The impact of histopathologically proven adenomyosis on surgical outcomes and total laparoscopic hysterectomy complication rates, types, and severity

This retrospective single-centre cohort study was conducted at the SanlıurfaTraining and Research Hospital in accordance with the Helsinki protocol after the approval of the ethics committee (Number: 15.04.2024/HRÜ.24/04/26). The participants were informed in detail about the study aims and the study protocol, and all provided written informed consent for participation. The histopathological results of 1211 patients who underwent hysterectomy were evaluated between January 2018 and August 2025. Of these, 630 were abdominal, 400 were laparoscopic, 160 were vaginal, and 21 were vaginal natural orifice transluminal endoscopic surgery (V-NOTES) hysterectomies. Among these, 332 patients who underwent TLH for benign indications were divided into two groups according to postoperative histopathologic results: with adenomyosis (Group 1) and without adenomyosis (Group 2). The flow chart of the study population is given in Fig.  1 . Fig. 1 Flowchart of the study population. BSO, bilateral salpingo-oophorectomy; TLH, total laparoscopic hysterectomy; TAH, total abdominal hysterectomy; VH, vaginal hysterectomy; V-NOTES, Vaginal natural orifice transluminal endoscopic surgery Flowchart of the study population. BSO, bilateral salpingo-oophorectomy; TLH, total laparoscopic hysterectomy; TAH, total abdominal hysterectomy; VH, vaginal hysterectomy; V-NOTES, Vaginal natural orifice transluminal endoscopic surgery The exclusion criteria for the study were malignancy and suspected malignancy, concomitant non-gynaecological surgeries during hysterectomy, subtotal/supracervical hysterectomy, obstetric indications, and patients with no pathology results available. The inclusion criteria were patients who underwent TLH for benign indications and clinical follow-up > 6 months after surgery. All surgical procedures were performed by senior surgeons with regular surgical activity using standard methods as described elsewhere [ 10 ]. In brief, an intrauterine manipulator is placed at the beginning of the procedure, and the hysterectomy starts with coagulation and division of the round ligament. Our preference for the uterine manipulator was the RUMI ® II, but manipulator choice, depending on the surgeon’s experience. The broad ligament is opened up to the uterovesical fold that is then incised with caudal reflection of the bladder. Depending on the patient’s age and the indication for surgery, the ovaries are left in place or removed, while the fallopian tubes are always removed. After the vessels were quagulated twice with a 5 mm LigaSure ® device, and cutting was made as close to the uterus as possible, the hysterectomy is completed by performing a circular colpotomy with a monopolar hook. The uterus is then extracted from the vagina, and vaginal cuff closure is performed either transvaginally or laparoscopically. We preferred laparoscopic cuff closure with absorbable 1 − 0 Vicryl suture because it reduces vaginal spotting bleeding. (Fig.  2 ). Fig. 2 a Laparoscopic view of uterine adenomyosis. b Laparoscopic vaginal-cuff suturing. c Adenomyosis in the hysterectomy specimen a Laparoscopic view of uterine adenomyosis. b Laparoscopic vaginal-cuff suturing. c Adenomyosis in the hysterectomy specimen TVUS features of adenomyosis according to the Morphological Uterus Sonographic Assessment (MUSA) group criteria were subendometrial microcysts, myometrial cysts, question mark sign, heterogeneous myometrium, uterine asymmetry, hyperechoic myometrial lesions, subendometrial thickening, disruption of the junctional zone (JZ), subendometrial linear striae, and uterine enlargement [ 3 , 11 ]. A preliminary diagnosis of adenomyosis was made in our clinic if at least three of these TVUS/MUSA criteria were present. Histopathological diagnostic criteria were used after surgery for definitive diagnosis. In macroscopic appearance, the uterus was large and soft or of a nodular consistency in most of the specimens, resembling multiple small intramural leiomyomas. Microscopy of adenomyosis myocytes revealed cell hypertrophy as well as differences in cytoplasmic, nuclear, and intercellular connections (Fig.  3 ) [ 12 ]. Fig. 3 a In macroscopic view, cystic adenomyosis areas located in ½ upper myometrium. b In the microscopic view, endometrial gland structures poor in stroma located within the myometrium in the left area (G1,2,3); atrophic endometrium (AE) in the right area (HE; original size X10) a In macroscopic view, cystic adenomyosis areas located in ½ upper myometrium. b In the microscopic view, endometrial gland structures poor in stroma located within the myometrium in the left area (G1,2,3); atrophic endometrium (AE) in the right area (HE; original size X10) The primary outcomes of the study, including complication rates, severity according to CD score, and types of complications, were analyzed in logistic regression with the presence of adenomyosis. Complications were classified as follows: urinary tract/bladder injuries, bowel injuries, paralytic ileus, vascular injuries, voiding dysfunction, postoperative fever/infection, postoperative bleeding/anaemia, vaginal cuff dehiscence, dyspareunia, and trocar-site incisional hernia. While damage to surrounding organs during surgery was considered an intraoperative complication, any complication reported during readmissions occurring within 30 days after surgery was considered a postoperative complication. The primary aim of the study was to compare complications in the two groups according to CD classification and describe any such complications in detail. The classification is as follows. Grade 1 indicates any deviation from the normal postoperative course without pharmacological treatment or surgical intervention, including bedside wound infections. Grade 2 indicates the need for pharmacological treatment, blood transfusion, and total parenteral nutrition. Grade 3 indicates the need for surgical or radiological interventions. Grade 4 indicates a life-threatening complication requiring intensive care unit (ICU) management, and Grade 5 indicates death [ 9 ]. Confounding factors included age (year), body mass index (kg/m 2 ), parity, comorbidities (DM, diabetes mellitus; HT, hypertension; and HL, hyperlipidaemia), history of previous surgeries (caesarean section, laparoscopy or laparotomy), smoking, menopausal status, indications of surgery (e.g., leiomyoma, endometriosis/pelvic pain, heavy menstrual bleeding, pelvic organ prolapse, postmenopausal bleeding, endometrial hyperplasia, and cervical dysplasia), histopathologies (e.g., adenomyosis, leiomyoma, endometriosis, endometrial /endocervical polyp and endometrial hyperplasia), hysterectomy with or without concomitant salpingooophorectomy, and mean uterus weight (grams). The secondary outcome measures were operative parameters (e.g., operative time/min, estimated blood loss/mL, conversion to laparotomy, and patients’ admittance to the ICU. Data were analysed using IBM SPSS V23. Pearson chi-square test, Yates continuity correction, and Fisher’s exact test with Monte Carlo correction to examine the association between the categorical variables. Compliance with normal distribution was examined using the Kolmogorov–Smirnov test. In comparisons of two independent groups without normal distribution, we used the Mann–Whitney U test. The effect of the independent variables being in group 1 on the overall variables was examined using univariate Binary Logistic Regression model without adjustment. During the logistic regression analysis, patients with Grade 5 were not included in the analysis because there was no patient. Since there was only one patient with Grade 4, it was combined with Grade 3 and grouped as Grade ≥ 3 in order for the logistic regression analysis to yield results. Odds ratios (ORs), 95% confidence intervals (CIs), and P-values were obtained. The significance level was taken as P < 0.05.

A total of 400 patients underwent TLH during the seven-year period of whom 332 had benign indications. Group 1 was comprised of 135 (40.7%) patients in whom adenomyosis pathology was detected, while Group 2 was comprised of 197 (59.3%) patients in whom adenomyosis was not detected in the final pathology. Compared to those in Group 2, Group 1 cases had a higher median age (51 years vs. 49 years, P  = 0.272). There was a statistically significant difference between Groups 1 and 2 with respect to the BMI (kg/m 2 ) and parity medians (respectively, 30.1 vs. 26.1, P  < 0.001; 4 vs. 3, P  = 0.024). There was a statistically significant difference between the groups for smoking (23% vs. 13.7%, P  = 0.042). When we look at surgical indications, the most common causes in Groups 1 and 2 were leiomyoma (45.2% vs. 41.1%, P  = 0.462) and heavy menstrual bleeding (54.8% vs. 43.1%, P  = 0.037). This high rate of heavy menstrual bleeding in Group 1 was statistically significant ( P  = 0.037). In addition, while the rate of endometrial hyperplasia, which is one of the surgical indications, was 30.4% in Group 1, it was 19.3% in Group 2, and the difference was statistically significant ( P  = 0.02) (Table  1 ). Table 1 Demographic and clinical characteristics of the groups Variables Total ( n  = 332) Group 1 ( n  = 135) Group 2 ( n  = 197) P -value Age (year) † 50 (33–82) 51 (33–70) 49 (38–82) 0.272 BMI (kg/m 2 ) † 28.25 (17.9–41.7) 30.1 (17.9–41.5) 26.1 (18.1–41.7) < 0.001 Parity † 4 (1–16) 4 (1–11) 3 (1–16) 0.024 Comorbidities ‡  Diabetes mellitus  Hypertension  Hyperlipidaemia 42 (12.7) 70 (21.1) 15 (4.5) 17 (12.6) 31 (23) 7 (5.2) 25 (12.7) 39 (19.8) 8 (4.1) 1.000 0.487 0.829 Prior cesarean section ‡ 94 (28.3) 39 (28.9) 55 (27.9) 0.847 Prior laparoscopy surgery ‡ 25 (7.5) 14 (10.4) 11 (5.6) 0.158 Prior laparotomy surgery ‡ 68 (20.5) 31 (23) 37 (18.8) 0.354 Smoker ‡ 58 (17.5) 31 (23) 27 (13.7) 0.042 Menopausal status ‡ 97 (29.2) 43 (31.9) 54 (27.4) 0.382 Indications of surgery ‡  Leiomyoma  Endometriosis/pelvic pain  Heavy menstrual bleeding  Pelvic organ prolapse  Postmenopausal bleeding  Endometrial hyperplasia  Cervical dysplasia 142 (42.8) 73 (22) 159 (47.9) 26 (7.8) 42 (12.7) 79 (23.8) 34 (10.2) 61 (45.2) 26 (19.3) 74 (54.8) 11 (8.1) 16 (11.9) 41 (30.4) 13 (9.6) 81 (41.1) 47 (23.9) 85 (43.1) 15 (7.6) 26 (13.2) 38 (19.3) 21 (10.7) 0.462 0.320 0.037 1.000 0.846 0.020 0.905 BMI Body mass index, Group 1 , Adenomyosis, Group 2 , No adenomyosis † Data are presented as median (range) . ‡ Data are presented as number (percentage) P  ≤ 0.05 is statistically significant Demographic and clinical characteristics of the groups Comorbidities ‡ Diabetes mellitus Hypertension Hyperlipidaemia 42 (12.7) 70 (21.1) 15 (4.5) 17 (12.6) 31 (23) 7 (5.2) 25 (12.7) 39 (19.8) 8 (4.1) 1.000 0.487 0.829 Indications of surgery ‡ Leiomyoma Endometriosis/pelvic pain Heavy menstrual bleeding Pelvic organ prolapse Postmenopausal bleeding Endometrial hyperplasia Cervical dysplasia 142 (42.8) 73 (22) 159 (47.9) 26 (7.8) 42 (12.7) 79 (23.8) 34 (10.2) 61 (45.2) 26 (19.3) 74 (54.8) 11 (8.1) 16 (11.9) 41 (30.4) 13 (9.6) 81 (41.1) 47 (23.9) 85 (43.1) 15 (7.6) 26 (13.2) 38 (19.3) 21 (10.7) 0.462 0.320 0.037 1.000 0.846 0.020 0.905 BMI Body mass index, Group 1 , Adenomyosis, Group 2 , No adenomyosis † Data are presented as median (range) . ‡ Data are presented as number (percentage) P  ≤ 0.05 is statistically significant Considering the histopathological results in Table  2 , leiomyoma was found to be the most common outcome, and the rates were similar between the groups (54.1% vs. 52.8%, P  = 0.818). Although the groups were similar in terms of endometriosis and endometrial hyperplasia outcomes, the rate in Group 1 was slightly higher than in Group 2 (3% vs. 2%, P  = 0.720; 17.8% vs. 12.2%, P  = 0.206). Median uterine weight in Group 1 was significantly greater than in Group 2 (221 g vs. 200 g, P  = 0.019). Conversion to laparotomy occurred in 17 (5.1%) cases (7 cases vs. 10 cases, P  = 1.000). Table 2 Surgical and histopathologic outcomes of TLH Variables Total ( n  = 332) Group 1 ( n  = 135) Group 2 ( n  = 197) P -value Histopathologic outcomes †  Leiomyoma  Endometriosis  Endometrial/Endocervical polyp  Endometrial hyperplasia  Cervical dysplasia  Others 177 (53.3) 8 (2.4) 91 (27.4) 48 (14.5) 16 (4.8) 77 (23.2) 73 (54.1) 4 (3) 37 (27.4) 24 (17.8) 7 (5.2) 29 (21.5) 104 (52.8) 4 (2) 54 (27.4) 24 (12.2) 9 (4.6) 48 (24.4) 0.818 0.720 0.999 0.206 1.000 0.541 Mean uterus weight (grams) ‡ 200 (40–940) 221 (54–660) 200 (40–940) 0.019 Concomitant USO/BSO † 224 (67.5) 92 (68.1) 132 (67) 0.827 Conversion to laparotomy † 17 (5.1) 7 (5.2) 10 (5.1) 1.000 Blood transfusion † 64 (19.3) 26 (19.3) 38 (19.3) 0.995 Hospital stay (days) ‡ 2 (1–7) 3 (2–5) 2 (1–7) 0.737 Operative time (min) ‡ 105 (45–420) 103 (45–378) 105 (50–420) 0.737 IC/ICU admission † 21 (6.3) 10 (7.4) 11 (5.6) 0.659 Group 1 Adenomyosis, Group 2 No adenomyosis, TLH Total laparoscopic hysterectomy, USO Unilateral salpingo-oophorectomy, BSO Bilateral salpingo-oophorectomy, IC Intermediate care, ICU Intensive care unit † Data are presented as number (percentage) ‡ Data are presented as median (range) P  ≤ 0.05 is statistically significant Surgical and histopathologic outcomes of TLH Histopathologic outcomes † Leiomyoma Endometriosis Endometrial/Endocervical polyp Endometrial hyperplasia Cervical dysplasia Others 177 (53.3) 8 (2.4) 91 (27.4) 48 (14.5) 16 (4.8) 77 (23.2) 73 (54.1) 4 (3) 37 (27.4) 24 (17.8) 7 (5.2) 29 (21.5) 104 (52.8) 4 (2) 54 (27.4) 24 (12.2) 9 (4.6) 48 (24.4) 0.818 0.720 0.999 0.206 1.000 0.541 Group 1 Adenomyosis, Group 2 No adenomyosis, TLH Total laparoscopic hysterectomy, USO Unilateral salpingo-oophorectomy, BSO Bilateral salpingo-oophorectomy, IC Intermediate care, ICU Intensive care unit † Data are presented as number (percentage) ‡ Data are presented as median (range) P  ≤ 0.05 is statistically significant As seen in Table  3 , a logistic regression model was applied to estimate the association between the presence of adenomyosis and primary outcomes, including the complication rates, severity (CD score), and types of complications. Patients with adenomyosis were less likely to report a total complication rate (OR 0.97, 95% CI 0.60–1.57, P  = 0.913) and postoperative complications (OR 0.92, 95% CI 0.55–1.53, P  = 0.766) than those without adenomyosis. However, they were more likely to report intraoperative complications (OR 1.26, 95% CI 0.41–3.84, P  = 0.682). Although the results were not statistically significant according to CD score, the effect of adenomyosis seemed to be lower in grade 1 complications (OR 0.50, 95% CI 0.17–1.43, P  = 0.197) and similar in CD grade 2 and grade ≥ 3 complications (OR 1.03, CI 0.58–1.84, P  = 0.903; OR 2.52, CI 0.64–9.83, P  = 0.183). The most common type of complication was postoperative bleeding/anaemia (18.1%) in CD grade 2. While a major complication of CD grade 4 was observed in one patient in Group 1, no CD grade 5 complications were observed in either group. Patients with adenomyosis had a slightly higher appearing risk of urinary tract/bladder injuries (OR 1.78, 95% CI 0.53–5.97, P  = 0.347), bowel injuries (OR 4.45, 95% CI 0.45–43.28, P  = 0.198), and vaginal cuff dehiscence (OR 1.47, 95% CI 0.29–7.39, P  = 0.640). The risk of vascular injuries (OR 0.48, 95% CI 0.05–4.68, P  = 0.530), voiding dysfunction (OR 0.72, 95% CI 0.13–4.01, P  = 0.713), postoperative fever/infection (OR 0.36, 95% CI 0.04–3.25, P  = 0.363), dyspareunia (OR 0.48, 95% CI 0.05–4.68, P  = 0.530), and trocar-site incisional hernia (OR 0.72, 95% CI 0.06–8.10, P  = 0.796) seemed slightly lower. Table 3 Operative complication of TLH. Variables † Total (n = 332) Group 1 (n = 135) Group 2 (n = 197) Odds ratio * (95% CI) P-value Complication rate  Intraoperative complications  Postoperative complications 97 (29.2) 13 (3.9) 84 (25.3) 39 (28.9) 6 (4.4) 33 (24.4) 58 (29.4) 7 (3.6) 51 (25.9) 0.97 (0.60–1.57) 1.26 (0.41–3.84) 0.92 (0.55–1.53) 0.913 0.682 0.766 Severity (Clavien–Dindo score)  Grade 1  Grade 2  Grade 3  Grade 4  Grade 5   Grade ≥ 3 major 19 (5.7) 58 (17.5) 18 (5.4) 1 (0.3) 0 (0) 19 (5.7) 5 (3.7) 24 (17.8) 8 (5.9) 1 (0.7) 0 (0) 9 (6.7) 14 (7.1) 34 (17.3) 10 (5.1) 0 (0) 0 (0) 10 (5.1) 0.50 (0.17–1.43) 1.03 (0.58–1.84) 1.17 (0.45–3.06) N.E. N.E. 2.52 (0.64–9.83) 0.197 0.903 0.737 N.E. N.E. 0.183 Types of complications  Urinary tract/bladder injuries  Bowel injuries  Paralytic ileus  Vascular injuries  Voiding dysfunction  Postoperative fever/infection  Postoperative bleeding/anemia  Vaginal cuff dehiscence  Dyspareunia  Trocar–site incisional hernia 11 (3.3) 4 (1.2) 5 (1.5) 4 (1.2) 6 (1.8) 5 (1.5) 60 (18.1) 6 (1.8) 4 (1.2) 3 (0.9) 6 (4.4) 3 (2.2) 2 (1.5) 1 (0.7) 2 (1.5) 1 (0.7) 26 (19.3) 3 (2.2) 1 (0.7) 1 (0.7) 5 (2.5) 1 (0.5) 3 (1.5) 3 (1.5) 4 (2) 4 (2) 34 (17.3) 3 (1.5) 3 (1.5) 2 (1) 1.78 (0.53–5.97) 4.45 (0.45–43.28) 0.97 (0.16–5.89) 0.48 (0.05–4.68) 0.72 (0.13–4.01) 0.36 (0.04–3.25) 1.14 (0.65–2.01) 1.47 (0.29–7.39) 0.48 (0.05–4.68) 0.72 (0.06–8.10) 0.347 0.198 0.976 0.530 0.713 0.363 0.642 0.640 0.530 0.796 CI Confidence interval,  Group 1 Adenomyosis.  Group 2 No adenomyosis,  TLH Total laparoscopic hysterectomy,  N. E . Not estimable, Grade ≥ 3 Major complications † Data are presented as number (percentage) P  ≤ 0.05 is statistically significant * Univariate logistic regression model without adjustment Operative complication of TLH. Complication rate Intraoperative complications Postoperative complications 97 (29.2) 13 (3.9) 84 (25.3) 39 (28.9) 6 (4.4) 33 (24.4) 58 (29.4) 7 (3.6) 51 (25.9) 0.97 (0.60–1.57) 1.26 (0.41–3.84) 0.92 (0.55–1.53) 0.913 0.682 0.766 Severity (Clavien–Dindo score) Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade ≥ 3 major 19 (5.7) 58 (17.5) 18 (5.4) 1 (0.3) 0 (0) 19 (5.7) 5 (3.7) 24 (17.8) 8 (5.9) 1 (0.7) 0 (0) 9 (6.7) 14 (7.1) 34 (17.3) 10 (5.1) 0 (0) 0 (0) 10 (5.1) 0.50 (0.17–1.43) 1.03 (0.58–1.84) 1.17 (0.45–3.06) N.E. N.E. 2.52 (0.64–9.83) 0.197 0.903 0.737 N.E. N.E. 0.183 Types of complications Urinary tract/bladder injuries Bowel injuries Paralytic ileus Vascular injuries Voiding dysfunction Postoperative fever/infection Postoperative bleeding/anemia Vaginal cuff dehiscence Dyspareunia Trocar–site incisional hernia 11 (3.3) 4 (1.2) 5 (1.5) 4 (1.2) 6 (1.8) 5 (1.5) 60 (18.1) 6 (1.8) 4 (1.2) 3 (0.9) 6 (4.4) 3 (2.2) 2 (1.5) 1 (0.7) 2 (1.5) 1 (0.7) 26 (19.3) 3 (2.2) 1 (0.7) 1 (0.7) 5 (2.5) 1 (0.5) 3 (1.5) 3 (1.5) 4 (2) 4 (2) 34 (17.3) 3 (1.5) 3 (1.5) 2 (1) 1.78 (0.53–5.97) 4.45 (0.45–43.28) 0.97 (0.16–5.89) 0.48 (0.05–4.68) 0.72 (0.13–4.01) 0.36 (0.04–3.25) 1.14 (0.65–2.01) 1.47 (0.29–7.39) 0.48 (0.05–4.68) 0.72 (0.06–8.10) 0.347 0.198 0.976 0.530 0.713 0.363 0.642 0.640 0.530 0.796 CI Confidence interval,  Group 1 Adenomyosis.  Group 2 No adenomyosis,  TLH Total laparoscopic hysterectomy,  N. E . Not estimable, Grade ≥ 3 Major complications † Data are presented as number (percentage) P  ≤ 0.05 is statistically significant * Univariate logistic regression model without adjustment

The results suggest that among patients who underwent TLH for benign disease and had histopathologically proven adenomyosis, there was no significant difference in total complication rate, severity (CD score), and types of complications, despite higher age, BMI, parity, and uterine weight. These results may reduce concerns of surgeons when operating on large uteri with adenomyosis scheduled for hysterectomy. If sufficient experience is available, adenomyosis alone should not be a reason to prefer laparotomy to TLH for benign indications. Some of the specific complications may have been so rare that statistical significance was not achieved. In addition, the most common complication was postoperative bleeding/anaemia, which corresponded to CD grade 2 due to blood transfusion in anemic patients from rural areas. Furthermore, classifying TLH complications according to CD score can facilitate understanding of their severity for researchers.

The present study showed that there was no significant difference in total complication rate, severity, and types of complications between patients with and without histopathologically proven adenomyosis who underwent TLH for benign disease. In addition, the most common complication was postoperative bleeding/anaemia (18.1%), which corresponded to CD grade 2 due to blood transfusion. Adenomyosis is a common gynaecological disease characterised by heterotopic endometrial glands and stroma in the myometrium [ 13 ]. Although advances in imaging modalities have facilitated preoperative diagnosis, hysterectomy remains the most important method for the definitive diagnosis and treatment of adenomyosis. Despite there being no consensus on diagnostic criteria and classification systems in general, histopathological diagnostic criteria are currently used [ 3 , 11 ]. To increase accuracy, we diagnosed adenomyosis if three of the TVUS/MUSA criteria were present, similar to Gracia et al. 7 In a recent study by Ajao MO et al., proven adenomyosis was detected in 39% of the histopathological evaluations of the uterus, while Krentel H. et al. found this rate to be 42% [ 4 , 14 ]. In the present study, the proven adenomyosis rate was found to be 40.7%, which is consistent with the literature. The reports identified specific diseases or pathological conditions closely associated with adenomyosis and endometriosis [ 15 ]. The results of a recent study suggest that the presence of adenomyosis may contribute to an increase in the rate of surgical complications in patients with endometriosis [ 7 ]. On the other hand, a new classification system has been described that includes different subtypes of adenomyosis, including intrinsic/extrinsic adenomyosis, external adenomyosis, and focal adenomyosis [ 16 ]. The focal type of these conditions usually affects the external part of the myometrium and adheres to the uterus with other structures, making surgery difficult, and may increase the risk of surgical complications [ 17 ]. This may explain the coexistence of endometriosis and adenomyosis. In a recent study, severe endometriosis was highly prevalent in the adenomyosis group (23.76% vs. 2.65%) [ 13 ]. However, in the present study, although the endometriosis pathology result was slightly higher in patients with adenomyosis, the result was not significant (3% vs. 2%). TLH is becoming increasingly popular and has resulted in a significant decrease in the number of open abdominal surgeries over the past few years. Recent studies have shown that especially the mini TLH is an effective and functional technique in the treatment of various gynecological disorders, offering advantages in terms of aesthetic results and reduced postoperative pain and recovery times [ 18 ]. Some studies suggest that thermal damage due to the use of monopolar and bipolar cautery may increase bladder and ureteral damage when this approach is chosen, but the true extent of this specific problem has largely subsided in recent years [ 19 ]. In previous studies on benign pathology, an increase in bladder and ureteral complications was reported after vaginal hysterectomy only in patients with adenomyosis, but this was not observed when the laparoscopic approach was taken [ 20 ]. Similarly, in our TLH study, no significant difference was found in terms of urinary tract/bladder injuries in the presence of adenomyosis. In a recent study, the complications detected during surgery were bladder injury (1.5%) and ureteral injury (0.5%), while in our study, both were found to be 3.3% [ 5 ]. On the other hand, postoperative complications accounted for 8.8% of all complications in a recent study of hysterectomy with adenomyosis by Mayer et al. [ 21 ]. In other studies, postoperative complications were recorded in 9.3% to 13.9% of patients [ 8 , 10 ]. We attribute the total complication rate of 29.2% in our study, of which 25.3% were postoperative, to the fact that blood transfusion is considered to be a complication under CD score grade 2. While blood transfusion was performed at a rate of 2.2% in the study by Casarin J et al., we performed a higher rate of blood transfusion at 19.3%. 10 In our clinic, blood transfusions are given to patients with hemoglobin levels below 7 g/dL, as recommended by the World Health Organization, or to those who are clinically symptomatic. We can attribute this to the fact that most of our patients live in rural areas and are an anaemic population. Moreover, the Casarin J et al. study recorded 7.2% intraoperative complications and a 1.7% conversion to laparotomy, while the present study recorded 3.9% intraoperative complications and a 5.1% conversion rate to laparotomy [ 10 ]. In another study, intraoperative complications were consistently low (3%), as in our study [ 8 ]. Ultimately, great efforts must be made to minimise intraoperative complications and the need for conversion to laparotomy. Again, in the study by Casarin J et al., bowel and vascular injuries were extremely rare events, each occurring in approximately 1 in 1000 cases. Similarly, in our study, bowel and vascular injuries were rare complications, occurring in 1.2% of cases [ 10 ]. Another complication is vaginal cuff dehiscence, which is reported to occur in 2.7% of vaginal closures and 1% of laparoscopic closures in some studies [ 22 ]. In our study, we preferred laparoscopic closure; the total vaginal cuff dehiscence rate was 1.8%, and this rate was not found to be significant between the groups due to adenomyosis. The rarest complication in our study was trocar-site incisional hernia, which occurred in 0.9% of patients and presented with ileus (Fig.  4 ). However, the power to detect differences in rare complications is limited, and results for specific types of complications need to be interpreted as exploratoryly. Fig. 4 Trocar-site incisional hernia view in sagittal a and transverse b sections. c Appearance of ileus on standing direct abdominal radiograph Trocar-site incisional hernia view in sagittal a and transverse b sections. c Appearance of ileus on standing direct abdominal radiograph The CD score is a five-grade classification system for postsurgical complications based on surgical intervention; this preferred approach allows the identification and international understanding of all events that may affect patient morbidity and mortality [ 9 ]. A large-scale study using the CD score demonstrated the importance of detecting and correcting intraoperative complications during hysterectomy, which ultimately leads to a lower reoperation rate and minimises postoperative morbidity and mortality in patients [ 23 ]. In the study conducted by Casarin J et al., CD grades 1–4 were seen at rates of 7.2%, 4.8%, 1.9%, and 0.1%, respectively, while in our study, the same grades were seen at rates of 5.7%, 17.5%, 5.4%, and 0.3%, respectively [ 10 ]. While CD grade 1 was the most common in this study, CD grade 2 was the most common in the current study. When we focus on rate of major complications, Gracia M et al. found a CD grade ≥ 3 rate of 5.19% in the adenomyosis group, Casarin J et al. found a CD grade ≥ 2 rate of 6.7% in all patients, Uccella S et al. found a CD grade > 2 rate of 7.5% in the endometriosis group and our study found a similar grade ≥ 3 rate of 6.7% in the adenomyosis group [ 7 , 10 , 19 ]. Although there was a significant increase in CD scores in the adenomyosis group in the study by Gracia M et al., our study found no significant difference in CD scores between the groups [ 7 ]. As regards indications for surgery, a recent study found that leiomyoma (33.08%) and adenomyosis (22.25%) were the most common reasons for surgery [ 5 ]. In a study by Stewart et al., the most common reasons for surgery were leiomyoma (43.7%) and heavy menstrual bleeding (33.5%) [ 24 ]. In our study, the most common surgical indications were heavy menstrual bleeding (47.9%) and leiomyoma (42.8%), which is consistent with the literature. Again, in our study, we found that heavy menstrual bleeding was significantly more common in the adenomyosis group, which supports the finding that it is the most common symptom of adenomyosis. When histopathological results were examined, Krentel et al. showed that adenomyosis and leiomyoma coexisted at a relatively high rate in 58.9% of adenomyosis cases [ 4 ]. The findings of our study are consistent with this result, and the most common histopathological finding in the adenomyosis group was leiomyoma with a rate of 54.1%. This excess of association increases both the risk of bleeding during surgery and the rate of blood transfusion. There are a limited number of studies in the literature addressing histopathologically proven adenomyosis in TLH surgery. Considering this, the contribution of the present study to the literature is a strong point. Furthermore, the flowchart and photographic images support understanding and are educational in nature. Unfortunately, limitations must also be acknowledged, namely, that a small number of patients was considered, and the study used a retrospective design. Further prospective randomized controlled trials are needed to obtain definitive results.

Adenomyosis is a pathology defined by the presence of endometrial glands and stroma within the myometrium. The primary hypothesis in the developmental pathway is related to the extension of the basal layer of the endometrium into the myometrium, but this hypothesis is controversial [ 1 , 2 ]. Risk factors for adenomyosis include estrogen-increasing conditions (increased parity, early menarche, short menstrual cycle, high body mass index (BMI), use of birth control pills and tamoxifen) and a history of previous uterine surgery (D&C, caesarean section, myomectomy, etc.) [ 3 ]. As adenomyosis can take asymptomatic forms, and different diagnostic methods are used, its prevalence is difficult to estimate. However, recent data indicate a prevalence rate of between 20% and 42% [ 2 , 4 ]. Definitive diagnosis is made histopathologically after hysterectomy, but advances in imaging modalities such as pelvic magnetic resonance imaging (MRI) and transvaginal ultrasound (TVUS) allow preoperative diagnosis and topographic planning [ 3 ]. The standard treatment for adenomyosis is hysterectomy, but treatment algorithms including medical treatment and minimally invasive treatment methods can be applied to patients who desire pregnancy [ 4 ]. Whenever possible, minimally invasive approaches to hysterectomy should be preferred because of their proven advantages over abdominal hysterectomy in terms of surgery-related morbidity and complications. Therefore, advances in equipment, surgical techniques, and training have made total laparoscopic hysterectomy (TLH) a well-tolerated, effective, and safe surgical method [ 5 ]. The advantages of this surgery include decreased postoperative pain, shorter hospital stay, reduced rates of infection and blood loss, and better cosmetic results [ 6 ]. Several studies have addressed complications associated with TLH-related surgery, but few studies have specifically analysed risk factors for complications [ 7 , 8 ]. Because the classification of complications is difficult, consensus among centres remains controversial. In 2004, Clavien and Dindo described a five-grade classification for surgical postoperative complications based on the treatment intervention. This preferred approach allows the identification and international understanding of all events that may affect patient morbidity and mortality [ 9 ]. Uteruses with adenomyosis are larger, have a higher potential for bleeding, and can sometimes make manipulation during hysterectomy more difficult. It can also be associated with endometriosis. Although studies focus on the association of adenomyosis with endometriosis, there are insufficient data on the effect of the presence of adenomyosis on TLH outcomes and complications [ 7 , 8 ]. Thus, the aim of this study was to compare the surgical outcomes and complications after TLH performed for a benign indication in patients with and without a histopathological diagnosis of adenomyosis.

Below is the link to the electronic supplementary material. Supplementary Material 1. Supplementary Material 1.