{"paper_id":"dfb74005-b2b5-4f13-931f-fc894d88aca5","body_text":"ARC Journal of Gynecology and Obstetrics                                            \nVolume 3, Issue 4, 2018, PP 25-34 \nISSN 2456-0561  \nDOI: http://dx.doi.org/10.20431/2456-0561.0304006 \nwww.arcjournals.org  \n \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 25  \nSurgical Uterine-Sparing Management of Adenomyosis: \nTechniques and Review of Literature \nAndres Vigueras Smith1,*, Ramiro Cabrera2, Monica Tessmann Zomer1, Carlos Trippia3, \nWilliam Kondo1 \n1Department of Gynecology, Sugisawa Hospital, Curitiba, Brazil \n 2Department of Minimally Invasive Surgery, Angels Hospital, City of Mexico, Mexico \n 3Department Department of Radiology, Nossa Senhora das Graças Hospital, Curitiba, Brazil \n \n \n1. OBJECTIVE \nTo analyze the current information related to \nconservative surgical treatment of adenomyosis, \nfocused in the surgical techniques described for \nboth focal and diffuse adenomyosis, and their \neffect in symptoms control and fertility \nimprovement. \n2. METHODS \nA comprehensive review of the literature was \nperformed with an extensive search of all the \nEnglish publications on PubMed and Google \nScholar related to adenomyosis and the non -\nradical surgical management. We included all \nstudies found under the search of following \nkeywords: Adenomyosis AND Laparoscopic \nSurgery OR Myometrectomy OR \nAdenomyomectomy OR Non-radical Surgery. \nOne author independently made a selection of \nrelevant abstracts according to the aim of this \nreview. The prim ary objective was to know and \ndescribe the main surgical techniques and  \nanalyze the post  operative fertility and \nsymptoms-control outcomes. \nAbstract \nObjectives: To analyze the current available data on the different conservative surgical techniques for the \nmanagement of focal and diffuse adenomyosis.  \nMethods: A comprehensive review of literature was made of publications in English on PubMed and Google \nScholar. The studies utilized were then selected by one author in line with the aim of this review.  \nResults: The uterine-sparing surgical treatment of adenomyosis could be classified in three groups regarding \nthe extension of the remotion of healthy myometrium and the integrity of the uterine wall: Type I: The \ncomplete resection of the Adenomyosis (Including Adenomyomectomy and Cystectomy); Type II: \nCitoreductive surgery (Partial Adenomyomectomy); and Type III: Non -excisional techniques. Many surgical \napproaches and variants has been described for each technique, predominantly for laparotomy approach. \nEven when the quality of evidence about benefits of these types of surgery (infertility and symptoms control) \nremains poor, an 80 % to 85 % of dysmenorrhea and 50  % to 75 % of AUB symptoms improvement is obtain, \nregardless the technique performed. A important benefit in terms of subfertility  - infertility is achieved, with \nmean pregnancy rates (at 1 year postoperative) of 50 % (Partial remotion) and 65 % (Complete remotion), \nsignificantly higher in younger patients. Up to date, no specific technique or approach showed higher benefits \nin intra or postoperative outcomes. No intra or post operative differences has been found between laparotomy \nor laparoscopy, therefore laparoscopy is a feasible and effective approach, with all the benefits of minimally \ninvasive surgery.  \nAbbreviations: MRI: Magnetic resonance imaging; AUC: Area under the curve; TVUS: Transvaginal \nultrasound; COC: Combined oral contraceptive; NSAIDs: Non-steroidal anti -inflammatory drugs; HIFU: \nHigh frequency ultrasound; RR: Relative risk; IVF: In-vitro fertilization; ICSI: Intra-cytoplasmatic sperm \ninjection; OR: Odds ratio; PR: Pregnancy rate; AUB: Abnormal uterine bleeding; ART: Assisted \nreproductive techniques. \nKeywords: Adenomyosis, Laparoscopic surgery, Adenomyomectomy, Conservative treatment, Non -Radical \nSurgery.  \n \n \n \n \n \n \n \n \n \n \n \n*Corresponding Author: Vigueras A, Gynecology unit of Sugisawa medical center, 1236, Iguaçu Avenue, \nCuritiba, Brazil, Email: afvigueras@gmail.com. \n \n \n \n \n \n \n \n \n \n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 26  \n3. INTRODUCTION, DEFINITIONS A ND \nEPIDEMIOLOGY \nOver a century has passed since adenomyosis \nwas described for the first t ime, and yet it \nremains a disease difficult to understand and \napproach for both clinicians and investigators. \nInitially named ‘Adenomyoma’ was firstly \ndescribed in 1860 by the German pathologist \nKarl Freiherr Von Rokitansky, who found \nendometrial glands wi thin the myometrium and \ndesignated this finding as a ’Cystosarcoma \nAdenoids Uterinum’. [1] \nThe first modern definition of the disease was \ndescribed by the American Journal of Obstetrics \nand Gynecology of 1972: “Adenomyosis may \nbe defined as the benign invas ion of \nendometrium into the myometrium, producing a \ndiffusely enlarged uterus which microscopically \nexhibits ectopic non -neoplastic, endometrial \nglands and stroma surrounded by the \nhypertrophic and hyper -plastic myometrium”.  \n[2,3] \nFinal diagnosis is histopathological, showing the \nclassic ectopic endometrium (Glands and/or \nStroma) more than 2.5 mm in -deep in the \nmyometrium or more than one microscopic field \nat 10X magnification from the endometrium - \nmyometrium junction, surrounded by bundles of \nhypertrophic smooth muscle cells in a “collar \nfashion”. [4] \nTable1.  Risk factors for Adenomyosis \nFactor Characterstics \nAge 70% to 80 % are \nin 4th our 5th \ndecade \nHigher hysterectomy \nrate at this age \nMultiparity Multiparous Pregnancy facilitate \nformation of \nadenomyotic foci due \ninvasive nature of \ntrophoblast \nPrior \nUterine \nSurgery \nInconsistent \nevidence \nSurgical disruption of \nEndometrial–\nMyometrial layer \nSmoking \nHabit \nControversial \nevidence \nDecrease serum levels \nof estrogen \nEctopic \nPregnancy \nHigher rate in \nAdenomyosis \npatients \nRisk factor of \nintramural ectopic \npregnancy \nNumber of \nTissue \nSamples \nDirectly \nprorportional to \nnumber of \nanalysis \nDiagnosis in the same \nuterus could rise from \n31% to 62% depending \non samples analyzed \nTamoxifen  Higher \nincidence in \ntamoxifen users \nEstrogen agonist at \nendometrium level \nThe largest series evaluating the prevalence of \nthe disease found a wide range, between 5% to \n70%, with a mean histological diagnosis of 20% \nto 30%. These wide variations are explained by \na combination o f patients characteristics and \ndiagnostics method. N evertheless, clear risk \nfactors have been reported, and are show in \nTable 1. [3] \nSuspicion is made based on clinical and imaging \nfindings, mostly on ultrasound and MRI \nexplorations. \nClinical manifestations commonly include \ndysmenorrhea and menorrhagia, but also \ndyspareunia, chronic pelvic pain and infertility \nhave been reported.[5] \nThe specificity of preoperative diagnosis of \nadenomyosis based on clinical findings is poor, \nranging from 2% to 26% and many cases of \nadenomyosis go undetected: Therefore, the \nunderstanding ofthe prevalence and clinical \nimpact is impaired.[6] \nThe classic ultrasound findings established by \nnumerous authors over time are shown in Table \n2.  \nTable2.  Imaging Signals of Adenomyiosis \nImaging \nMethod \nSignals \n \n \nTransvag\ninal \nUltrasou\nnd \nAsymetric \nThickening of \nMiometryum \nHyperecogenic Islets \nParalel Shadows - \nLinear Striations \nNodular Heterogéneal \nMyometrtial Mass \nMyometrial Cysts Irregular Myometrial-\nEndometrtial Junction \nZone \nGlobular or \nSpherical Shape \nFocal “ Honeycomb” \nScatered-Cystic –\nAnechoic Lacunae \nBlurred Endometrial - \nMyometrial Border \n \n \n \n \nMRI \nFocal or Global \nThickening of  \nJunction Zone \nLineal  Striations \nOutside the \nEndometrium \nIll Defined Intra-\nMyometrial \nNodule \nMinimum Width at \nJunction Zone ( 5 to \n12 mm) \nIntro-myometrial  \nHipereintensity \nFoci \nLow Intensity at \nJunction Zone \nHigh-Intensity \nSpots Scattered \nwithin the \nJunction Zone \nFocal and Uneven \nWidth at Junction \nZone \nThe major studies show a sensibility, specificity \nand AUC of 72%, 81% and 0.85 respectively.[7] \nA meta-analisis published by Meredith in 2009 \n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 27  \nconfirm the TVUS as a moderately accurate but \na easy, wide available and cost-effective \npreoperative diagnostic test. [8] \nMeanwhile, MRI show better results because it \nis less operator dependent, show reliable \nfindings and had better correlation with \nhistology analysis .Common findings are shown \nin Table 2. The sensibility,  specificity and AUC  \nreported are 77%,  89% and 0.92 \nrespectively.[7] \nMany theories has born trying to explain the \norigin of the disease, neverthel ess four are the \nmost accepted and are showed in Table 3.[7] \nTable 3. Theories for Adenomyosis Origin \nTheory- Author Characteristics \nEndometrial \nInvagination \nBergeron 2006 - Parrot \n2001 \nMyometrial invasion from \nthe endometrium basalis \nDe Novo Development of \nEctopic Endometrium \nMatsumoto 1999 - Propst \n2001 \nMullerian remnants \nMetaplasia of pluri-\npotential mullerian cells \nInvagination of Junction \nZone by the Lymphatic \nSystem \nSampson 1927 \nPotential pathogenesis of \nendometriosis \nBone Marrow Stem \nCells \nHufnagel 2015 \nEndometrial cells \nmobilized by the vascular \nsystem \nThe first line treatment for adenomyosis is \nmedical, based on hormone therapy and \nsymptomatic drugs, including NSAIDs, GnRH \nagonists, Danazol, COC, among others. In when \nsuch treatments are c ontraindicated, failed or \nwhen patient seek for fertility, surgical treatment \nis indicated. [9] \nSince Hyams first suggested the use and benefits \nof the conservative surgical management for \nadenomyosis in 1952, many surgical tech niques \nhave been described. [10] \nThe aforementioned passages highlight the \ncurrent level of conceptual understanding \nregarding the techniques to treat adenomyosis, \nhowever, on a global scale the general level of \nknowledge surrounding these procedures is still \nin the development stages for laparoscopy . \nTherefore the intent of this review analyses the \navailable proposals of surgical uterine -sparing \ntechniques focused on laparoscopic approach for \nthe treatment of symptomatic adenomyosis, and \ntries to assess the effect of each type of surgical \ntreatment on future fertility and symptoms \ncontrol. We start giving definitions and \nepidemiological infor mation. Afterward, \nreviews of conserv ative surgical techniques are  \npresented. Finall y, we discuss these techniques \nin terms of fertility and symptoms control issues \nand draw conclusions. \n4. CLASSIFICATION OF CONSERVATIVE UTERINE-\nSPARING SURGICAL TECHNIQUES \nBroadly talking, surgical management of  \nadenomyosis can be separated in two main \noptions: Radical and Conservative. Radical \ninclude the hysterectomy, a invasive, definitive \nand no fertility sparing approach. \nBefore discussing the conservative surgical \ntechniques, classification can be made base d on \nthe extent of removal of adjacent healthy \nmyometrium and the preservation of the uterus \nintegrity. [9] \nThe basic principle of all “uterine -sparing” \ntechniques is th at most of the time a piece of \nhealthy myometrium is resected, despite the \ntechnique preformed. \nTherefore, three types of conservative surgical \ntreatments had been established: \n1. Complete Excision of Adenomyosis (Type \nI). Includes Adenomyomectomy and \nCystectomy. Preferably used in cases of \nlocalized adenomyosis (Adenomyoma) but \nalso in selecte d cases of more diffuse \nadenomyosis with reconstruction of the \nuterine wall. This includes the complete \nremoval of all recognizable macroscopic \ndisease. The integrity of uterine wall is \nmaintained. It is the most r adical approach \nand offers the major advantages among all.  \n[11-14] \n2. Partial Adenomyomectomy (Type II) . \nCytoreductive surgery used in cases of \ndiffuse adenomyosis, including partial \nremoval of clinically recognizable disease \nincluding as much of macroscopic lesions as \npossible. Generally, it is more related to less \nsymptom control efficacy and higher \npostoperative recurrence rate. [12, 14, 15] \n3. Non-Excisional Techniques (Type III) . A \nheterogeneous group of procedures where \nremoval of adenomyotic tissue is not \nincluded. This Include laparoscopic, \nhisteroscopic and combined procedures, \nusing devascularization, coagulation and \nablation techniques. [14,15] \nA resume of these surgeries, specific techniques \nand variants is described in Table 4 \n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 28  \nTable4. Conservative surgical management of \nAdenomyosis \nType of Surgery Techniques and Variants \nComplete Excision Classic Technique - Hyams \n1952 - Grimbizis 2008 \n \n \nAdenomyomectomy \nTriple Flap Method - Osada \n2011 \nU- Shaped Suture- Sun 2011 \nOverlapping Flaps - Tacheshi \n2006 \nCystectomy Classic Technique \n \nCitoreductive \nExcision \nClassic technique -   Fujishita \n2004 \nTransverse H incision - \nFujishita 2004 \n \nPartial \nAdenomyomectomy \nWedge resection of uterine wall \n-  Sun 2011 \nAssimetric dissection of uterine \nwall - Nishida 2010 \n \n \nNon-Excisional   \nSurgery \nUterine artery ligation -  Wang \n2002 \nElectrocoagulation of \nmyometrium - Wood 1998 \nEndometrial resection - Wood \n1998 \nLaparoscopic Endometrial ablation - \nPreuthhupan 2010 \nHisteroscopic Hysteroscopic cystectomy \nCombined High frequency ultrasound - \nYang 2009 \n \n \nOthers     \nEndometrial non-hysteroscopic \nablation by \n Radiofrequency - Ryo 2006 \n Microwave - Kanaoka 2004 \n Ballon - Chan 2001 \nDifferences exist between these three types of \nsurgery, clearly presented by Horng in 2014. [9]   \nA comparison between type I and II surger ies \nare presented in Table 5. (Showed Adapted from \nHorng et al. 2014) \nTable5. Main characterstics of Type I and II \nsurgeries \nCharacteristics Type I Type II \nDisease Excision Complete Citoreduction \nResidual Disease None Optimal or Sub-\noptimal \nSurgical Technique Easier Difficult \nRisk of Enter the \nMiometrium \nLow High \nRisk of Damaging \nFunctional \nMyometrium \nLow High \nUterine Integrity Conserved Probably \nconserved \nRisk of Gestacional \nUterine Rupture \nLow High \nSymptom Control Good or \nExcellent \nAcceptable \nFertility Preservation       High                                                                Probably low \nThe election of the best surgical approach \ndepends in many variables, but mainly in the \nanatomical locations of the disease diagnosed in \nthe preoperative imaging exams. (Focal or \nDiffuse) \n4.1. Complete Excision of Adenomyosis (Type \nI Procedures) \n4.1.1. Adenomyomectomy \nThe Adenomyomectomy technique is based on a \ncompletely new idea that differs from \nconventional surgical procedures. The method \ninvolves reconstruction of the uterine wall \nsurgical defect using normal uterine wall \nmuscle. The technique is not only effectiv e for \ndiffuse, but also for focal adenomyosis, and it \nhas the potential to contribute to the prevention \nof uterine ruptures during future pregnancies. \nThe classic and the overlapping flaps techniques \n(with their variants) will be described. [16] \n4.1.2. Classic Technique \nThe Adenomyomectomy (open or laparoscopic) \nincludes the same steps performed in a \nmyomectomy, including a linear myometrial \nincision and find (and remain) in the right \ncleavage plane. [11] \nThe major problem here is that Adenomyoma \nshow intra -operative Ill - defined limits and \nabsence of a pseudo -capsule around him, this \ndifficult the surgical approach since no clear \ncleavage plane is obtained during dissection. \nHence, bloodless and complete resection \nprocedure turns challenging. \nThe technique could b e performed either by \nlaparoscopy or laparotomy, it includes the \nfollowing consecutive  6 steps clearly presented \nby Grimbizis in 2014:1. Recognition of the \nlesion's location and borders by inspection and \ndirect palpation (or laparoscopic grasper haptic \nfeedback); 2.Longitudinal incision of the uterine \nwall  direct over the lesion; 3. Sharp and blunt \ndissection of the adenomyoma with scissors, \ngraspers, and/or diathermy similarly to \nperformed during a myomectomy;4.Suturing of \nthe uterine cavity using 4 -0  s ynthetic \nabsorbable suture (if the endometrium cavity \nwas opened); 5.Closure of the uterine wall with \n1-0  synthetic absorbable suture layer by layer; \n6.Closure of the serosa layer with 4 -0 or 5 -0 \nabsorbable sutures.[9,11] As we see,the surgical \ntechnique is  quite similar to myomectomy, and \nis presented in  Figure 1. \n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 29  \n \nFigure1. Classic Technique for \nAdenomyomectomy:  Steps are quite similar to a \nlaparoscopic myomectomy.  \n1: Longitudinal myometrial incision over the \nadenomyoma. 2: Blunt and sharp dissection of the \nAdenomyoma trying to remain in the macroscopic \nlesion edge-plane. 3and 4: Closure of wound effect in \nat least two layers using synthetic re-absorbable \nsuture. If endometrium is opened, suture of this layer \nmust be done independently. \nEnding the procedure, the key steps are always \nperform a sero -muscular closure (one or two \nplanes) and use an adequate morcelation \ntechnique under protection. The use of intra -\noperative ultrasonographic guidance could \nimprove the result of the resection. \nThere are two major modifications for this \nclassic technique: The U-shaped Suturing  \nproposed by Sun in 2011 and the  Overlapping \nFlaps of Takeshi in 2006, both for the \nlaparoscopic approach.  \nThe U-shaped Suturing  consists in the \napproximation of the uterine walls using U -\nshape sutures at the muscle layer, trying to \ncompletely approximate the “walls cave like \nwound” resulted after disease resection. \nPosteriorly, the sero-muscular layer is closed by \nfigure eight stitches, using the same threads  as \nthe classic technique. [11] \nIn the Overlapping Flaps , a transverse incision \nis made over the adenomyotic tissue, and the \nlesion is excised with a monopolar needle, \nfollowing the macroscopic edges of the disease, \ntrying to respect all the clinical adenomyosis.  \n \nFigure2. Overlapping Flaps Variation: 1: \nTransverse myometrial incision over the \nAdenomyotic tissue. 2: Resection of disease tissue  \nfollowing the macroscopic (apparent) edge-plane \nusing monopolar needle. 3 and 4: Sero-muscular \nlayers are overlapped and closed to the contract the \nmuscles loss, and avoiding any reach spaces \nThe remaining sero -muscular layer is \noverlapped and sutured to counteract the lost \nmuscle layer of the uterus resulted after the \nresection. [11] The surgical technique is showed \nin Figure 2. \n4.1.3. Triple flap Technique \nOsada in 2011present the Triple -Flap Method, \nanother Type I procedure described for \nlaparotomy, startingwith a transverse suprapubic \nincision, leaving after the excision, 1cm margin \nof tissue above the endometrium and a 1 cm \nmargin of tissue below the serosal surface. This \nsurgical technique is described for laparotomy \nand it is performed following 6 consecutive \nsteps: 1. Use a r ubber tourniquet placed in the \nItsmical area for hemostasis; 2. Bisection of the \nuterus in the midline and in the sagittal plane \nwith a cold scalpel until the uterine cavity is \nreached and opened; 3.Introduction of the index \nfinger to guide excision of the adenomyotic \ntissue; 4.Use of a Martin forceps to resect the \nadenomyotic tissue from  he althy surrounding \nmyometrium; 5.Closure of the endometrium \nwith multifilament synthetic reabsorbable thread \n(3–0 Vicryl);  6. Closure of myometrium walls \nand uterine serosa: on one side of the bisected \nuterus they are approximated in the antero -\nposterior pl ane with interrupted sutures of 2 –0 \nVicryl, while the contra lateral side is brought \nover the reconstructed first side in such a way as \nto cover the sero-muscular suture line. [12] \nSpecial care must be taken for do not overlap \nthe suture lines; only myomet rial tissue flaps \nmust overlap. To perform this, the serosal \nsurface of the underlying flaps must first be \nstripped, that is, the myometrium of the \nunderlying flap must be denuded of serosa. [12] \n4.2. Partial Adenomyomectomy ( Type II \nProcedures) \nSince the major part of these techniques and \nvariations are describ ed for laparotomy, no \ndetailed description of these procedures is \npresented here. \nMany techniques has been described for \ncitoreductive treatment, and four are clas sically \npresented: The Cla ssic Technique, The \nTransverse H Incision, The Wedge resection of \nthe Uterine Wall  and The Asymmetric \nDissection of the Uterine Wall. [11] \n\n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 30  \n4.2.1. The Classic Technique  \nThis technique is performed in four consecutive \nsteps starting with a vertical or transverse \nincision in the middle of  uterine wall, \nrecognition and resection of all macroscopic \ndisease and a final wound closure in at least 2 \nlayers, taken care of not leave any uterine defect \nbehind. \n4.2.2. The Transverse H Incision Technique  \nThis technique consists in a  modification of th e \nclassic technique, indicated for adenomyosis \naffecting the anterior uterine wall. Helped by a \nvasoconstriction agent, a vertical incision is \nperformed followed by two transverse incisions \nperpendicularly to the initial one, along the \nupper and lower edges of the uterus.  Resection \nof all macroscopic adenomyotic tissue is \nperformed in a slicing fashion, helped by direct \nmanual palpitation. Closure is finally made in at \nleast two layers of interrupted stitches. \n4.2.3. The Wedge Resection of Uterine Wall  \nIt is another technique, that could be performed \nin both laparotomy and laparoscopy approaches. \nConsist in a wedge resection of the sero -\nmuscular layer related to the adenomyotic \nlesion. Afterward, closure is performed similarly \nto the classic technique previously described. \n4.2.4. Asymmetric Dissection of the Uterine Wall \n It is an appr oach where the uterine wall is \ndissected longitudinally using electrosurgery in \nan asymmetrical fashion, to divide the inside \nfrom the outside, preserving both the uteri ne \ncavity and uterine arteries. Posteriorly, the \nmyometrium is dissected diagonally until \nendometrial cavity is opened and adenomyotic \ntissue is excised usi ng a loop electrode, helped \nby the index finger inserted into endometrial \ncavity. Finally, wound clo sure is performed \nseparately, initially for the endometrial cavity \nand then for the myometrial and serosal layers. \n \nImage1. Main TVUS findings:  Direct: A: Anechoic \n2-4 mm sub-endometrial micro-cysts (Blue Arrows). \nB: Ill defined or thickening junctional zone (Green \nArrows). C: Heterogeneous myometrial appearance \ncombined with small hypoecogenic ill- defined sub \nendometrial pseudo-nodular formations without \nmass effect (Yellow Arrows) and hyperechoic linear \nstriations (Red Arrows) Indirect: A: Asymmetrical \nuterine walls (Hypertrophy signal). B: Enlarged and \nglobulous uterus appearance, with regulars margins.  \nC: Linear pattern of myometrial vascularization \nthrough the adenomyotic lesions. \n4.3. Non Excisional Technique (Type III  \nProcedures) \nThe following groups o f non -excisional \ntechniques have been described in the literature \nfor the uterine -sparing management of \nadenomyosis. As previously said, removal of \nadenomyotic tissue is not the aim of the surgery. \n4.3.1. Laparoscopic Non-Excisional Techniques \nThese techniques in clude laparoscopic electro \ncoagulation of the myometrium [15,  17, 18] and \nlaparoscopic uterine artery ligation.  [19] Both \nare described as fertility sparing techniques, \nwith minor effects  in future fertility. \n \nImage2. Main MRI findings: A: Globous uterus \nwith irregular margins. B: Asymmetrical thickening \nof myometrial walls (more often in posterior wall). \nC: Thickening of junctional zone (more than 12 mm) \nD: Focal hyper-intense points lateral to \nendometrium corresponding to dilated endometrial \nglands fill with blood (Yellow arrow) \n4.3.2. Hysteroscopic Non-Excisional Techniques \nThese techniques include operative \nhysteroscopy [20], roller ball endometrial \nablation [21], trans -cervical resection of the \nendometrium [22,  23], and endomyometrial \nresection. [15] Many autho rs report these \ntechniques as a fertility harming procedures, \nsince all of them will include some degree of \ndamage to endometrium and/or myometrium. \n \nImage3. Laparoscopic main view of Adenomyosis:  \nNote the global enlargement in. A “globulous” \nfashion, without nodularities in the major view and \nlaparoscopic haptic feed back of the myometrium. \n\n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 31  \n4.3.3. Other Techniques  \nThese techniques include ablation of focal \nadenomyosis with high frequency ultrasound \n(HIFU) [24], Alcohol instillation under \nultrasound guidance (for the treatment of cystic \nadenomyosis) [25], radiofrequency ablation of \nfocal adenomyosis [26], microwave endometrial \nablation [27], and balloon thermo -ablation [28] \nfor diffuse adenomyosis. As well as \nhysteroscopic techniques, these techniqu es have \nbeen reported as fertility harming. \n \nImage4.  Laparoscopic view of Focal Adenomyosis:  \nNote the focal enlargement of the posterior uterine \nsurface. Adenomyomectomy is performed using \nUltrasound Scalpel and closure is made in two layers \nusing figure of eight interrupted (Myometrial) and \nrunning “Baseball style” (Sero-muscular) Caprofyl-\n0 suture. \nAlso, the combination of excisional (Type II) \nand non- excisional technique (Type III) could \nbe perform in order to improve postoperative \nresults. The main combination will be the \nlaparoscopic resection of adenomyosis after a \nprevious uterine artery occlusion. This occlusion \ncould be transient or permanent. [29] \nIf some part of the adenomyotic tissue is \nresected, and as Type II procedures, it is nearly \nimpossible to remove all adenomyotic foci. \nAdditionally, concomitant resection of a large \namount of healthy myometrium with destruction \nof functional myometrium cannot be totally \navoided. [10, 30] \n5. SYMPTOM CONTROL OUTCOMES AFTER \nCONSERVATIVE TREATMENT \nThe ma in symptoms related to adenomyosis is \nthe dysmenorrhea, menorrhagia and chronic \npelvic pain. [3] \nThe clinical effectiveness of conservative \nuterine-sparing surgery for adenomyosis is \nreported in the literature as promising. In the \nreview of Gregoris Grimb izis presented in the \nFertility and Sterility of 2014, this surgical \napproach provide significantly improvement of  \nsymptom control, achieving reduction of more \nthan 81% of dysmenorrhea  and 50% of \nmenorrhagia. Hence, symptoms improvement in \nmore than tw o-thirds of patients after type I \nuterine- sparing surgery, and nearly a half of the \npatients after type II uterine -sparing procedures \nis reported. Meanwhile for a Type III, the major \nstudies report a reduction in 54% of \ndysmenhorrea and 73% of AUB. [11] \n6. FERTILITY OUTCOMES A FTER \nCONSERVATIVE TREATMENT \nBroadly talking, adenomyosis appears to have a \ndetrimental impact on reproductive performance \nin terms of decreased clinical pregnancy rate \n(PR) and increased abor tion rate. Nevertheless, \nclear and direct rel ationship between \nadenomyosis and fertility is still a controversial \nissue.  \nSome retrospective studies showed an absence \nof a direct relationship between adenomyosis \nand the clinical PR, with no significant \ndifferences in PR among women with and \nwithout adenomyosis. [31] \nBy contrast, prospective evidence are show \nsignificantly lower PR in affected patients. In \nthe study of Vercillini and Cosonni in 2014, \ncomparing pregnancy rates in between 98 \npositive to 567 negative adenomyosis patients, \nwomen's with ade nomyosis had a significantly \nlower clinical PR (24/98, 24.5%) than women \nwithout adenomyosis (245/567, 43.2%), with a  \nRR of 0.55. [31] \nThe summary of findings in terms of \nreproductive outcomes in women with and \nwithout adenomyosis, demonstrate that patients  \nwith the disease has a significantly decreased \nclinical PR and increased miscarriage rate, \ncontributing to a important decrease in the final \nlive birth rate. These results hardly suggest that \nthere is a strong association between \nadenomyosis and fertility. [32] \nBut, even though these studies are more \nbalanced towards the side of adenomyosis as an \nassociated factor in the negative impact on a \nwoman's fertility, we must bear in mind that \nthere is no definitive consensus on when to \nchoose between medical or conservative surgery \nas a primary treatment. \nAs well, women with adenomyosis submitted to \nART seemed to have a lower implantation rate \nper embryo transfer, PR and live birth rate, but a \nhigher spontaneous abortion rate. Therefore, a \nsignificant decrease in t he clinical PR is \nreported (RR 0.72), and a twofold risk of \nmiscarriage is also observed (RR 2.12). These \nfindings suggest that the adenomyotic uterine \nenvironment increases the risk of miscarriage \n\n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 32  \nindependently of oocyte and embryo quality.  \n[31] \nK.-H.Tsui suggest an approach initially with a \nlong-protocol GnRH agonist suppression for \nnatural conception in women with normal \novarian function, but an urgent IVF procedure in \nwomen's with diminished ovarian reserve. When \nrepeat failure of along GnRH agonist -based \nIVF/ICSI therapy is observed, conservative \nuterine -sparing surgery of adenomyosis should \nbe indicated, and urgent following long -protocol \nIVF/ICSI 3 months later after complete \ntreatment it’s also recommended. [32,33] \nAccording to published, the uterine -sparing \nsurgical treatment certainly improve the \npregnancy outcome. Pregnancy rates are around \n60% in women's with Type I and over 46% in \nwomen's with Type II surgery. Two-thirds of the \nwomen treated with Type II surgery and more \nthan four-fifths of the wom en treated with Type \nI surgery had a successful delivery.  \nWomen's with localized adenomyosis after \nadenomyomectomy had a pregnancy rate that \nranged from 48.2% to 77.5%, with a successful \ndelivery rate between 26.8% to 69.0%. [24,34] \nAlthough conservative surgery might not have a \nsimilarly promising effect on reproductive \nperformance in women with diffuse -type \nadenomyosis, the PR reported after sparing \nsurgery in this group range between 30% - 40% \n, amounting to nearly 25% to 30% of the women \nwho had a successful delivery.[11,35,36] \nNevertheless, clinician must never forget that \nthe most critical factor of fertility is age, and has \nbeen demonstrated thatPR among women with \nadenomyosis treated with conservative surgery \nvary significantly according to this va riable. A \nJapanese study published in 2014 including102 \npatients showed that the clinical PR among \nwomen with adenomyosis treated with \nconservative laparoscopic surgery were 41.3% \nin those aged 39 years and 3.7% in those aged \n40 years, suggesting a direct adverse impact of \nage (OR 0.77). Therefore, the authors \nrecommended that conservative surgery for \nadenomyosis could be a beneficial treatment for \nwomen who experienced IVF treatment failures, \nespecially those aged 39 years or less. [33] \n The major benefits of this surgery in both \nfertility and pain control outcomes, is in those \npatients with the association of adenomyosis \nand endomet riosis. Hence, efforts must be \nincrease in this specific group. \nFinally, surgeons must remember that this \nsurgery could lead to pelvic and endometrial \nadhesions, uterine cavity deformations and \nreduction of uterine capacity, all of them \npotentially harming the fertility success. Hence, \na broad preoperative patient counselling, a \nmeticulous surgical technique and a t horough \npost-operative follow -up is always \nrecommended. \n7. CONCLUSIONS \nConservative uterine -sparing surgical \nmanagement of adenomyosis is a safe and \nfeasible, but technically difficult treatment for \nthose women with future pregnancy desire, \nachieving both goo d symptom control and \npreservation of fertility. Independently of the \ntype of surgery performed, significant benefits \nare reported, with mean control of \nDysmenorrhea about 50%, AUB in 50% to 75% \nand a 12 months postoperative pregnancy rate \nbetween 50% to 65%. \nThe success rate will vary according the type of \nprocedure performed. For Type I surgeries, 82% \nof pain reduction and 68% of bleeding reduction \nis reported, with a mean of 60.5% of PR. \nMeanwhile for type II disease, 84% to 86% of \nsymptoms control is ac hieved. Finally, Type III \ntechniques will achieve a 54% of pain reduction, \n73% of bleeding reduction and 55 % of PR. \nLaparoscopy is a feasible approach, and must be \nused regularly to treat the disease, with lower \nrisk of conversions and intra - post operative \ncomplications. The main advantage of \nlaparotomy is the direct palpation and clear \nrecognition of the lesion (and their limits), \ndifficult to achieve by the reduced haptic \nfeedback of the laparoscopy. Nevertheless, this \nis completely split with th e actual MRI exams, \nclearly delimiting and defining the disease, \ngiving and excellent preoperative work - up, \nallowing a safely and effectively approach by \nlaparoscopy. \nTo date, the lack of good ev idence mislead the \nefficacy of different surgical technique s for the \ntreatment of the adenomyosis. It will be \nnecessary to study the benefits of each technique \nthrough large -scale randomized studies with \nadequate follow-ups. \nREFERENCES \n[1] Benagiano G, Brosens I.History of \nadenomyosis. Best Practice and Research: \nClinical Obstetrics and Gynaecology, 20 (4)  \npp. 449-463.(2006) \n[2] Frankl O. Adenomyosis uteri. American \nJournal of Obstetrics & Gynecology , Volume \n10, Issue 5, 680 – 684. (1925) \n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 33  \n[3] Taran FA, Stewart EA, Brucker \nS.Adenomyosis: Epidemiology, Risk Factors, \nClinical Phenotype and Surgical and \nInterventional Alternatives to Hysterectomy. \nGeburtshilfe Und Frauenheilkunde, 73(9), \n924–931.(2013) \n[4] Bergeron C, Amant F, Ferenczy A. Pathology \nand physiopathology of adenomyosis. Best \nPract Res Clin Obstet Gynaecol.  20: \n511e21.(2006) \n[5] Kim JK, Shin CS, Ko YB, et al.Laparoscopic \nassisted adenomyomectomy using double flap \nmethod. Obstet Gynecol Sci 57: 128 -\n135.(2014) \n[6] Benagiano G, Brosens I, Habiba M. \nAdenomyosis: a life -cycle approach. Reprod \nBiomed Online;30:220e32.(2015) \n[7] Argawal M, Mettler L, Alkatou I. A manual of \nminimally invasive gynecological surgery.  \nJaypee Brothers Medical Publishers, First \nEdition (2015) \n[8] Meredith SM, Sanchez -Ramos L, Kaunitz \nAM. Diagnostic accuracy of trans -vaginal \nsonography for the diagnosis of adenomyosis : \nsystematic review and metaanalysis. Am J \nObstet Gyneco.201:107. e1ee6.(2009) \n[9] Horng HC, Chen CH, Chen CY, et al.Uterine -\nsparing surgery for adenomyosis and/or \nadenomyoma. Taiwan J Obstet Gynecol 53: 3 -\n7.(2014) \n[10] Hyams LL. Adenomyosis; its conservative \nsurgical treatment (hysteroplasty) in young \nwomen. N Y State J Med 52: 2778 -\n2784.(1952) \n[11] Grimbizis G, Mikos T, Tarlatzis B. Uterus -\nsparing operative treatment for adenomyosis. \nFertility and Sterility 2014, Volume 101, Issue \n2, 472 - 487.e8.(2014) \n[12] Osada H, Silber S, Kakinuma T, et al. Surgical \nprocedure to conserve the uterus for future \npregnancy in patients suffering from massive \nadenomyosis. Reprod Biomed Online.22:94–9. \n(2011) \n[13] Protopapas A, Millingos S, Markaki S, et al. \nCystic uterine tumors. Gynecol Obstet Invest. \n65:275–80. (2008) \n[14] Takeuchi H, Kitade M, Kikuchi I, et al. \nDiagnosis, laparoscopic management, and \nhistopathologic findings of juvenile cystic \nadenomyoma: a review of nine cases. Fertil \nSteril.94:862–8.(2010) \n[15] Wood C. Surgical and medical treatment of \nadenomyosis. Hum Reprod Update. 4:323 – \n36.(1998) \n[16] Osada H. Uterine adenomyosis and \nadenomyoma: the surgical approachFertility \nand Sterility® Vol. 109, No. 3, March, 0015 -\n028.(2018) \n[17] Phillips DR, Nathanson HG, Milim SJ, et al. \nLaparoscopic bipolar coagulation  for the \nconservative treatment of adenomyomata. J \nAm Assoc Gynecol Laparosc. 4:19–24.(1996) \n[18] Wood C. Adenomyosis: difficult to diagnose, \nand difficult to treat. Diagn Ther Endosc. \n7:89–95.(2001) \n[19] Wang CJ, Yen CF, Lee CL, et al. \nLaparoscopic uterine artery l igation for \ntreatment of symptomatic adenomyosis. J Am \nAssoc Gynecol Laparosc. 9:293–6.(2002) \n[20] Fernandez C, Ricci P, Fernandez E. \nAdenomyosis visualized during hysteroscopy. \nJ Minim Invasive Gynecol. 14:555–6.(2007) \n[21] Preutthipan S, Herabutya Y. Hysteroscopic  \nrollerball endometrial ablation as an \nalternative treatment for adenomyosis with \nmenorrhagia and/or dysmenorrhea. J Obstet \nGynaecol Res.36:1031–6.(2010) \n[22] Kumar A, Kumar A. Myometrial cyst. J \nMinim Invasive Gynecol. 14:395–6.(2007) \n[23] Maia H Jr, Maltez A, Coelho G, et al. Insertion \nof mirena after endometrial resection in \npatients with adenomyosis. J Am Assoc \nGynecol Laparosc. 10:512–6.(2003) \n[24] Yang Z, Cao YD, Hu LN, et al. Feasibility of \nlaparoscopic high-intensity focused ultrasound \ntreatment for patients with uterine localized \nadenomyosis. Fertil Steril. 91:2338–43.(2009) \n[25] Furman B, Appelman Z, Hagay Z, et al. \nAlcohol sclerotherapy for successful treatment \nof focal adenomyosis: a case report. \nUltrasound Obstet Gynecol. 29:460–2.(2007) \n[26] Ryo E, Takeshita S, Shiba M , et al. \nRadiofrequency ablation for cystic \nadenomyosis: a case report. J Reprod Med. \n51:427–30.(2006) \n[27] Kanaoka Y, Hirai K, Ishiko O. Successful \nmicrowave endometrial ablation in a uterus \nenlarged by adenomyosis. Osaka City Med J. \n50:47–51.(2004) \n[28] Chan CL, A nnapoorna V, Roy AC, et al. \nBalloon endometrial thermoablation an \nalternative management of adenomyosis with \nmenorrhagia and dysmenorrhoea. Med J \nMalaysia 2001;56:370–3.(2001) \n[29] Kang L, Gong J, Cheng Z, et al. Clinical \napplication and midterm results of \nlaparoscopic partial resection of symptomatic \nadenomyosis combined with uterine artery \nocclusion. J Minim Invasive Gynecol. 16: \n169–73.(2009) \n[30] Leyendecker G, Kunz G, Kissler S, et al. \nAdenomyosis and reproduction. Best Pract Res \nClin Obstet Gynaecol. 20:523–46.(2006) \n[31] Vercellini P, Consonni D, Dridi D, et al. \nUterine adenomyosis and in vitro fertilization \noutcome: a systematic review and meta -\nanalysis. Hum Reprod 29:964e77.(2014) \n\nSurgical Uterine-Sparing Management of Adenomyosis: Techniques and Review of Literature \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 34  \n[32] Kuan-Hao T, Fa -Kung L, Kok -Min \nS.Conservative surgical treatment of \nadenomyosis to i mprove fertility: \nControversial values, indications, \ncomplications, and pregnancy outcomes. \nTaiwanese Journal of Obstetrics & \nGynecology 54:635e640.(2015) \n[33] Kishi Y, Yabuta M, Taniguchi F.Who will \nbenefit from uterus -sparing surgery in \nadenomyosisassociated subfertility?. Fertil \nSteril;102:802e7.(2014) \n[34] Chang WH, Wang KC, Lee NR,et al. \nReproductive performance of severely \nsymptomatic women uterine adenomyoma \nwho wanted preservation of the uterus and \nunderwent combined surgical -medical \ntreatment. Taiwan J Obste t Gynecol. \n52:39e45.(2013) \n[35] Wang PH, Fuh JL, Chao HT, et al. Is the \nsurgical approach beneficial to subfertile \nwomen with symptomatic extensive \nadenomyosis J Obstet Gynaecol \nRes.35:495e502.(2009) \n[36] Huang BS, Seow KM, Tsui KH, et al. Fertility \noutcome of infertile women with adenomyosis \ntreated with the combination of a conservative \nmicrosurgical technique and GnRH agonist: \nlong-term follow -up in a series of nine \npatients. Taiwan J Obstet Gynecol. 51:212e6. \n(2012) \n \n \n \n \n \n \n \n \n \n \n \nCitation: Andres Vigueras Smith, Ramiro Cabrera, Monica Tessmann Zomer, Carlos Trippia, William \nKondo, Surgical Uterine -Sparing Management of Adenomyosis: Techniques and Review of Literature . ARC \nJournal of Gynecology and Obstetrics. 2018; 3(4):25-34. DOI:dx.doi.org/10.20431/2456-0561.0304006.                         \nCopyright: © 2018 Authors. This is an open -access article distributed under the terms of the Creative \nCommons Attribution License, which permits unrestricted use, distribution, and reproduc tion in any medium, \nprovided the original author and source are credited.","source_license":"CC0","license_restricted":false}