patient, a natural pregnancy occurred 4 months after surgery. \nPregnancy proceeded without complications, but at 34 weeks, \nagainst the background of complete well-being, acute abdominal \npain and a clinic of hemorrhagic shock developed. During \nlaparotomy, a uterine wall rupture of 8 cm was detected along the \nposterior wall with a transition to the bottom. To stop the bleeding, \n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 3-Issue 3\nCitation: Rukhliada Nikolai N. Experience of Surgical Treatment of Adenomyosis and Reproductive Outcomes. W J Gynecol Women’s Health. \n3(3): 2020. WJGWH.MS.ID.000564.  DOI: 10.33552/WJGWH.2020.03.000564.\nPage 4 of 5\na hysterectomy was performed (intraoperative blood loss 5150ml). \nThe mass of the newborn was 2032 g, the Apgar score was 4 points \n[27].\nLaparoscopic adenomyomectomy leads to incomplete \nelimination of muscle defects compared with laparotomy surgery. \nThus, the risk of uterine rupture is believed to increase after \nlaparoscopic surgery [16].\nIt is reported that the effectiveness of myomectomy with \nlaparoscopic assist, which was described by Nezhat, et al. [44] high \nenough. Researchers have found that this is a safe alternative to \nmyomectomy by laparotomy, technically simpler than laparoscopic \nmyomectomy and allows you to fully reconstruct the uterine wall; \nhowever, less time is required to complete the operation.\nConclusion\nAdenomyomectomy in various forms of manifest adenomyosis \nhas proved its worth in the surgery of this disease. From an \nexperimental operation or “despair intervention” , it has become a \ncommon type of intervention, which is increasingly used in modern \nsurgery.\nAcknowledgement\nNone.\nConflict of Interest\nAuthors declare no conflict of interest.\nReferences\n1. Rukhlyada NN, Krylov KY, Biryukova EI (2019) Organ-preserving \nsurgery for adenomyosis. Obstetrics and gynecology 5: 86-89. \n2. Amor R (2001) Endometriosis. Symptoms and diagnosis. J Gynecol \nObstet Мех 69: 288-296.\n3. Morita M, Asakawa Y, Nakakuma M, Kubo H (2004) Laparoscopic excision \nof miometrial adenomyomas in patients with adenomyosis uteri and \nmain symptoms of severe dysmenorrhea and hypermenorrhea. J Am \nAssoc Gynecol Laparosc 11(1): 86-95.\n4. Nawroth F, Schmidt T , Foth D, Landwehr P , Römer T (2001) Menorrhagia \nand adenomiosis in a patient with hyperhomo-cysteinemia, recurrent \npelvic vein trombosis and extensive uterine collateral circulation \ntreatment by supracervical hysterectomy. Eur J Obstet Gynecol Reprod \nBiol 98(2): 240-243.\n5. Deffieux X, Fernandez H (2004) Physispathologic, diagnostic and \ntherapeutic evolution in the management of adenomyosis: review of the \nliterature. J Gynecol Obstet Biol Reprod 33(8): 703-712.\n6. Somigliana E, Chiodini A, Odorizzi MP , Pompei F, Viganò P (2003) The \ntherapy of endometriosis. New prospects. Minerva Gynecol 55(1): 15-\n23.\n7. Damirov NN (2004) Adenomyosis M. BINOM: 384.\n8. Adamyan LV, Kulakov VI, Andreeva EN (2006) Endometriosis M. \nMedicine: 416.\n9. Baskakov VP , Tsvelev Yu V, Kira EF (2002) Endometrioid disease. SPb, \nPublishing House NL: 452.\n10. Atri M, Reinhold C, Mehio AR, Chapman WB, Bret PM (2000) \nAdenomiosis: US features with histologic correlation in an in-vitro study. \nRadiology 215(3): 783-790.\n11. Ishenko AI, Kudrina EA (2002) Endometriosis: diagnosis and treatment. \nGEOTAR-MED: 104.\n12. Korczynski J, Sobkiewicz S (2001) Adenomiosis, Diagnostic technique \nand treatment. Ginekol. Pol 72(5): 317-321.\n13. Rukhliada NN (2004) Diagnosis and treatment of manifest adenomyosis. \nTsvelev Yu V (edts) SPb .: ELBI-SPb: 205.\n14. Radzinsky VE, Gus AI, Siemyatov SM, Butarev LB (2001) Endometriosis: \neducational-methodical. Publishing House of RUDN: 64.\n15. Kitade M, Kumakiri K, Kuroda J, Jinushi M, Ujihira Y, et al. (2017) Is \nlaparoscopic uterine preservation surgery effective against infertility \nassociated with uterine adenomyosis? A study of perinatal prognosis by \npostoperative pregnancy rate and the presence of prior surgery. J Jpn \nSoc Endometriosis 38: 70.\n16. Osada H, Nagaishi M, Teramoto S (2017) Adenomyomectomy by uterine \nmuscle flap method: Clinical outcome and investigation of the preventive \neffect on uterine rupture. Obstet Gynecol 84: 1303-1315.\n17. Kikuchi I, Takeuchi H, Aida T , Kitade M, Shimanuki H (2003) A study of \nfertility preservation surgery in uterine adenomyosis. Obstet Gynecol \nSurg 14: 93-99.\n18. Ota Y, Hada T , Natsuura T , Kanao H, Takaki Y, et al. (2008) Convex lens \nresection of adenomyosis with laparoscopic adenomyomectomy in our \nhospital. J Jpn Soc Endometriosis 29: 85-90.\n19. Van Praagh I (1965) Conservative surgical treatment for adenomyosis \nuteri in young women: Local excision and metroplasty. Can Med Assoc J \n93(22): 1174-1175.\n20. Kawamura R, Mishima Y, Nakagome H, Iwaki A, Kanemaki Y (1991) \nMicrosurgical treatment for uterine adenomyosis. J Jpn Soc Gynecol \nMicrosurg 4: 18-21.\n21. Fedele L, Bianchi S, Zanotti F, Marchini M, Candiani GB (1993) Fertility \nafter conservative surgery for adenomyomas. Hum Reprod 8(10): 1708-\n1710.\n22. Fujishita A, Hiraki K, Kitajima M, Matsumoto Y, Satoh H, et al. (2010) \nUterine adenomyosis and uterine preservation treatment. J Obstet \nGynecol Prac 59: 769-776.\n23. Nishimoto M, Nabeshima H (2011) Adenomyomectomy. J Obstet. \nGynecol Prac 60: 1001-1007.\n24. Saremi AT , Bahrami H, Salehian P , Hakak N, Poolad A (2014) Treatment \nof adenomyomectomy in women with severe uterine adenomyosis using \na novel technique. Reprod Biomed Online 28(6): 753-760.\n25. Osada H (2009) Uterine adenomyosis. In: Osada H, Laparoscopy for \ngynecology: a comprehensive manual and procedure DVD. Tokyo: \nMedical View: 118-153.\n26. Struble J, Reid S, Bedaiwy MA (2016) Adenomyosis: a clinical review of a \nchallenging gynecologic condition. J Minim Invasive Gynecol 23(2): 164-\n185.\n27. Kodama K, Shirane A, Yamanaka A, Yanai S, Nakajima S, et al. (2015) A \ncase of hysterectomy due to uterine rupture and placenta accreta after \nlaparoscopic adenomyomectomy. J Jpn Soc Endometriosis 36: 189-192.\n28. Ofir K, Sheiner E, Levy A, Katz M, Mazor M (2003) Uterine rupture: risk \nfactors and pregnancy outcome. Am J Obstet Gynecol 189(4): 1042-\n1046.\n29. Rukhlyada NN, Krylov K Yu, Biryukova EI (2018) Possibilities of organ-\npreserving surgery for adenomyosis in the aspect of maintaining \nreproductive function. Obstetrics and gynecology 7: 120-124. \n30. Morimatsu Y, Matsubara S, Higashiyama N, Kuwata T , Ohkuchi A, et al. \n(2007) Uterine rupture during pregnancy soon after a laparoscopic \nadenomyomectomy. Reprod Med Biol 6(3): 175-177.\n31. Azziz R (1986) Adenomyosis in pregnancy. A review. J Reprod Med \n31(4): 224-247.\n\nCitation: Rukhliada Nikolai N. Experience of Surgical Treatment of Adenomyosis and Reproductive Outcomes. W J Gynecol Women’s Health. \n3(3): 2020. WJGWH.MS.ID.000564.  DOI: 10.33552/WJGWH.2020.03.000564.\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 3-Issue 3\nPage 5 of 5\n32. Suginami H, Taniguchi F, Tokushige M (2008) Surgical treatment of \nadenomyosis. Obstet Gynecol 75: 72-78.\n33. Wada S, Kudo M, Minakami H (2006) Spontaneous uterine rupture of a \ntwin pregnancy after a laparoscopic adenomyomectomy: A case report. J \nMinim Invasive Gynecol 13(2): 166-168.\n34. Yoshiki H (2004) Adenomymectomy by laparotomy. J Jpn Soc Reprod \nSurg 1: 14-18.\n35. Honda R, Katabuchi H (2009) Surgical therapy and fertility for \nadenomyosis. Obstet Gynecol 76: 1554-1558.\n36. Nabeshima H, Murakami T , Terada Y, Noda T , Yaegashi N, et al. \n(2003) Total laparoscopic surgery of cystic adenomyoma under \nhydroultrasonographic monitoring. J Am Assoc Gynecol Laparosc 10(2): \n195-199.\n37. Kishi Y, Yabuta M, Taniguchi F (2014) Who will benefit from uterus-\nsparing surgery in adenomyosis-associated subfertility? Fertil Steril \n102(3): 802-807.\n38. Tanaka Y, Tsuji S, Ono T , Ishikawa A, Kita N, et al. (2014) A study of 11 \ncases of adenomyomectomy in our hospital. J Jpn Soc Perin Neon Med \n50: 905.\n39. Nishida M, Otsubo Y, Ichikawa R, Arai Y, Sakanaka S (2016) Prevention \nof uterine rupture during pregnancy after adenomyomectomy. Obstet \nGynecol Surg 27: 69-76.\n40. Grimbizis GF, Mikos T , Tarlatzis B (2014) Uterus-sparing operative \ntreatment for adenomyosis. Fertil Steril 101(2): 472-487.\n41. Kim JK, Shin CS, Ko YB, Nam SY, Yim HS, et al. (2014) Laparoscopic \nassisted adenomyomectomy using double flap method. Obstet Gynecol \nSci 57(2): 128-135.\n42. Huang X, Huang Q, Chen S, Zhang J, Lin K, et al. (2015) Efficacy of \nlaparoscopic adenomyomectomy using double-flap method for diffuse \nuterine adenomyosis. BMC Women’s Health 15: 24.\n43. Makarenko TA, Tskhai VB (2016) The experience of organ-preserving \nsurgical treatment of patients with severe adenomyosis. Journal of \nObstetrics and Women’s Diseases 65 (5): 96-99.\n44. Nezhat C, Nezhat F, Bess O, Nezhat CH, Mashiach R (1994) \nLaparoscopically assisted myomectomy: a report of a new technique in \n57 cases. Int J Fertil Menopausal Stud 39(1): 39-44.","source_license":"CC0","license_restricted":false}