Uterine-Sparing Surgery for Adenomyosis Prof. Aboubakr Elnashar

Uterine-Sparing Surgery for
Adenomyosis
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
5/7/2017ABOUBAKR ELNASHAR

Is there a role for
uterine sparing surgery in
diffuse adenomyosis
to improve fertility
? 5/7/2017ABOUBAKR ELNASHAR

Contents
I. Adenomyosis associated infertility
II. Uterine spraining surgery for adenomyosis
1.Types
2.Route
3.Steps; Video
4.Techniques
5.Indications
6.Complications
7.Outcome
1.Symptoms
2.Fertility
3.Pregnancy
8.Comparison with other tt
Conclusion 5/7/2017ABOUBAKR ELNASHAR

Adenomyosis and infertility
Strong association between adenomyosis and
fertility.
Infertile women should be evaluated for the
possibility of adenomyosis
[Vercellini et al, 2014 ].
Decreased CPR
Increased abortion rate

Adenomyosis and ICSI
(Vercellini et al, 2014; Benagianoet al, MA, 2015]
lower
implantation rate/ET
CPR
(RR 0.72, 95% CI 0.55e0.95)
LBR
(RR 0.70, 95% CI 0.56e0.87).
 higher
spontaneous abortion rate.
(RR 2.12, 95% CI 1.20e3.75)
{adenomyotic uterine environment}

Treatment of adenomyosis associated infertility
Highly controversial
No consensus
Extremely challenging
Multiple treatment modalities
1. Hormonal therapy with GnRha
(Lin et al, 2000)
Effect is often transient:
Rapid regrowth of adenomyosis
Relapse of S and S.

2. ART:
Two studies:
positive effect of prolonged down-regulation
on IVF outcomes
(Wang et 2009, Koo t al, 2011 )
Another study:
negative effect
(Fujishita et al, 2004).

3. Conservative surgical procedures:
(Nishida et al, 2010).
Increasingly used
More women delay their 1st pregnancy until 30
or 40 y
Feasible
Satisfactory
Fertility preservation
Quality-of-life improvement

III. Uterine-Sparing Surgery for Adenomyosis
1. Types

(Horng et al, 2014)

2. Route of surgery
For localized adenomyosis=Type I
The first series:
through laparotomy
[Fedele et al,1993; Tadjerouni et al, 1995 ]
Nowadays:
safely and effectively performed
laparoscopically.
(Huang et al, 2015)

For Diffuse adenomyosis= Type II
Best performed via laparotomy
{digital palpation of the uterus to:
identify affected areas
selective and piecemeal removal of lesions]

4. Techniques
Complete excision= Adenomyomectomy=Type I
1. Classic technique
(Hyams 1952; Grimbizis et al., 2008; Wang et al. 2009)/
plus intraoperative ultrasound guidance
(Nabeshima et al. 2003; Nabeshima et al. 2008)
2. U-shaped suturing
(Sun et al. 2011)
3. Overlapping flaps
(Tacheshi et al. 2006)
4. Triple flap method
(Osada et al. 2011)

Classic technique:
(a)Longitudinal incision along the adenomyoma. (b) Sharp and blunt dissection
with scissors, graspers and/or diathermy. (c) Suturing of the endometrial
cavity. (d) Suturing of the uterine wall.

overlapping flaps:
(a) Transverse incision. (b) The lesion is excised with monopolar needle. (c, d)
The remaining seromuscular layers are overlapped and sutured to counteract
the lost muscle layer of the uterus

Triple flap technique:
(a)Bisection of the uterus in
the midline and in the
sagittal plane
(b) Opening of the endometrial
cavity and excision of
adenomyotic tissues leaving a
myometrial thickness of 1 cm.
(c) Closure of the
endometrium.
(d) Closure of the flaps
approximating the
myometrium and serosa of the one
side of the bisected uterus in the
anteroposterior plane
(e) The contralateral side of
the uterine wall is brought over
the reconstructed first side in
such a way as to cover it.

Diagrammatic depiction of the stages of the triple-flap method.

II. Partial excision (cytoreductive surgery) Partial
adenomyomectomy = Type II
1. Classic technique
(Fujishita et al. 2004)
2. Transverse H incision
(Fujishita et al. 2004)
3. Wedge resection of the uterus
(Sun et al. 2011)
4. Asymmetric dissection of the uterus
(Nishida et al. 2010)

5. Indications
Desire for pregnancy.
IVF failures
Age ≤39 years.
{No benefit on fertility ≥40 y
(Kishi et al, 2014)
CPR:
41.3% in those aged ≤ 39 y
3.7% in those aged 40 y}
[odds ratio (OR) 0.77, 95% CI 0.67e0.88, p ¼ 0.002]

Decision should be taken carefully after
1. Extensive counseling
2. Consideration of alternatives
3. Low index of suspicion with uterine rupture in
women who conceive after uterine sparing
surgery
[Pepas et al, 2012 ].

Management of women with adenomyosis-
associated infertility
Tsui et al, 2015.
1.Routine infertility investigation plus ORT
Normal: long agonist protocol and natural
conception
Abnormal: IVF
2. Failed natural conception or IVF:
repeat IVF
3. Failed IVF:
conservative surgery
IVF after 3 m

6. Complications
I. Before pregnancy
1. Asherman syndrome
2. Uterine deformities
3. Reduced uterine capacity.
[Liu et al, 2014]
The incidence of these complications: unknown.

II. During pregnancy
1. Rapid growth of adenomyosis or adenomyoma in
pregnancy,
2. Spontaneous miscarriage
3. Preterm birth
4. IUGR
5. Preeclampsia
6. Obstetric hemorrhages
{defective remodeling of the spiral arteries during the
decidualization process: vascular resistance and
an increased risk of defective deep placentation}
[Vercellini et al, 2014].
7. Spontaneous rupture of an unscarred uterus during
pregnancy or labor
[Wang et al, 2000; Benagiano et al, 2015].

103 women: excision of diffuse adenomyosis
through laparotomy
 residual myometrial thickness was at least 0.5 cm
70 of whom wished to conceive
21 pregnancies: 16 reached term.
2 (9.5 %) cases of uterine rupture which
occurred at 32 and 37 w
Postoperative Asherman syndrome:
4 out of 103 (3.9 %) patients.
(Saremi et al.2014)

Causes of Uterine rupture
1. Poor healing of the uterine defect
2. Weakness of the uterine scar.
[Wang et al, 2009]
The defect contains adenomyotic foci.
Decidualization of residual adenomyotic
fragments: weakens the scar
[Ukita et al, 2011 ].
Inadequate repair
Decreased tensile strength of the uterus
[Takeuchi et al, 2006; Horng et al, 2013; Grimbizis et al 2014]

How to decrease uterine rupture
(Osada et al., 2011)
1. No intramural dead spaces
2. Preserve at least 1 cm of myometrial
thickness:
no uterine rupture among 14 women who
subsequently had a term delivery
Video

Fertility outcome
(Berlanda et al, 2016)
Type I

(Berlanda et al, 2016)
Type II

Pregnancy outcome
Type I:
Four-fifths had a successful delivery
Type II:
Two-thirds had a successful delivery
(Grimbizis et al 2014]

Mode of delivery:
Elective CS after Type I or Type II
(Grimbizis et al 2014].
Although a few case reports showed the possibility
of successful vaginal deliveries in women with
adenomyosis after conservative surgery, the majority
of cases were completed by cesarean section.

8. Comparison with GNRHa in management of
symptomatic women
Higher CPR in the surgical group
[Wang et al, 2009].
Conservative surgery or combination therapy provides more
effective and longer durable symptom control in the
management of symptomatic women with extensive
uterine adenomyosis, compared with GnRHa alone.
Reproductive performance was also better in patients treated
with conservative surgery with/without GnRHa

CONCLUSION
Uterine-sparing surgery of adenomyosis:
Feasible and effective.
Technically demanding, especially in cases of
diffuse disease
Women have to be extensively counseled about
the risk of uterine rupture in a future pregnancy.
Myometrial reconstruction has to be performed
meticulously
leaving at least 1 cm of myometrial thickness
no intramural dead spaces

Control of symptoms is achieved in
80% (dysmenorrhea control)
50% (menorrhagia control)
45% CPR
Results are difficult to compare between surgical
series but it seems that LBR after excision of
adenomyosis around 30 %.

ABOUBAKR ELNASHAR
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura
5/7/2017

Uterine-Sparing Surgery for Adenomyosis Prof. Aboubakr Elnashar

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