Organ-sparing surgery for adenomyosis

Adenomyosis, being one of the frequent diseases that cause uterine bleeding, algomenorrhea, infertility, serves as an indication for prolonged hormone therapy or hysterectomy [1-4]. The use of organ-preserving methods of surgical treatment for adenomyosis in order to preserve fertility and eliminate symptoms is an important modern aspect of therapy [5, 6].

A review of the medical literature showed that at least 2,300 adenomyomectomies have been performed since 1990, including 2,123 (89.8%) done in Japan. It was reported that 397 pregnancies occurred after organ-sparing operations. In 337 (84.89%) cases, pregnancies ended in childbirth, while 23 pregnancies were complicated by uterine ruptures [7].

Adenomyomectomy is an accepted method for the treatment of symptomatic adenomyosis in combination with uterine myoma, manifested as dysmenorrhea, menorrhagia and infertility. However, pregnant women after adenomyomectomy have a higher risk of spontaneous abortion, insolvency of uterine scar or spontaneous rupture of the uterus during pregnancy and childbirth, according to Ota Y. et. al [8]. Exposure to surgical energies during the operation on the uterus increases the risks of uterine rupture [9, 10]. Currently, various surgical treatments for adenomyosis are being tested.

The objective of the study is to analyze the results of organ-sparing treatment of women with adenomyosis.

Materials and Methods

Since 2003, we have performed 203 adeno­myomectomies in patients with initial uterus sizes from 9 to 22 weeks of gestation. We made a number of interventions using the novel technique: on one side the myometrial flap was rolled and stitched to the bottom of the formed niche, and the second flap completely covered the defect, repeatedly blocking it. Thus, at least 4–5 layers but not 1–2 layers of the myometrium were formed over the uterine cavity (Fig. 1). We performed more than half of all operations using this technique; a quickly absorbable synthetic material was used as a suture material for the inner layers.

If patients were diagnosed with anemia, they were preoperatively given ulipristal according to the standard scheme, namely 50 mg per day for at least 8 weeks until the hemoglobin level reached at least 100 g/L. In order to reduce intraoperative blood loss, the standard technique for distal hemostasis was used (applying a temporary tourniquet on the uterus isthmus and ovarian vessels), which allowed us to minimize blood loss and work on the “dry uterus”. This approach is extremely important, since even moderate bleeding makes it impossible to perform a thorough excision of the affected myometrium (Fig. 2).

In four patients with a large uterus (more than 20 weeks) and the inability to achieve temporary distal hemostasis due to the necessity of excision and the isthmus of the uterus, we used temporary ligation of the common iliac arteries with silicone vascular tourniquets for 12–15 minutes, which allowed us to excise large volumes of the myometrium without any blood. We also use this technique routinely in abnormal attachments of the placenta into the uterus to reduce blood loss in metroplasty (Fig. 3).

Results

The experience of performing these operations by laparotomy shows that there is no standard surgical technique; the choice of incisions and the technique for suturing the myometrium depend both on the size of the uterus and on the location of the affected myometrium, its symmetry and uniformity, as well as on the volume of the remaining healthy tissue and the defect form. In some cases, it is not possible to restore the integrity of the uterine wall in layers with the above-mentioned techniques due to the rigidity of the uterine walls (the remaining myometrium) after excision of adenomyosis. So, the surgeon performs “myometrial plastics with local tissues”.

The results of the operation are of particular interest in terms of eliminating the symptoms of the disease. Pain syndrome was completely reduced only in 15% of women, whereas the intensity of pain within three months after surgery significantly decreased from 8.2 ± 2.4 points to 3.2 ± 2.2 (p <0.001). Such dynamics was observed in 74% of women, and only in 11% of cases the operation did not lead to a decrease in the severity of pain syndrome (p <0.001). In turn, the assessment of postoperative changes in the volume of menstrual blood loss is often extremely complex and biased. The administration of combined oral contraceptives and other hormonal drugs may influence an adequate assessment of changes in the menstrual cycle. However, we consider the criterion for the elimination of anemia, which was observed before the operation, to be an adequate comprehensive positive result of the operation in term of assessing the quality of patients’ lives for more than 6 months after the operation. The indication for adenomyomectomy was ineffectiveness of hormone therapy in the elimination of anemia. During the observation period up to 12 months after the intervention, we observed normalization of hemoglobin level in 84% of cases in the absence of pregnancy, and we did not reveal any patterns associated with taking certain hormone-containing drugs (p> 0.05).

Of the 203 surgeries, we performed 82 operations to restore fertility, while the total number of pregnancies occurred was 39 (47.6% or 19.2% of the total number of interventions). In other cases, the purpose of the operation was to normalize the volume of menstrual blood loss and eliminate the pain syndrome (if the proposed hysterectomy was abandoned). Reproductive outcomes were as follows: 8 cases of spontaneous abortion for the period up to 22 weeks gestation; 26 cases of childbirth, 11 of them were premature (20.5%, 66.7% and 28.2%, respectively). Thus, the total share of “successful pregnancies” was 31.7% of those aimed at birth. Only two pregnancies occurred spontaneously, all the rest resulted from assisted reproductive technologies. Multiple pregnancies (four cases) accounted for 10.2% of the total number of pregnancies that occurred. It should be noted that according to the authors, the average frequency of spontaneous abortion varies from 12 to 44%, averaging 24.5% [11, 12]; the average frequency of pregnancies of the total number of adenomyomectomies performed by 2018 was 18.9%.

In spite of the fact that in the hospital discharge report we strongly recommended the patients operative delivery after adenomyomectomy, one woman informed us about the spontaneous vaginal birth of full-term twins. The obstetric profile of pregnancies was complicated by the tight attachment of the placenta in three cases and in one case by the growth of the placenta into the scar in the fundus of the uterus (Fig. 4). The patient was performed operative delivery in the maternity hospital number 9 in St. Petersburg; cesarean section in the lower segment was done, the patient had metroplasty with excision of the myometrium and placenta percreta.

The reproductive results of such operations indicate their similarity with multiple myomectomy in transmural localization of the nodes [13], and the postoperative management tactics, obstetric approaches and risks are the same.

Conclusion

The control of bleeding and elimination of anemia in 84% of cases, and a significant reduction of pain in 74% of the operated patients, allow us to draw conclusions about improving the quality of life of patients with adenomyosis after adenomyomectomy.