Introduction
Adenomyosis is a benign tumor process of the uterus, one of the forms of endometrioid disease. Surgical treatment of adenomyosis to this day is the subject of discussion by many authors, but the principle of surgical interventions remains the same - excision of the myometrium affected by glandular invasion. The article discusses the main methods of adenomyomectomy, the results of surgical interventions in terms of the reproductive function of women. In addition, its own original technique for suturing the uterus after surgical interventions is given.
Adenomyosis, being one of the frequent diseases that cause uterine bleeding, algomenorrhea, infertility, is an indication for prolonged hormone therapy or hysterectomy [1-4]. The use of organ-saving methods of surgical treatment for adenomyosis in order to maintain fertility and eliminate symptoms is an important modern aspect of therapy [5,6]. Among all the causes of female infertility, adenomyosis accounts for about 20% [7].
Many authors point to a steady increase in the detection of adenomyosis in all age groups, including a tendency to increase the incidence of adenomyosis in young women who did not realize reproductive function. The frequency of its detection in the population, according to various authors, varies from 10 to 61% [8-12]. After hysterectomies in the preparations, the frequency of detection of adenomyosis reaches 46–70% in the population [13]. The lack of effect of conservative treatment methods leads to an increase in the number of radical surgical interventions in young women [14].
At the same time, a review of the medical literature shows that since 1990 at least 2,300 adenomyomectomies have been performed, including 2,123 (89.8%) in Japan. 397 pregnancies were reported after organ-saving surgeries. In 337 (84.89%) pregnancies ended in childbirth, while 23 pregnancies were complicated by uterine ruptures [15-17].
Adenomyomectomy is a recognized method of treatment of manifest adenomyosis in combination with uterine myoma, manifested by dysmenorrhea, menorrhagia and infertility. However, pregnant women after adenomyomectomy have a higher risk of spontaneous abortion, uterine scar failure or spontaneous uterine rupture during pregnancy and childbirth, says Ota Y, et. al. [18]. The impact of surgical energies during uterine surgery increases the risk of uterine rupture [15,16]. Various surgical treatments for adenomyosis are currently being tested. Indications for surgery are dysmenorrhea and hypermenorrhea, resistant to conservative therapy, infertility, habitual miscarriage, and the desire to maintain fertility or menstrual function with a significant increase in the size of the uterus.
Surgical Treatment
Organ-preserving surgical treatment of adenomyosis in young women was first described by Van Praagh in 1952 [19]. Then the technique of wedge-shaped resection of the myometrium was adopted. In 1991, the results of resection of the affected myometrium in 37 patients were presented. In the described cases, microsurgical resection of the affected myometrium by laparotomy access was performed. As a result, 6 women became pregnant after the operation, and all pregnancies ended in childbirth [20]. It was reported that in 1993 a series of operations of this modification was performed with partial removal of adenomyoma in 28 patients. Of the 18 women trying to get pregnant, 13 achieved the desired result. As a result, there were 9 (50.5%) live births and 7 (38.8%) miscarriages, according to Fedele L, et. al [21].
Interesting experience in performing Fujishita A, et. al. [22] laparotomic modification of adenomyomectomy with an H-shaped incision in the bottom of the uterus with a wide separation of the serous part [6]. The altered myometrial tissue was dissected using an electrosurgical scalpel or scissors. The uterine wall was restored with a two-row suture. The first row of sutures (muscular-muscular) restored the uterine wall, while the suture was also hemostatic. Bilateral serous flaps that appear after a vertical incision, as well as upper and lower flaps resulting from a transverse incision, were sutured with nodular gray-serous sutures.
Based on the data collected before 2010, in 41 patients undergoing the H-section method, 31 attempted to become pregnant; 12 (38.7%) reached clinical pregnancy, 5 (16.1%) miscarriages and 7 (22.5%) reported live births [22]. In another study, Nishimoto M, et. al. 14 women were registered who performed this technique [23]. At the same time, all women after the operation planned a pregnancy, 3 (21.4%) reached pregnancy, and all had healthy children.
In a recent study by Saremi AT, et al. [24] a wedge-shaped resection of the uterine wall was reported up to the endometrium after a sagittal section of the uterus [24]. Reconstruction of the uterine wall is performed by a continuous horizontal mattress suture. A screw-on gray-serous suture is then applied to reduce the risk of adhesions. Of the 103 patients operated on, 70 attempted to become pregnant during the study period, of which 21 (30%) reached clinical pregnancies. In 16 (22.8%) pregnancies ended in successful live births.
The methods of complete excision of adenomyosis include the triple flap method. This adenomyomectomy technique is based on a completely new idea that differs from standard surgical methods [25]. The method involves reconstruction of a defect in the uterine wall using the remaining normal uterine muscle. In a study by Osada H, et al. 2017 [16], in which 113 women were evaluated after surgery using this method, it was shown that within 6 months the blood flow in the area of action returned to normal in almost all cases (92/113, 81.4 %). Of the 62 women planning a pregnancy, 46 became pregnant and 32 gave birth to a healthy baby through a planned cesarean section. There were no cases of uterine rupture. During the study period (27 years), only 4 cases (3.5%) of relapses requiring repeated surgical treatment were recorded. In cases where the resection of uterine adenomyosis is performed without opening the uterine cavity, and the uterine wall is formed by a serous-muscular flap, the operation is called the double flap method [15].
Laparoscopic Surgery for Adenomyosis
In the first report on laparoscopic adenomyomectomy, the uterine defect after removal of adenomyosis was restored using the method of cross flaps [26]. A total of 14 patients with focal adenomyosis (up to 30mm in diameter) diagnosed with MRI performed resection of adenomyosis, which included transverse incisions in the uterus with a monopolar electrode. The flaps were superimposed on each other in an oblique direction to compensate for the lost muscle layer. If the uterine cavity is opened intraoperatively, then with such an operation it is closed by suturing. Pregnancy after surgery was achieved in 2 patients. By 2017, this method was completed by Kitade M, et al. [15] in 74 patients. 31 patients planned pregnancy, 13 (41.9%) pregnancy occurred: 4 miscarriages and 9 (29.0%) ended in live births. In this case, cases of uterine ruptures were not recorded.
Kodama, et al [27] reported 71 cases in which an adenomyomectomy was performed with good results. Of all the patients who underwent this operation, 32 (45.1%) planned a pregnancy; 16 women reached clinical pregnancy, including 3 (18.7%), miscarriage and 13 cases of live births (40.6%). One case of uterine rupture was also recorded.
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