Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long management of adenomyosis

Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long management of adenomyosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long management of adenomyosis Jilan Jiang, Jin Yu, Ye Zhang, Yeping Yang, Hong Xu, Feng Sun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2029690/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Jan, 2024 Read the published version in BMC Women's Health → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Laparoscopic adenomyomectomy combined with intraoperative placement of levonorgestrel-releasing intrauterine device (LNG-IUS) is a novel conservative surgical procedure for adenomyosis. Our study aimed to compare the efficacy of surgery with or without intraoperative placement of LNG-IUStreatment in adenomyosis. Methods: We retrospectively studyed the medical records of adenomyosis patients who received laparoscopic adenomyomectomy from January 2017 to December 2018, including 50 patients surgery-LNG-IUS as group A and 48 patients undegoing surgery alone as group B. Demographic data, surgery-related conditions, and symptom replapse 3 years after surgery were analyzed and compared. Results: Visual analog scale and Mansfield-Voda-Jorgensen Menstrual Bleeding Scale scores of group A at 6, 12, 24, and 36 months were significantly lower than those of group B at the corresponding points ( P < .001 for both scales). Individuals in both groups showed statistically significant symptom relief. The recurrence rate in group A was significantly lower than that in group B (6.0% vs. 22.9%, P = .017). Conclusions: Conservative surgery with intraoperative placement of LNG-IUS is more effective for adenomyosis long-term therapy and has a lower recurrence rate of adenomyosis compared to surgery alone. Adenomyosis Conservative surgery Laparoscopic adenomyomectomy Levonorgestrel-releasing intrauterine system Recurrence Figures Figure 1 Background Uterine adenomyosis is described as a benign gynecological disease featured by aberrant development of endometrial glands and stroma within the myometrium [1]. Diffuse and/or focal lesions can occur in the internal or external layers of the myometrium [2]. Clinical symptoms associated with adenomyosis include menorrhagia, dysmenorrhea, and an enlarged uterus [3]. Because an increasing number of women choose to preserve their uteri and fertility, conventional hysterectomy has become less acceptable as treatment for adenomyosis [4]. Various treatment strategies can be used for adenomyosis [5].Drug therapy,such as nonsteroidal anti-inflammatory drugs, oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists, and progestins can all be used for symptom relief. However, once these treatments stop, symptoms will soon reoccur. A surgical approach for adenomyosis may be considered when medical management fails, either due to breakthrough of pain or intolerable side effects from drug therapy or the patient wants a definitive diagnosis [6]. Laparoscopic adenomyomectomy has been increasingly performed worldwide and has been demonstrated to be a safe and effective therapeutic modality [7]. It is reported that, after conservative surgery, over three-fourths of patients achieved complete relief , and the recurrence rate of symptoms is about 9% after the complete excision [8]. As conservative surgery for adenomyosis cannot remove adenomyotic focus thoroughly, even if adenomyosis is characterized by focal lesions, adenomyosis recurrence is unavoidable thus the efficacy of adenomyomectomy decreases over time after surgery. There are still some patients suffering from symptoms relapsed within 1 year of surgery. By releasing levonorgestrel locally, LNG-IUS exerts progesterone-like effect on the endometrium, which then relieves dysmenorrhea and reduces menstrual flow [9]. The LNG-IUS is a suitable alternative to surgery for the management of dysmenorrhea. However, in patients with large adenomyosis, the LNG-IUS has a high expulsion rate (37.5%) [10]. Lee et al.reported the LNG-IUD expulsion rate increased significantly when the uterine volume was greater than 150 ml[11]. Laparoscopic adenomyomectomy reduces the size of the uterus by removing the lesions, thus creating appropriate conditions for LNG-IUS placement. Previously, we reported that the combination of laparoscopic adenomyomectomy with LNG-IUSis an effective and novel conservative surgical procedure for adenomyosis[12]. However, the symptom recurrence rate associated with this modality has not yet been reported. Therefore, we conducted this retrospective study to compare surgery alone with combined surgical-LNG-IUS treatment in adenomyosis to explore the risk factors for symptom recurrence. Methods We enrolled 98 patients who underwent laparoscopic adenomyomectomy at the International Peace Maternity and Child Health Hospital of China Welfare Institute in Shanghai between January 2017 and December 2018. The enrollment criteria included: (1) age between 20 and 45 years, (2) severe dysmenorrhea and/or menorrhagia, (3) availability for transvaginal ultrasound examination data , and (4) postoperative histopathological confirmation of adenomyosis. The exclusion criteria included: (1) submucous myoma, (2) breast cancer, (3) pathologic discoveries of malignancy (e.g., endometrial cancer), (4) previous surgery for adenomyosis, (5) GnRH agonist therapy, or other hormone therapies after surgery. This study has been approved by the ethic committee of the International Peace Maternity and Child Health Hospital of the China Welfare Institute (GKLW 2017-71). A scale ranging from 1 to 6 was used to assess menstrual blood loss according to the Mansfield–Voda–Jorgensen menstrual bleeding scale (MVJ). Menorrhagia is defined as the MVJ score ≥ 5 [13]. The degree of menstrual pain was evaluated by visual analog scale (VAS) [14]. And transvaginal ultrasonography was applied to measure the uterinevolume by the formula: volume = 0.5233 × D1 × D2 × D3, where D1 ,D2, D3 represented the longitudinal dimension, anteroposterior dimension, and the transverse dimension,respectively [15]. On ultrasonography, the extent of an adenomyosis was determined by its maximum diameter. A hemoglobin level of < 120 g/L was defined as anemia [16]. The serum carbohydrate antigen 125 (CA125) levels were determined using a sandwich ELISA kit (R&D Systems, Minneapolis, MN, USA) according to the manufacturer's instructions. The surgical procedure and methods of laparoscopic adenomyomectomy were the same as the previous study in our center [12]. To verify, if the depth was < 10 cm, we inserted an LNG-IUS (Mirena, Bayer, Shanghai, China) containing 52 mg of levonorgestrel immediately after the completion of the operation,and if not, we did not insert an LNG-IUS. All patients underwent the same type of laparoscopic adenomyomectomy by one experienced operator (Feng Sun). In the end, 50 patients undergoing laparoscopic adenomyomectomy combined with intraoperative insertion of LNG-IUS were included in group A and 48 patients undergoing laparoscopic adenomyomectomy only were included in group B. Through the hospital record system, we collected the demographics of the enrolled patients and conducted a telephone interview to obtain the additional data 3 years after the surgery. Symptom relapse included both dysmenorrhea and menorrhagia reoccur, which was defined as when VAS increased by a threshold of 2 and by participants asking for other medical treatments for symptom relief or the MVJ score ≥ 5 [17]. Statistical analysis For continuous variables with Gaussian distributions, mean + standard deviation is used, or median is used with its interquartile range (1st quartile–3rd quartile). Categorical variables were expressed as numbers/ categories. Parametric continuous variables were compared using Student’s t-test, while nonparametric variablesusing the Wilcoxon rank-sum test. The chi-squared test was used to compare categorical variables. Significance was assumed when P was < .05. We used SPSS 26.0.0 for all analyses (SPSS, Inc. Chicago, IL, USA). Results Patient characteristics are presented in Table 1. No significant differences in age, body mass index (BMI), uterine volume, parity, previous abortions, previous abdominal surgery, hemoglobin levels, VAS scores, or menorrhagia were found between the two groups (P > .05, Table 1). Compared with the women in group B, the women in group A had larger maximum diameters of adenomyosis lesions (6 [5.2, 6.6] vs. 5.2 [5, 5.6] cm, P = .01). The operative findings between the two groups are shown in Table 2. None of the women required conversion to laparotomy. The operative time in group A was significantly longer than in group B (182 [150, 207.5] vs. 150 [125, 180] min, P = .001). An analysis of blood loss, specimen weight, hospital stay, and postoperative hemoglobin revealed no significant differences. One patient in group A underwent intraoperative blood transfusion for the large adenomyosis leisions. The hemorrhage and blood transfusion volumes were approximately 1000 ml and 400 ml, respectively. No postoperative complications, such as severe infection or intestinal obstruction, were observed in any patient. No significant differences were found in the number of concomitant ovarian endometria or deeply infiltrating endometriosis between the two groups. The changes in VAS scores, MVJ scores, and uterine volume are shown in Table 3. Pre-surgery VAS scores of 9 (8, 9) and 8 (8, 9) fell to 0 (0, 1) and 2 (1, 2), respectively, at 6-month follow-up in Groups A and B, respectively, and then remained unchangedat at 12, 24, 36 month. The differences in VAS scores between pre-surgery and subsequent follow-up scores at 6, 12, 24, and 36 months were all statistically significant (P < .001). The VAS scores were significantly lower in group A than in group B at 6, 12, 24, and 36 months after surgery (P < .001). At the end of 6 months, the median MVJ scores for menorrhagia showed a decline from the baseline of 6 (5, 6) to 0 (0, 1) and remained low at the end of the 36-month follow-up in group A (P < .001). The median MVJ scores for menorrhagia in group B fell from 5 (5, 6) to 3 (2, 3) and maintained the low level at 36 months (P < .001). The median MVJ scores were significantly lower in group A than in group B at 6, 12, 24, and 36 months after surgery (P < .001). The uterine volume of group A decreased continuously from 198 (135.8, 247.7) preoperatively to 62.6 (45.0, 88.0), 56.2 (34.6,83.9) , 56.0 (40.4, 78.7) ,and 54.8 (43.4, 64.3) at 6, 12, 24, 36 months and, compared to the preoperative levels, the differences at each point were significant (P < .01). Meanwhile, the uterine volume of group B decreased from 177 (148.8, 200.0) to 68.8 (41.9, 79.7), 64.4 (53.7, 81.7), 70.7 (53.7, 84.9), and 70.4 (53.6, 82.2) at 6, 12, 24, and 36 months after surgery, respectively, and the differences showed a significant decline after the surgery (P .05). The overall recurrence rate was 14/98 (14.3%). 12 patients had dysmenorrhea relapsed for further medical treatment and 2 had menorrhagia recurred and caused anemia. Moreover, the cumulative recurrence rate during the follow-up period was 3/50 (6%) in group A and 11/48 (22.9%) in group B, and the difference was significant (P = .017). Kaplan-Meier curves revealed significant differences (P = .025) in recurrence rates between the two groups ( Figure 1). Discussion The conventional treatment for women with symptomatic adenomyosis is hysterectom. There is, however, an increase in the number of women with adenomyosis who wish to retain their uteri because of the recent trend toward organ-preserving surgery and delayed pregnancy. The challenge of treating symptomatic women who want to maintain their fertility is daunting [18]. Medical management can be effective, but it is often transient, and relapse of symptoms and signs almost always occurs once treatment is halted [19]. Conservative surgery is similar to myomectomy, either by laparotomy, laparoscopy [20], or robot-assisted laparoscopy [21]. In a two-year study, more than 90% of patients were satisfied and experienced dramatic improvement in their symptoms after the uterine-sparing surgery [17]. Uterine-sparing surgery for adenomyosis or adenomyoma has shown promising results [22]. There is a good chance that severe diffuse uterine adenomyosis can be treated successfully with double-flap laparoscopic adenomyomectomy [23]. All surgeries in our study were performed laparoscopically without conversion to laparotomy. Our study showed that conservative surgery, whether with or without LNG-IUS, effectively relieved the severity of the adenomyosis symptoms, as assessde by the VAS and MVJ scores [24]. But, we found that the surgery-LNG-IUS group had a significantly lower symptom relapse rate than the surgery alone group during the 3-year follow-up period. Accordingly, our study confirms the benefits of surgical LNG-IUS treatment for adenomyosis symptom improvement, which is in line with previous studies [25]. Although our study suggests a benefit of intraoperative placement of LNG-IUS in the management of women with symptomatic focal adenomyosis, many limitations could not be avoided. First, this was a retrospective study; thus, it may contain biases with regard to patient characteristics. For example, patients in the surgery-LNG-IUS group had higher MVJ scores and larger maximum adenomyoma diameters than those in the surgery-alone group. Second, the sample size in each group of patients was small, and the clinical data originated from a single hospital rather than multiple centers. Larger randomized clinical studies are needed to evaluate the clinical usefulness of this treatment and long-term follow-up data are required to confirm our results. To the best of our knowledge, this is the first study comparing the effectiveness and symptoms recurrence rates of adenomyosis following conservative surgery with or without LNG-IUS intraoperatively. Moreover, based on our three-year follow-up, conservative surgery-LNG-IUS treatment was more effective than surgery alone in controlling symptoms and reducing recurrence rates. Conclusion In conclusion, conservative surgery with intraoperative placement of LNG-IUS is effective and well-accepted for long-term therapy with a lower recurrence rate for adenomyosis. Abbreviations BMI, body mass index; CA125, carbohydrate antigen 125; DIE, deep invasive endometriosis; GnRH, gonadotropin-releasing hormone; LNG-IUS, levonorgestrel-releasing intrauterine device; MVJ, Mansfield–Voda–Jorgensen menstrual bleeding scale; VAS, visual analog scale. Declarations Ethics approval and consent to participate This retrospective case-control study was approved by the Ethics Committee of the International Peace Maternity and Child Health Hospital of the China Welfare Institute ( December 28,2017/GKLW 2017-71), and written informed consent was waived. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing Interests The authors declare that they have no conflicts of interest and nothing to disclose. Funding This work received financial support from the Medicine and Engineering Interdisciplinary Research Fund of Shanghai Jiao Tong University [YG2019QNB06], Shanghai Municipal Key Clinical Specialty [NO. shslczdzk01802], the National Natural Science Foundation of China [NO. 82071622]. Author Contribution JLJ designed the study protocol, performed the statistical analysis and was a major contributor in writing the manuscript. JY collected and analyzed the patient data and wrote the manuscript. YZ and YPY helped to collect and analyzed the patient data. FS performed the surgeries and designed the study. HX conceived the study concept and co-ordinate the whole research procedure. All authors read and approved the final manuscript. 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Baseline characteristics and treatment outcomes of two groups a Group A (n = 50) Group B (n = 48) P Age (years) 40 (37, 42) 39 (36, 42) .527 BMI 21.6 ± 3.38 22.6 ± 1.64 .607 Uterine volume (cm 3 ) 198 (135.8, 247.7) 177 (148.8, 200.0) .374 Maximum diameter (cm) 6 (5.2, 6.6) 5.2 (5, 5.6) .010 Nullipara 6 6 .940 Multipara 44 42 Number of abortions 1 (0, 2) 1 (0, 2) .726 Previous abdominal surgery Cesarean section 21 (42%) 23 (43.8%) .556 Myomectomy 1 (2%) 0 ＞.005 Appendectomy 1 (2%) 0 ＞.005 Adnexal surgery 4 (8%) 8 (16.7%) .191 Preoperative hemoglobin, g/dL 114.0 ± 13.1 116.9 ± 13.1 .271 Preoperative CA125 91.5 (62.4, 248.3) 77.9 (46.5, 124.7) .15 Dysmenorrhea, VAS score 9 (8, 9) 8 (8, 9) .137 Menorrhagia MVJ ≥ 5 (n%) 38 (76 %) 29 (60.4%) .097 Severe Dysmenorrhea (VAS ≥ 7) 45 (90%) 47 (97.9%) .205 BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); CA125, carbohydrate antigen 125; VAS, visual analog scale. a Values are given as mean ± standard deviation, median (range), or number (percentage) Table 2. Operation findings in two groups Variables Group A (n = 50) Group B (n = 48) P Operation time (min) 182 (150, 207.5) 150 (125, 180) .001 Blood loss (ml) 125 (100, 300) 100 (100, 225) .795 Postoperative hemoglobin D1, g/dL 106.6 ± 10.85 108.7 ± 13.13 .381 Concomitant ovarian endometrium 8 9 .719 Concomitant DIE 17 13 .458 Hospital stay (days) 8 (7, 9) 7 (7, 8) .075 Conversion to laparotomy 0 0 Postoperative complications 0 0 Intraoperative blood transfusion (n%) 1 (2%) 0 >.05 DIE, deep invasive endometriosis; Postoperative hemoglobin D1, on the first postoperative day Table 3. Mean differences in VAS score, MVJ score, and uterine volume after surgery Preoperative 6 months 12 months 24 months 36 months Dysmenorrhea (VAS) Group A 9 (8, 9) 0 (0, 1) * 0 (0, 1) * 0 (0, 1) * 0 (0, 1) * Group B 8 (8, 9) 2 (1, 2) * 2 (1, 2) * 2 (1, 3) * 2 (1, 2.3) * P .137 < .001 < .001 < .001 < .001 Menorrhagia (MVJ ≥ 5) Group A (n = 38) 6 (5, 6) 1 (0, 1) * 1 (0, 1) * 1 (0, 1) * 1 (0, 1) * Group B (n = 29) 5 (5, 6) 3 (2, 3) * 3 (2, 3) * 3 (2, 3) * 3 (2, 3) * P .520 < .001 < .001 < .001 < .001 Uterine volume (cm 3 ) Group A 198 (135.8, 247.7) 62.6 (45.0, 88.0) ** 56.2 (34.6, 83.9) ** 56 (40.4, 78.7) ** 54.8 (43.4, 64.3) ** Group B 177 (148.8, 200.0) 68.8 (41.9, 79.7) ** 64.4 (53.7, 81.7) ** 70.7 (53.7, 84.9) ** 70.4 (53.6, 82.2) ** P .374 .657 .694 .151 .142 MVJ, Mansfield-Voda-Jorgensen Menstrual Bleeding Scale; VAS, visual analog scale; a Values are given as mean ± standard deviation, median (range), or number (percentage); *compared with preoperative, P < .01; **compared with preoperative, P < .001 Cite Share Download PDF Status: Published Journal Publication published 08 Jan, 2024 Read the published version in BMC Women's Health → Version 1 posted Reviewers agreed at journal 13 Mar, 2023 Reviewers invited by journal 22 Nov, 2022 Editor invited by journal 18 Nov, 2022 Editor assigned by journal 10 Oct, 2022 First submitted to journal 09 Oct, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2029690","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":154218995,"identity":"dcc81ae1-0077-43cc-88bf-a04e38f3cc2a","order_by":0,"name":"Jilan Jiang","email":"","orcid":"","institution":"International Peace Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jilan","middleName":"","lastName":"Jiang","suffix":""},{"id":154218996,"identity":"abdcea38-7b24-4551-a0ff-5e61963f7391","order_by":1,"name":"Jin Yu","email":"","orcid":"","institution":"International Peace Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Yu","suffix":""},{"id":154218997,"identity":"283744a7-0456-4a9d-8bec-0f77040de0e7","order_by":2,"name":"Ye Zhang","email":"","orcid":"","institution":"International Peace Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ye","middleName":"","lastName":"Zhang","suffix":""},{"id":154218998,"identity":"b3b44954-6dce-4ea7-bd16-388a15a7cf3a","order_by":3,"name":"Yeping Yang","email":"","orcid":"","institution":"International Peace Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yeping","middleName":"","lastName":"Yang","suffix":""},{"id":154218999,"identity":"e14e8a94-876a-4307-b73b-2d0ed714e5c7","order_by":4,"name":"Hong Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYFACHhAhUW/f3nyAQQIskkCUFosEA55jCQwSCcRrqUgwkMgxgKomoMXgRu7BxwW/JPLMec58/mD54zADPztQ788duLVIzshLNp7ZJ1Fs2d67TUIi4TCDZM8bA8beM7i18EvkmEnz9kgwNpw5u40BpMXgRo4BM2Mbbi1scC03ch5/AGmxJ6QFbAvPD4nEDTdyGMAOA4UDXi1Alxsb8zZIGEv2HDOTkEhL55E486zgYC8eLQbHcwwf8/ypk+Nnb378WcLGWo6/PXnjg594tIABzBnMEtBoOkBAAxD8gWr9QFjpKBgFo2AUjEAAAAgTTldTLT4JAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-0314-9145","institution":"International Peace Maternity and Child Health Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hong","middleName":"","lastName":"Xu","suffix":""},{"id":154219000,"identity":"a3858434-4fac-4918-8823-ce1fa9b36621","order_by":5,"name":"Feng Sun","email":"","orcid":"","institution":"International Peace Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2022-09-04 03:13:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2029690/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2029690/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-023-02795-1","type":"published","date":"2024-01-08T15:01:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":29918095,"identity":"887f8be0-021a-4737-9cdc-7a4425d776ac","added_by":"auto","created_at":"2022-12-05 17:40:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":231862,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier curves for time to relapse subsequent to adenomyomectomy of two groups\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-2029690/v1/16116e623883cabb36150cf3.png"},{"id":49629307,"identity":"fedab635-cc49-443e-b8bc-5d6b7ff5be82","added_by":"auto","created_at":"2024-01-15 15:10:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":323682,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2029690/v1/491461e1-70a3-4bf1-a4c4-f83f7c9f6a53.pdf"}],"financialInterests":"","formattedTitle":"Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long management of adenomyosis","fulltext":[{"header":"Background","content":"\u003cp\u003eUterine adenomyosis is described as a benign gynecological disease featured by aberrant development of endometrial glands and stroma within the myometrium [1]. Diffuse and/or focal lesions can occur in the internal or external layers of the myometrium [2]. Clinical symptoms associated with adenomyosis include menorrhagia, dysmenorrhea, and an enlarged uterus [3]. Because an increasing number of women choose to preserve their uteri and fertility, conventional hysterectomy has become less acceptable as treatment for adenomyosis [4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVarious treatment strategies can be used for adenomyosis [5].Drug therapy,such as nonsteroidal anti-inflammatory drugs, oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists, and progestins can all be used for symptom relief. However, once these treatments stop, symptoms will soon reoccur. A surgical approach for adenomyosis may be considered when medical management fails, either due to breakthrough of pain or intolerable side effects from drug therapy or the patient wants a definitive diagnosis [6]. Laparoscopic adenomyomectomy has been increasingly performed worldwide and has been demonstrated to be a safe and effective therapeutic modality [7].\u003c/p\u003e\n\u003cp\u003eIt is reported that, after conservative surgery, over three-fourths of patients achieved complete relief , and the recurrence rate of symptoms is about 9% after the complete excision [8]. As conservative surgery for adenomyosis cannot remove adenomyotic focus thoroughly, even if adenomyosis is characterized by focal lesions, adenomyosis recurrence is unavoidable thus the efficacy of adenomyomectomy decreases over time after surgery. There are still some patients suffering from symptoms relapsed within 1 year of surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;By releasing levonorgestrel locally, LNG-IUS exerts progesterone-like effect on the endometrium, which then relieves dysmenorrhea and reduces menstrual flow [9]. The LNG-IUS is a suitable alternative to surgery for the management of dysmenorrhea. However, in patients with large adenomyosis, the LNG-IUS has a high expulsion rate (37.5%) [10]. Lee et al.reported the LNG-IUD expulsion rate increased significantly when the uterine volume was greater than 150 ml[11]. Laparoscopic adenomyomectomy reduces the size of the uterus by removing the lesions, thus creating appropriate conditions for LNG-IUS placement.\u003c/p\u003e\n\u003cp\u003ePreviously, we reported that the combination of laparoscopic adenomyomectomy with LNG-IUSis an effective and novel conservative surgical procedure for adenomyosis[12]. However, the symptom recurrence rate associated with this modality has not yet been reported. Therefore, we conducted this retrospective study to compare surgery alone with combined surgical-LNG-IUS treatment in adenomyosis to explore the risk factors for symptom recurrence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe enrolled 98 patients who underwent laparoscopic adenomyomectomy at the International Peace Maternity and Child Health Hospital of China Welfare Institute in Shanghai between January 2017 and December 2018. The enrollment criteria included: (1) age between 20 and 45 years, (2) severe dysmenorrhea and/or menorrhagia, (3) availability for transvaginal ultrasound examination data , \u0026nbsp;and (4) postoperative histopathological confirmation of adenomyosis. The exclusion criteria included: (1) submucous myoma, (2) breast cancer, (3) pathologic discoveries of malignancy (e.g., endometrial cancer), (4) previous surgery for adenomyosis, (5) \u0026nbsp;GnRH agonist therapy, or other hormone therapies after surgery. This study has been approved by the ethic committee of the International Peace Maternity and Child Health Hospital of the China Welfare Institute (GKLW 2017-71).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA scale ranging from 1 to 6 was used to assess menstrual blood loss according to the Mansfield\u0026ndash;Voda\u0026ndash;Jorgensen menstrual bleeding scale (MVJ). Menorrhagia is defined as the MVJ score \u0026ge; 5 [13]. The degree of menstrual pain was evaluated by visual analog scale (VAS) [14]. And transvaginal ultrasonography was applied to measure the uterinevolume by the formula: volume = 0.5233 \u0026times; D1 \u0026times; D2 \u0026times; D3, where D1 ,D2, D3 represented the longitudinal dimension, \u0026nbsp;anteroposterior dimension, and the transverse dimension,respectively [15]. On ultrasonography, the extent of an adenomyosis was determined by its maximum diameter. A hemoglobin level of \u0026lt; 120 g/L was defined as anemia [16]. The serum carbohydrate antigen 125 (CA125) levels were determined using a sandwich ELISA kit (R\u0026amp;D Systems, Minneapolis, MN, USA) according to the manufacturer\u0026apos;s instructions.\u003c/p\u003e\n\u003cp\u003eThe surgical procedure and methods of laparoscopic adenomyomectomy were the same as the previous study in our center [12]. To verify, if the depth was \u0026lt; 10 cm, we inserted an LNG-IUS (Mirena, Bayer, Shanghai, China) containing 52 mg of levonorgestrel immediately after the completion of the operation,and if not, we did not insert an LNG-IUS. All patients underwent the same type of laparoscopic adenomyomectomy by one experienced operator (Feng Sun).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the end, 50 patients undergoing laparoscopic adenomyomectomy combined with intraoperative insertion of LNG-IUS were included in group A and 48 patients undergoing laparoscopic adenomyomectomy only were included in group B.\u003c/p\u003e\n\u003cp\u003eThrough the hospital record system, we collected the demographics of the enrolled patients and conducted a telephone interview to obtain the additional data 3 years after the surgery. Symptom relapse included both dysmenorrhea and menorrhagia reoccur, which was defined as when VAS increased by a threshold of 2 and by participants asking for other medical treatments for symptom relief or the MVJ score \u0026ge; 5 [17].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor continuous variables with Gaussian distributions, mean + standard deviation is used, or median is used with its interquartile range (1st quartile\u0026ndash;3rd quartile). Categorical variables were expressed as numbers/ categories. Parametric continuous variables were compared using Student\u0026rsquo;s t-test, while nonparametric variablesusing the Wilcoxon rank-sum test. The chi-squared test was used to compare categorical variables. Significance was assumed when P was \u0026lt; .05. We used SPSS 26.0.0 for all analyses (SPSS, Inc. Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient characteristics are presented in Table 1. No significant differences in age, body mass index (BMI), uterine volume, parity, previous abortions, previous abdominal surgery, hemoglobin levels, VAS scores, or menorrhagia were found between the two groups (P \u0026gt; .05, Table 1). Compared with the women in group B, the women in group A had larger maximum diameters of adenomyosis lesions (6 [5.2, 6.6] vs. 5.2 [5, 5.6] cm, P = .01).\u003c/p\u003e\n\u003cp\u003eThe operative findings between the two groups are shown in Table 2. None of the women required conversion to laparotomy. The operative time in group A was significantly longer than in group B (182 [150, 207.5] vs. 150 [125, 180] min, P = .001). An analysis of blood loss, specimen weight, hospital stay, and postoperative hemoglobin revealed no significant differences. One patient in group A underwent intraoperative blood transfusion for the large adenomyosis leisions. The hemorrhage and blood transfusion volumes were approximately 1000 ml and 400 ml, respectively. No postoperative complications, such as severe infection or intestinal obstruction, were observed in any patient. No significant differences were found in the number of concomitant ovarian endometria or deeply infiltrating endometriosis between the two groups.\u003c/p\u003e\n\u003cp\u003eThe changes in VAS scores, MVJ scores, and uterine volume are shown in Table 3. Pre-surgery VAS scores of 9 (8, 9) and 8 (8, 9) fell to 0 (0, 1) and 2 (1, 2), respectively, at 6-month follow-up in Groups A and B, respectively, and then remained unchangedat at 12, 24, 36 month. The differences in VAS scores between pre-surgery and subsequent follow-up scores at 6, 12, 24, and 36 months were all statistically significant (P \u0026lt; .001). The VAS scores were significantly lower in group A than in group B at 6, 12, 24, and 36 months after surgery (P \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003eAt the end of 6 months, the median MVJ scores for menorrhagia showed a decline from the baseline of 6 (5, 6) to 0 (0, 1) and remained low at the end of the 36-month follow-up in group A (P \u0026lt; .001). The median MVJ scores for menorrhagia in group B fell from 5 (5, 6) to 3 (2, 3) and maintained the low level at 36 months (P \u0026lt; .001). The median MVJ scores were significantly lower in group A than in group B at 6, 12, 24, and 36 months after surgery (P \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003eThe uterine volume of group A decreased continuously from 198 (135.8, 247.7) preoperatively to 62.6 (45.0, 88.0), 56.2 (34.6,83.9) , 56.0 (40.4, 78.7) ,and 54.8 (43.4, 64.3) \u0026nbsp;at 6, 12, 24, 36 months and, compared to the preoperative levels, the differences at each point were significant (P \u0026lt; .01). Meanwhile, the uterine volume of group B decreased from 177 (148.8, 200.0) to 68.8 (41.9, 79.7), 64.4 (53.7, 81.7), 70.7 (53.7, 84.9), and 70.4 (53.6, 82.2) at 6, 12, 24, and 36 months after surgery, respectively, and the differences showed a significant decline after the surgery (P \u0026lt; .01). Differences in uterine volumes were not observed between the two groups at 0, 6, 12, 24, and 36 months (P \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003eThe overall recurrence rate was 14/98 (14.3%). 12 patients had dysmenorrhea relapsed for further medical treatment and 2 had menorrhagia recurred and caused anemia. Moreover, the cumulative recurrence rate during the follow-up period was 3/50 (6%) in group A and 11/48 (22.9%) in group B, and the difference was significant (P = .017). Kaplan-Meier curves revealed significant differences (P = .025) in recurrence rates between the two groups ( Figure 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe conventional treatment for women with symptomatic adenomyosis is hysterectom. There is, however, an increase in the number of women with adenomyosis who wish to retain their uteri because of the recent trend toward organ-preserving surgery and delayed pregnancy. The challenge of treating symptomatic women who want to maintain their fertility is daunting [18]. Medical management can be effective, but it is often transient, and relapse of symptoms and signs almost always occurs once treatment is halted [19]. Conservative surgery is similar to myomectomy, either by laparotomy, laparoscopy [20], or robot-assisted laparoscopy [21]. In a two-year study, more than 90% of patients were satisfied and experienced dramatic improvement in their symptoms after the uterine-sparing surgery [17]. Uterine-sparing surgery for adenomyosis or adenomyoma has shown promising results [22]. There is a good chance that severe diffuse uterine adenomyosis can be treated successfully with double-flap laparoscopic adenomyomectomy [23]. All surgeries in our study were performed laparoscopically without conversion to laparotomy. Our study showed that conservative surgery, whether with or without LNG-IUS, effectively relieved the severity of the adenomyosis symptoms, as assessde by the VAS and MVJ scores [24]. But, we found that the surgery-LNG-IUS group had a significantly lower symptom relapse rate than the surgery alone group during the 3-year follow-up period. Accordingly, our study confirms the benefits of surgical LNG-IUS treatment for adenomyosis symptom improvement, which is in line with previous studies [25].\u003c/p\u003e\n\u003cp\u003eAlthough our study suggests a benefit of intraoperative placement of LNG-IUS in the management of women with symptomatic focal adenomyosis, many limitations could not be avoided. First, this was a retrospective study; thus, it may contain biases with regard to patient characteristics. For example, patients in the surgery-LNG-IUS group had higher MVJ scores and larger maximum adenomyoma diameters than those in the surgery-alone group. Second, the sample size in each group of patients was small, and the clinical data originated from a single hospital rather than multiple centers. Larger randomized clinical studies are needed to evaluate the clinical usefulness of this treatment and long-term follow-up data are required to confirm our results.\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, this is the first study comparing the effectiveness and symptoms recurrence rates of adenomyosis following conservative surgery with or without LNG-IUS intraoperatively. Moreover, based on our three-year follow-up, conservative surgery-LNG-IUS treatment was more effective than surgery alone in controlling symptoms and reducing recurrence rates.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, conservative surgery with intraoperative placement of LNG-IUS is effective and well-accepted for long-term therapy with a lower recurrence rate for adenomyosis.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI, body mass index; CA125, carbohydrate antigen 125; DIE, deep invasive endometriosis; GnRH, gonadotropin-releasing hormone; LNG-IUS, levonorgestrel-releasing intrauterine device; MVJ, Mansfield\u0026ndash;Voda\u0026ndash;Jorgensen menstrual bleeding scale; VAS, visual analog scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective case-control study was approved by the Ethics Committee of the International Peace Maternity and Child Health Hospital of the China Welfare Institute ( December 28,2017/GKLW 2017-71), and written informed consent was waived.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest and nothing to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work received financial support from the Medicine and Engineering Interdisciplinary Research Fund of Shanghai Jiao Tong University [YG2019QNB06], Shanghai Municipal Key Clinical Specialty [NO. shslczdzk01802], the National Natural Science Foundation of China [NO. 82071622].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJLJ designed the study protocol, performed the statistical analysis and was a major contributor in writing the manuscript. JY collected and analyzed the patient data and wrote the manuscript. YZ and YPY helped to collect and analyzed the patient data. FS performed the surgeries and designed the study. HX conceived the study concept and co-ordinate the whole research procedure. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHarada T, Khine YM, Kaponis A, et al (2016) The Impact of Adenomyosis on Women\u0026apos;s Fertility. Obstet Gynecol Surv 9:557-568.https://doi.org/10.1097/OGX.0000000000000346\u003c/li\u003e\n \u003cli\u003eShwayder J and Sakhel K (2014) Imaging for uterine myomas and adenomyosis. J Minim Invasive Gynecol 3:362-376.https://doi.org/10.1016/j.jmig.2013.11.011\u003c/li\u003e\n \u003cli\u003eDevlieger R, D\u0026apos;Hooghe T and Timmerman D (2003) Uterine adenomyosis in the infertility clinic. Hum Reprod Update 2:139-147.https://doi.org/10.1093/humupd/dmg010\u003c/li\u003e\n \u003cli\u003eSaremi A, Bahrami H, Salehian P, et al (2014) Treatment of adenomyomectomy in women with severe uterine adenomyosis using a novel technique. Reprod Biomed Online 6:753-760.https://doi.org/10.1016/j.rbmo.2014.02.008\u003c/li\u003e\n \u003cli\u003eKho KA, Chen JS and Halvorson LM (2021) Diagnosis, Evaluation, and Treatment of Adenomyosis. JAMA 2:177-178.https://doi.org/10.1001/jama.2020.26436\u003c/li\u003e\n \u003cli\u003eStratopoulou CA, Donnez J and Dolmans MM (2021) Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach. J Clin Med21.https://doi.org/10.3390/jcm10214878\u003c/li\u003e\n \u003cli\u003eKwack JY and Kwon YS (2017) Laparoscopic Surgery for Focal Adenomyosis. JSLS 2https://doi.org/10.4293/JSLS.2017.00014\u003c/li\u003e\n \u003cli\u003eYounes G and Tulandi T (2018) Conservative Surgery for Adenomyosis and Results: A Systematic Review. J Minim Invasive Gynecol 2:265-276.https://doi.org/10.1016/j.jmig.2017.07.014\u003c/li\u003e\n \u003cli\u003eStreuli I, Dubuisson J, Santulli P, et al (2014) An update on the pharmacological management of adenomyosis. Expert Opin Pharmacother 16:2347-2360.https://doi.org/10.1517/14656566.2014.953055\u003c/li\u003e\n \u003cli\u003eLockhat FB, Emembolu JO and Konje JC (2005) The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up. Hum Reprod 3:789-793.https://doi.org/10.1093/humrep/deh650\u003c/li\u003e\n \u003cli\u003eLee KH, Kim JK, Lee MA, et al (2016) Relationship between uterine volume and discontinuation of treatment with levonorgestrel-releasing intrauterine devices in patients with adenomyosis. Arch Gynecol Obstet 3:561-566.https://doi.org/10.1007/s00404-016-4105-y\u003c/li\u003e\n \u003cli\u003eSun F, Zhang Y, You M, et al (2021) Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system in the treatment of adenomyosis: Feasibility and effectiveness. J Obstet Gynaecol Res 2:613-620.https://doi.org/10.1111/jog.14571\u003c/li\u003e\n \u003cli\u003eMansfield PK, Voda A and Allison G (2004) Validating a pencil-and-paper measure of perimenopausal menstrual blood loss. Womens Health Issues 6:242-247.https://doi.org/10.1016/j.whi.2004.07.005\u003c/li\u003e\n \u003cli\u003eGerlinger C, Schumacher U, Wentzeck R, et al (2012) How can we measure endometriosis-associated pelvic pain? Journal of Endometriosis 3:109-116.https://doi.org/10.5301/je.2012.9725\u003c/li\u003e\n \u003cli\u003ePark DS, Kim ML, Song T, et al (2015) Clinical experiences of the levonorgestrel-releasing intrauterine system in patients with large symptomatic adenomyosis. Taiwan J Obstet Gynecol 4:412-415.https://doi.org/10.1016/j.tjog.2014.05.009\u003c/li\u003e\n \u003cli\u003eStoltzfus RJ (1997) Rethinking anaemia surveillance. Lancet 9067:1764-1766.https://doi.org/10.1016/S0140-6736(96)12355-2\u003c/li\u003e\n \u003cli\u003eWang PH, Liu WM, Fuh JL, et al (2009) Comparison of surgery alone and combined surgical-medical treatment in the management of symptomatic uterine adenomyoma. Fertil Steril 3:876-885.https://doi.org/10.1016/j.fertnstert.2008.07.1744\u003c/li\u003e\n \u003cli\u003ePepas L, Deguara C and Davis C (2012) Update on the surgical management of adenomyosis. Current opinion in obstetrics \u0026amp; gynecology 4:259-264.https://doi.org/10.1097/GCO.0b013e328355213a\u003c/li\u003e\n \u003cli\u003eVannuccini S, Luisi S, Tosti C, et al (2018) Role of medical therapy in the management of uterine adenomyosis. Fertility and sterility 3:398-405.https://doi.org/10.1016/j.fertnstert.2018.01.013\u003c/li\u003e\n \u003cli\u003eMorita M, Asakawa Y, Nakakuma M, et al (2004) Laparoscopic Excision of Myometrial Adenomyomas in Patients with Adenomyosis Uteri and Main Symptoms of Severe Dysmenorrhea and Hypermenorrhea. The Journal of the American Association of Gynecologic Laparoscopists 1:86-89.https://doi.org/10.1016/s1074-3804(05)60018-7\u003c/li\u003e\n \u003cli\u003eChung YJ, Kang SY, Choi MR, et al (2016) Robot-Assisted Laparoscopic Adenomyomectomy for Patients Who Want to Preserve Fertility. Yonsei Med J 6:1531-1534.https://doi.org/10.3349/ymj.2016.57.6.1531\u003c/li\u003e\n \u003cli\u003eTellum T, Omtvedt M, Naftalin J, et al (2021) A systematic review of outcome reporting and outcome measures in studies investigating uterine-sparing treatment for adenomyosis. Hum Reprod Open 3:hoab030.https://doi.org/10.1093/hropen/hoab030\u003c/li\u003e\n \u003cli\u003eZhu L, Chen S, Che X, et al (2019) Comparisons of the efficacy and recurrence of adenomyomectomy for severe uterine diffuse adenomyosis via laparotomy versus laparoscopy: a long-term result in a single institution. J Pain Res:1917-1924.https://doi.org/10.2147/JPR.S205561\u003c/li\u003e\n \u003cli\u003eLin CJ, Hsu TF, Chang YH, et al (2018) Postoperative maintenance levonorgestrel-releasing intrauterine system for symptomatic uterine adenomyoma. Taiwan J Obstet Gynecol 1:47-51.https://doi.org/10.1016/j.tjog.2017.12.036\u003c/li\u003e\n \u003cli\u003eWang PH, Yang TS, Lee WL, et al (2000) Treatment of infertile women with adenomyosis with a conservative microsurgical technique and a gonadotropin-releasing hormone agonist.Fertility and sterility 5:1061-1062.https://doi.org/10.1016/s0015-0282(00)00411-8\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Baseline characteristics and treatment outcomes of two groups \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003eGroup A (n = 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003eGroup B (n = 48)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e40 (37, 42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e39 (36, 42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e21.6 \u0026plusmn; 3.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e22.6 \u0026plusmn; 1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.607\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eUterine volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e198 (135.8, 247.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e177 (148.8, 200.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.374\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eMaximum diameter (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e6 (5.2, 6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e5.2 (5, 5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eNullipara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"39.75903614457831%\"\u003e\n \u003cp\u003eMultipara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.907630522088354%\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eNumber of abortions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e1 (0, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e1 (0, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.726\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003ePrevious abdominal surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eCesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e21 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e23 (43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.556\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eMyomectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e＞.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eAppendectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e＞.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eAdnexal surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e8 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.191\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003ePreoperative hemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e114.0 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e116.9 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.271\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003ePreoperative CA125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e91.5 (62.4, 248.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e77.9 (46.5, 124.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eDysmenorrhea, VAS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e9 (8, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e8 (8, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eMenorrhagia MVJ \u0026ge; 5 (n%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e38 (76 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e29 (60.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.78839590443686%\"\u003e\n \u003cp\u003eSevere Dysmenorrhea (VAS \u0026ge; 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.32764505119454%\"\u003e\n \u003cp\u003e45 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.866894197952217%\"\u003e\n \u003cp\u003e47 (97.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.017064846416382%\"\u003e\n \u003cp\u003e.205\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); CA125, carbohydrate antigen 125; VAS, visual analog scale. \u003csup\u003ea\u0026nbsp;\u003c/sup\u003eValues are given as mean \u0026plusmn; standard deviation, median (range), or number (percentage)\u003c/p\u003e\n\u003cp\u003eTable 2. Operation findings in two groups\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003eGroup A (n = 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003eGroup B (n = 48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e182 (150, 207.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e150 (125, 180)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eBlood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e125 (100, 300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e100 (100, 225)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e.795\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003ePostoperative hemoglobin D1, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e106.6 \u0026plusmn; 10.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e108.7 \u0026plusmn; 13.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e.381\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eConcomitant ovarian endometrium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e.719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eConcomitant DIE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e.458\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eHospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e8 (7, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e7 (7, 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eConversion to laparotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.04882459312839%\"\u003e\n \u003cp\u003eIntraoperative blood transfusion (n%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.593128390596746%\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.78481012658228%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.573236889692586%\"\u003e\n \u003cp\u003e\u0026gt;.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eDIE, deep invasive endometriosis; Postoperative hemoglobin D1, on the first postoperative day\u003c/p\u003e\n\u003cp\u003eTable 3. Mean differences in VAS score, MVJ score, and uterine volume after surgery\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e24 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e36 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eDysmenorrhea (VAS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e9 (8, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e0 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e0 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e0 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e0 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e8 (8, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e2 (1, 2) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e2 (1, 2) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e2 (1, 3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e2 (1, 2.3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eMenorrhagia (MVJ \u0026ge; 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eGroup A\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n = 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e6 (5, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e1 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e1 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e1 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e1 (0, 1) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eGroup B\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n = 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e5 (5, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e3 (2, 3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e3 (2, 3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e3 (2, 3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e3 (2, 3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e.520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eUterine volume (cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eGroup A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e198\u003c/p\u003e\n \u003cp\u003e(135.8, 247.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e62.6 (45.0, 88.0) **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e56.2 (34.6, 83.9) **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e56 (40.4, 78.7) **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e54.8 (43.4, 64.3) **\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003eGroup B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003cp\u003e(148.8, 200.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e68.8 (41.9, 79.7) **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e64.4 (53.7, 81.7) **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e70.7 (53.7, 84.9) **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e70.4 (53.6, 82.2) **\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.47826086956522%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.659420289855074%\"\u003e\n \u003cp\u003e.374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.130434782608695%\"\u003e\n \u003cp\u003e.657\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.028985507246375%\"\u003e\n \u003cp\u003e.694\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.398550724637682%\"\u003e\n \u003cp\u003e.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.304347826086957%\"\u003e\n \u003cp\u003e.142\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMVJ, Mansfield-Voda-Jorgensen Menstrual Bleeding Scale; VAS, visual analog scale;\u0026nbsp;\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eValues are given as mean \u0026plusmn; standard deviation, median (range), or number (percentage); *compared with preoperative, \u003cem\u003eP\u003c/em\u003e \u0026lt; .01; **compared with preoperative, \u003cem\u003eP\u003c/em\u003e \u0026lt; .001\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adenomyosis, Conservative surgery, Laparoscopic adenomyomectomy, Levonorgestrel-releasing intrauterine system, Recurrence","lastPublishedDoi":"10.21203/rs.3.rs-2029690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2029690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eLaparoscopic adenomyomectomy combined with intraoperative placement of levonorgestrel-releasing intrauterine device (LNG-IUS) is a novel conservative surgical procedure for adenomyosis. Our study aimed to compare the efficacy of surgery with or without intraoperative placement of LNG-IUStreatment in adenomyosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe retrospectively studyed the medical records of adenomyosis patients who received laparoscopic adenomyomectomy from January 2017 to December 2018, including 50 patients surgery-LNG-IUS as group A and 48 patients undegoing surgery alone as group B. Demographic data, surgery-related conditions, and symptom replapse 3 years after surgery were analyzed and compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eVisual analog scale and Mansfield-Voda-Jorgensen Menstrual Bleeding Scale scores of group A at 6, 12, 24, and 36 months were significantly lower than those of group B at the corresponding points (\u003cem\u003eP\u003c/em\u003e \u0026lt; .001 for both scales). Individuals in both groups showed statistically significant symptom relief. The recurrence rate in group A was significantly lower than that in group B (6.0% vs. 22.9%,\u003cem\u003eP \u003c/em\u003e= .017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eConservative surgery with intraoperative placement of LNG-IUS is more effective for adenomyosis long-term therapy and has a lower recurrence rate of adenomyosis compared to surgery alone.\u003c/p\u003e","manuscriptTitle":"Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long management of adenomyosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-05 17:40:51","doi":"10.21203/rs.3.rs-2029690/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2023-03-14T01:38:20+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-11-22T14:43:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"BMC Women's Health","date":"2022-11-18T09:29:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-10-10T05:09:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2022-10-09T05:57:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"49c695af-48af-46f4-9f95-f6d1ddc37b52","owner":[],"postedDate":"December 5th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-15T15:10:32+00:00","versionOfRecord":{"articleIdentity":"rs-2029690","link":"https://doi.org/10.1186/s12905-023-02795-1","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2024-01-08 15:01:03","publishedOnDateReadable":"January 8th, 2024"},"versionCreatedAt":"2022-12-05 17:40:51","video":"","vorDoi":"10.1186/s12905-023-02795-1","vorDoiUrl":"https://doi.org/10.1186/s12905-023-02795-1","workflowStages":[]},"version":"v1","identity":"rs-2029690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2029690","identity":"rs-2029690","version":["v1"]},"buildId":"M1DPXKE8UapkOyQliHcFZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}