{"paper_id":"d862f4b4-e69e-47cb-ade8-bd967ade34bd","body_text":"Research Article\nVolume 4 Issue 5 - June 2018\nDOI: 10.19080/GJORM.2018.04.555650\nGlob J Reprod Med\nCopyright © All rights are reserved by Vitaly Tskhay\nCombined Results of New Surgery Approach  \nand Hormone Therapy with Massive Diffuse  \nForms of Adenomyosis\nVitaly Tskhay*, Grebennikova E and Mikaela G\nDepartment of Perinatology, Obstetrics and Gynecology, Krasnoyarsk State Medical University, Russia\nSubmission: May 08, 2018; Published: June 21, 2018\n*Corresponding author: Tskhay V, Department of Perinatology, Obstetrics and Gynecology, Krasnoyarsk State Medical University named after prof. \nV.F. Voino-Yasenetsky, Krasnoyarsk, Russia, Tel: ; Email: \nIntroduction\nUterine adenomyosis is a gynecologic condition whose \ndiagnosis and clinical significance remains somewhat \nenig¬matic [1-3]. Adenomyosis is defined as a benign invasion of \nthe endome¬trium into the myometrium, producing a diffusely \nenlarged uterus, which microscopically exhibits ectopic, non-\nneoplastic endometrial glands and stroma surrounded by \nthe hypertrophic and hyperplastic myometrium [4]. The role \nof surgery in managing extensive uterine adenomyosis and \nsubfertility is still highly controversial, partly because the \ndiagnosis of adenomyosis has always been retro¬spective, \nand adenomyosis often involves the whole uterus diffusely, \nwith difficulty separating normal myometrial tissue from \nmyometrial tissue invaded by adenomyosis [5-9]. In 2011 a \nJapanese professor Hisao Osada published an observation of \nconducted organ-preserving surgical treatment of patients \nwith adenomyosis in the period from 1998 to 2008 [10]. In \nJuly 2012, for the first time, we performed the operation of \nadenomyomectomy with the reconstruction of the uterus wall by \nthree-flap method proposed by Hisao Osada.\n \nObjective\nThe aim of our study was to assess the long-term efficacy \nof conservative surgery by the method of H. Osada combined \nwith hormonal therapy for the patients with massive diffuse \nadenomyosis.\nMaterials and Methods \nThis is a prospective case series followed from October \n2012 to March 2018 of 26 women with severe adenomyosis. \nThe average age of patients amounted to 35.3±7.2 (22 to 47) \nyears. However 8 patients were not interested in reproductive \nfunctions, but insisted on having conservative surgery. All \npatients (100%) complained about chronic abnormal uterine \nbleeding, 22 (84.6%)-algomenorrhea, 16 (61.5%)- dyspareunia, \n19 (73.07%) patients had chronic hemorrhagic anemia of varying \nseverity. 18 (69.2%) patients had history of infertility. In all \npatients records there were repeated but unsuccessful courses \nof adenomyosis treatment with hormonal therapy (progestin, \nagonists of gonadoliberin, combined hormonal contraceptives).\nGlob J Reprod Med 4(5): GJORM.MS.ID.555650 (2018)  0091\nAbstract\nThe advised treatment for severe adenomyosis is hysterectomy, but the patients wishing to preserve their uterus were operated with a novel \nconservative surgery, called adenomyomectomy. The history of this new surgery approach dates back to 2011 when Japanese Professor Hisao \nOsada worked it out and applied this new method of surgery for his patients. Adenomyomectomy, in this method, suggests radically excised \nadenomyotic tissues and reconstructed uterine wall by a triple-flap method, without overlapping suture lines, to prevent uterine rupture in \nsubsequent pregnancies. This is a prospective case series followed for 6 years from October 2012 to January 2018 of 26 women with massive \ndiffuse adenomyosis verified histologically and diagnosed with ultrasound. 18 women of 26 wished to conceive; 3 patients became spontaneous \npregnant and delivered healthy babies. There were no cases of uterine rupture. Adenomyosis symptoms did not recur in all 26 cases. Thus, \nour experience of intraoperative radical resection of adenomyotic tissues suggests that this technique may be a surgery of the patient’s choice, \nespecially for women of reproductive age with diffuse adenomyosis, we use it for those aging ones who wish to preserve the uterus.\nKeywords: Hormone therapy; Adenomyosis; Hysterectomy; Adenomyomectomy; Adenomyotic tissues; Uterine wall; Triple-flap method; \nInfertility; Conservative surgery; Diffuse adenomyosis; Uterine adenomyosis; Hyperplastic myometrium; Subfertility; Algomenorrhea; \nDyspareunia; Gonadoliberin; Hormonal contraceptives; Extraperitonealization; Hemostasis; Uterine cavity; Epigenetic therapy; Gonadotropin\nAbbreviations: COCs: Combined Hormonal Contraceptives\n\n\nHow to cite this article: V Tskhay, E Grebennikova,G Mikailly. Combined Results of New Surgery Approach and Hormone Therapy with Massive Diffuse \nforms of Adenomyosis. Glob J Reprod Med. 2018; 4(5): 555650. DOI: 10.19080/GJORM.2018.04.555650.0092\nGlobal Journal of Reproductive Medicine\nResults\nA total of 26 women with pathologically proven \ndiffuse adenomyosis underwent new surgical method of \nadenomyomectomy, where adenomyotic tissues were radically \nexcised and the uterine wall was reconstructed by a triple-flap \nmethod (named after H. Osada) and later had a subsequent \n12-month course of hormonal treatment; were evaluated semi-\nannually during a follow-up period of at least 5 years. This \nlaparotomy technique involves: \nI. Extra peritonealization of the uterus and rubber \ntourniquet placement for hemostasis; \nII. Bisection of the uterus in the midline and in the sagittal \nplane with a scalpel until the uterine cavity is reached \n(Figure1 & 2); \nFigure 1: Bisection of the uterus in the midline. The size of the \nuterus equals about 13 weeks of gestation.\nFigure 2: Bisection of the uterus in the midline and in the sagittal \nplane with a scalpel until the uterine cavity is reached.\nIII. Opening of the endometrial cavity to permit the \nintroduction of the index finger to guide during excision of \nadenomyotic tissues; \nIV. The use of Martin forceps to grasp adenomyotic tissues \nand to excise them from surrounding myometrium, leaving \na myometrial thickness of 1 cm from serosa above and \nendometrium below (Figure 3). \nFigure 3: Adenomyomectomy - adenomyotic tissues are \nradically excised.\nV. Closure of the endometrium with 3-0 Vicryl; and \nVI. Closure of the flaps of the uterine wall approximating \nthe myometrium and serosa of one side of the bisected uterus \nin the anteroposterior plane with interrupted 2-0 Vicryl, \nwhile the contralateral side of the uterine wall is brought \nover the reconstructed first side in such a way as to cover it \n(Figure 4 & 5) [9,10].\nFigure 4: Closure of the flaps of the uterine wall approximating \nthe myometrium and serosa of the one side of the bisected \nuterus in the anteroposterior plane with interrupted 2-0 Vicryl, \nwhile the contralateral side of the uterine wall is brought over the \nreconstructed first side in such a way as to cover it.\nFigure 5: Final results of operation- uterus image.\n\n\nHow to cite this article: V Tskhay, E Grebennikova,G Mikailly. Combined Results of New Surgery Approach and Hormone Therapy with Massive Diffuse \nforms of Adenomyosis. Glob J Reprod Med. 2018; 4(5): 555650. DOI: 10.19080/GJORM.2018.04.555650.0093\nGlobal Journal of Reproductive Medicine\nDuring the operation it was seen that in 12 patients the size \nof the uterus fitted 12 to 14 weeks of pregnancy, in 13 patients-15 \nto 18 weeks and in 1 patient-up to 20 weeks. The average \nduration of surgery was 156.8±52.2 minutes. The average blood \nloss during the operation amounted to 512.9±219.4 ml. Tissue \nremoved during surgery of the uterus affected by adenomyosis, \naveraged 416.6±254.1 gram. Simultaneously with hormonal \ntreatment from the first days of the postoperative period all the \npatients were subjected to epigenetic therapy for 12-months. \nWith the purpose to increase the efficiency of surgical treatment \nand prevent disease recurrence in the postoperative period, we \ndeveloped hormonal therapy protocol: gonadotropin-releasing \nhormone agonist for 4-6 months-Dienogest for 6 months - \ncombined hormonal contraceptives (COCs) in continuous \nmode for 6 months or more. There was a strong reduction in \nboth dysmenorrhoea and hypermenorrhoea and all patients \nreturned to having normal menstrual cycles. Up to now 3 of \nthe patients got spontaneously pregnant and delivered healthy \nkids and (Table 1). For the follow-up period recurrence of \nаdenomyosis symptoms in all 26 cases were not seen. There \nwere no recurrences before the 36-month follow-up visit. We \nquestioned the women about their life quality before and after \noperation. Most of them answered-«very satisfied», no one was \n«dissatisfied» (Table 2) [11].\nTable 1: Outcomes of adenomyomectomy with a triple-flap method as \nan infertility treatment (October 2012 – March 2018).\nParameter Study Data\nPatients 26\nAge (years) 35.3±7.2 (22 to 47)\nPatients wishing to conceive 18/26 (69,2)\nPregnancies 3/18 (61.5)\nSpontaneous 3\nIVF –\nElective Caesarean section 3\nTable 2:  Satisfaction of women treated with combined surgical–\nmedical therapy during follow-up.\nVery Satisfied Satisfied Dissatisfied\nAt the end of \nthe first year\n17 (100) 0 (0.0) 0 (0.0)\nAt the end of \nthe second year\n8 (88.9) 1 (11.1) 0 (0.0)\nAt the end of \nthe third year\n4 (80) 1 (20) 0 (0.0)\nDiscussion\nTreatment options for women with adenomyosis are \ndiverse and consist of analgesic therapies, hormonal therapies, \nconservative or minimal invasive surgery, assisted reproduction \ntechnologies, or of a combination of these methods of \nadenomyosis treatment [12]. Treatment has to be customized \nto the individual needs of the patient [13,14]. Moreover, \nendometriosis has been shown to be a disease that cannot be \ncured easily and therefore can be regarded as a chronic disease in \nmany women [15-17]. The surgical approach for preserving the \nuterus has become more popular, partly because some patients \nwant to preserve their future fertility, and their dysmenorrhea \ndoes not respond to drug treatment [5,8,10,11]. In our view, \nsurgical triple-flap method of adenomyosis for the patients \nwith diffuse adenomyosisis currently is the best one, especially \ntargeted for infertile women, wishing to conceive. Most of the \nwomen in our study wanted to get pregnant, that was the major \nreason for organ- preserving operation. Before considering the \nbenefits of conservative surgery in the management of these sub \nfertile women with adenomyosis, we could not overlook the age \nfactor, because it might be the most critical factor of fertility. It is \nwell known that fertility declines after 35 years of age [18]. Our 3 \npatients who underwent this type of surgery and had subsequent \ncourse of hormone therapy got spontaneously pregnant. They \nwere at the age of 28, 30 and 31 - as an argument in favor of the \nearly age factor.\nConclusion\nThus, our experience of intraoperative radical resection \nof adenomyotic tissues suggests that this technique may be \na surgery of the patient’s choice, especially for women of \nreproductive age with diffuse adenomyosis, for those who have \nnot realized their fertility yet. Also, this type of surgery may \nbe recommended for a patient of late reproductive age, when \nhysterectomy is not their preference. Our results indicate that \nconservative surgery combined with hormone therapy in the \ntreatment of massive diffuse forms of adenomyosis is effective \nin relief of symptoms, results in a high satisfaction rate among \npatients and a high success rate for preservation of the uterus \nfor at least 5 years.\nReferences\n1. Barrier BF, Malinowski MJ, Dick EJ, Hubbard GB, Bates GW (2004) \nAdenomyosis in the baboon is associated with primary infertility. Fertil \nSteril 82(Suppl 3): 1091-1094.\n2. Benagiano G, Habiba M, Brosens I (2012) The pathophysiology of \nuterine adenomyosis: an update. Fertil Steril 98: 572-579.\n3. Levgur M (2007) Diagnosis of adenomyosis: a review. J Reprod Med \n52(3): 177-193.\n4. Bird CC, McElin TW, Manalo-Eslrella P (1972) The elusive adenomyosis \nof the uterus. Am J Obstet Gynecol 112(5): 583-593.\n5. Huang BS, Seow KM, Tsui KH, Huang CY, Lu YF, et al. (2012) Fertility \noutcome of infertile women with adenomyosis treated with the \ncombination of a conservative microsurgical technique and GnRH \nagonist: long-term follow-up in a series of nine patients. Taiwan J \nObstet Gynecol 51(2): 212-216.\n6. Wang PH, Yang TS, Lee WL, Chao HT , Chang SP , et al. (2000) Treatment \nof infertile women with adenomyosis with a conservative microsurgical \ntechnique and a gonadotropin-releasing hormone agonist. Fertil Steril \n73(5): 1061-1062.\n7. Wang PH, Liu WM, Fuh JL, Cheng MH, Chao HT (2009) Comparison \nof surgery alone and combined surgical-medical treatment in the \n\nHow to cite this article: V Tskhay, E Grebennikova,G Mikailly. Combined Results of New Surgery Approach and Hormone Therapy with Massive Diffuse \nforms of Adenomyosis. Glob J Reprod Med. 2018; 4(5): 555650. DOI: 10.19080/GJORM.2018.04.555650.0094\nGlobal Journal of Reproductive Medicine\nYour next submission with Juniper Publishers    \n      will reach you the below assets\n• Quality Editorial service\n• Swift Peer Review\n• Reprints availability\n• E-prints Service\n• Manuscript Podcast for convenient understanding\n• Global attainment for your research\n• Manuscript accessibility in different formats \n         ( Pdf, E-pub, Full Text, Audio) \n• Unceasing customer service\n                        Track the below URL for one-step submission \n              https://juniperpublishers.com/online-submission.php\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nDOI: 10.19080/GJORM.2018.04.555650\nmanagement of symptomatic uterine adenomyoma. Fertil Steril 92(3): \n876-885.\n8. Wood C (1998) Surgical and medical treatment of adenomyosis. Hum \nReprod Update 4(4): 323-336.\n9. 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Dancet EA, Ameye L, Sermeus W, Welkenhuysen M, Nelen WL, et al. \n(2011) The ENDOCARE questionnaire (ECQ): a valid and reliable \ninstrument to measure the patient-centeredness of endometriosis care \nin Europe. Hum Reprod 26: 2988-2999.\n15. Guo SW (2009) Recurrence of endometriosis and its control. Hum \nReprod Update 15(4): 441-461.\n16. Vercellini P , Crosignani PG, Abbiati A, Somigliana E, Vigan ò P , et al. \n(2009)The effect of surgery for symptomatic endometriosis: the other \nside of the story. Hum Reprod Update 15(2): 177-188. \n17. Berlanda N, Vercellini P , Fedele L (2010) The outcomes of repeat \nsurgery for recurrent symptomatic endometriosis. Curr Opin Obstet \nGynecol 22(4): 320-325.\n18. Templeman C, Marshall SF, Ursin G, Horn-Ross PL, Clarke CA, et al. \n(2008) Adenomyosis and endometriosis in the California Teachers \nStudy. Fertil Steril 90(2): 415-424.","source_license":"CC0","license_restricted":false}