technique of cytoreductive surgery in patients with myomas ... · transverse h incision step wise...
TRANSCRIPT
![Page 1: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/1.jpg)
Technique of Cytoreductive Surgery in Patients with Myomas and
AdenomyosisGeorge A Pistofidis
![Page 2: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/2.jpg)
Structure of presentation
• What is adenomyosis-definition & etiology• Myomas and adenomyosis• Is adenomyosis a single disorder?• How frequent & what age groups? • Best way to make the diagnosis• Laparoscopic technique for myomectomy• Laparoscopic technique for adenomyomatectomy• What are the dangers• Conclusions
![Page 3: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/3.jpg)
What is adenomyosis?
‘is the benign invasion of endometrium into themyometrium, producing a diffusely enlarged uterus
which microscopically exhibitsectopic, non-neoplastic endometrial glands and
stroma surrounded by hypertrophicand hyperplastic myometrium’
C Bird e al 1972 Am J O&G
![Page 4: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/4.jpg)
Etiology of adenomyosis
• 1) Invagination of endometrial glands into the myometrium
• 2) Embryonically misplaced tot potential Mullerianremnants
• 3) Endometrium invaginates and proceeds along the myometrial lymphatics
• 4) Misplaced bone marrow stem cells displaced through the vasculature
L Garcia & K Isaacson 2011 Min Inv Gynecol
![Page 5: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/5.jpg)
Is adenomyosis a single disorder?
![Page 6: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/6.jpg)
It seems that endometriosis and adenomyosis are first degree relatives
• Endometriosis and adenomyosis share some common aetio-pahogenic mechanisms (genetic, enviromental, immunological)
Apoptosis and bel-2 expression in normal human endometrium, endometriosis and adenomyosisRebecca K Jones et al 1998
Distribution o cycloxygenase-2 in eutopic and ectopic endometrium in endometriosis and adenomyosisHirotaka Ota et al 2001
Oestrogen receptor alpha genes polymorphism is associated with endometriosis, adenomyosis and leiomyomata
Jo Kitawaki et al 2001Association between genetic polymorphisms in fibroblast growth factor (FGF)1 and FGF2 and risk of
endometriosis and adenomyosis in chinese womenShan Kang et al 2010
Is adenomyosis ann immune disease?Hirotaka Ota et al 1998
![Page 7: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/7.jpg)
In some publications, adenomyosis is found with endometriosis…
• The prevalence of adenomyosis in 160 women with endometriosis was 79%
• And in women under the age of 34 with endometriosis 90%!
G Kunz, D Beil, P Huppert et al. Hum Reprod 2005
• There is a high correletion of endometriosis and adenomyosis in first degree relatives
• Possibly both are phenotypes of a single disorder rather than two distinct diseases
S Kennedy, R Hadfield et al. Lancet 1998
![Page 8: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/8.jpg)
Thus, adenomyosis similarly to endometriosis is a complex condition with multiple etiologies, and
variable clinical expressions
1 2
3 4
2
![Page 9: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/9.jpg)
Laparoscopic myomectomy
![Page 10: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/10.jpg)
Myomas, regardless of their position and size…
uterus
myoma
uterusmyomauterus
myoma
![Page 11: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/11.jpg)
…are surrounded by a clear anatomical plane, the pseudo-capsule
uterus
myoma
pseudo-capsule
uterus
![Page 12: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/12.jpg)
The vasculature is peripherally arranged around the myomatous pseudo-capsule
By Andrea Tinelli
![Page 13: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/13.jpg)
Myoma vasculature before and after vasopressin injection
before after
![Page 14: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/14.jpg)
On the other hand, adenomyosis has undefined planes
![Page 15: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/15.jpg)
Since T. Cullens classic definition of Adenomyosis 90 years ago, various terms have been coined to describe Adenomyosis.
But, there has not been a consensus classificationVarious terms proposed by various authors
• Adenomyoma-nodule & diffuse adenomyosis• Diffuse adenomyosis of the posterior or anterior
uterine wall • Focal lesions• Infiltrative lesions
Thomas Cullen 1920, Kaser O et al 1972, Novak ER & Woodruff JD 1979
![Page 16: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/16.jpg)
Over fourteen years we’ve observed repeatedly four distinct expressions of uterine adenomyosis
• Some occurred more frequently, others were noticeably uncommon
• However, these types were accompanied with specific symptomatology and occurred at different age groups
• We placed them in four groups based on our clinical observation, symptomatology, macroscopic appearance and histological findings
![Page 17: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/17.jpg)
Finally, we managed to publish our work in 2013, under the title
• Distinct types of uterine adenomyosis based on laparoscopic and histopathologic criteria
G Pistofidis, E Makrakis, O Koukoura et al 2013 ClinExp Obstet & Gyn
![Page 18: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/18.jpg)
37 (54.5%)9 (13%)
19 (28%)
3 (4.5%)
Adenomyosis
Diffuse
Sclerotic
Nodular
Cystic
Our classification system of uterine adenomyosis
![Page 19: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/19.jpg)
How frequent and what age groups?
![Page 20: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/20.jpg)
Age
Patient age distribution and adenomyosis types
Mean (yrs) St Dev (yrs) Range (yrs)
Total 41.2 6.7 [27 – 59]
Diffuse (orange) 44.4 6.0 [27 – 59]
Sclerotic (dark blue) 40.1 6.4 [30 – 47]
Nodular (yellow) 37.7 5.2 [27 – 45]
Cystic (light blue) 30.7 2.5 [28 – 33]
37 (54.5%)9 (13%)
19 (28%)
3 (4.5%)
Adenomyosis
Diffuse
Sclerotic
Nodular
Cystic
![Page 21: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/21.jpg)
Comparison of patients age between the 4 groups
• [ Diffuse ] vs [ Nodular ]Difference (yrs): 6.7 – P˂ 0.001
• [ Diffuse ] vs [ Cystic ]Difference (yrs): 13.7 – P= 0.001
• [ Sclerotic ] vs [ Nodular ] – NSS
• [ Diffuse ] vs [Sclerotic ] – NSS
• [ Sclerotic ] vs [ Cystic ] – NSS
• [ Diffuse ] vs [Cystic ] – NSS
![Page 22: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/22.jpg)
Symptoms in adenomyosis, endometriosis and fibroids patients
Indications for surgery – Pre-op Symtoms
9% 7%
34%40%
63%71%
0%
20%
40%
60%
80%
100%
Δx of Endometriosis
Infertility Δx of Fibroids Pelvic pain -Dysmenorrhoea -
Dyspareunia
Menorrhagia Dx ofAdenomyosis
Until 2013
![Page 23: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/23.jpg)
Adenomyosis is pretty uncommon compared to fibroids
508460
90.5%
367%
122.5%
0
100
200
300
400
500
600
Total No
Fibroids only
(D&S) Adenomyosis /Adenomyomas only
(D&S) Adenomyosis /Adenomyomas + Fibroids
Out of 508 women with uterine pathology, 36 (7%) had diagnosed adenomyosis
![Page 24: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/24.jpg)
Which diagnostic test?
![Page 25: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/25.jpg)
Terms used to define adenomyosis with Vaginal Ultrasound
• Heterogeneous myometrial area• Globular asymmetric uterus• Irregular cystic spaces• Myometrial linear striations• Poor definition of endometrial myometrial junction• Myometrial anterior posterior asymmetry• Thickening of anterior/posterior wall with
increased/decreased echogenicity
Sensitivity 0.79 and Specificity 0.85
![Page 26: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/26.jpg)
Terms used to define adenomyosis with MRI
• Diffuse or local widening of junctional zones (JZ)• JZ thickness of 15mm• Subjective thickening of JZ, localized or diffuse• Ill-defined low intensity lesion• JZ wider than 12mm• Uterine enlargement with small hypo-intense
myometrial spots
Sensitivity 74% and Specificity 91%
![Page 27: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/27.jpg)
Normal JZ thicknes 7-8 mm maximum up to 10mm
Adenomyotic minor focal lesion
Larger focal adenomyosis of Ant Ut wall
Diffuse adenomyosis
Kunz G et al Hum Reprod 2005 Various adenomyotic lesions as they appear on MRI
![Page 28: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/28.jpg)
Principles of laparoscopic myomectomy
![Page 29: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/29.jpg)
We separate fibroids into anterior or posterior depending whether they position in the front or
behind the red line
![Page 30: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/30.jpg)
Anterior myomectomy - transverse incision, suturing through the right port
![Page 31: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/31.jpg)
Posterior myomectmy – longitudinal incision, suturing through middle port
![Page 32: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/32.jpg)
Avoid excessive use of diathermy
![Page 33: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/33.jpg)
Always work within the pseudocapsule
![Page 34: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/34.jpg)
Posterior myomectomy-technique
![Page 35: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/35.jpg)
Adenomyosis surgeryAdenomyosis can resemble fibroids
![Page 36: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/36.jpg)
Schematic classificationFour types of uterine adenomyosis
Adenomyotic nodule
Sclerotic adenomyosis
Diffuse adenomyosis
Cystic adenomyosis
![Page 37: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/37.jpg)
Laparoscopic appearance of the four types• A) Adenomyotic nodule• B) Sclerotic myometrial adenomyosis• C) Diffuse adenomyosis• D) Adenomyotic cyst or cystic adenomyosis
A B C D
![Page 38: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/38.jpg)
A) Adenomyotic nodule, clinical appearanceAppearance on U/S spherical, well defined lesion in younger womenPresenting with exagerated dysmenorrhea, disproportionate for a myomaFrequently found in the cornual region or the round ligaments Resembling type III deep endometriotic lesion of the rectovaginalseptum
![Page 39: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/39.jpg)
Nodular adenomyoma
![Page 40: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/40.jpg)
B) Sclerotic myometrial adenomyosisFrequently presenting with endometriosisPresenting with subfertility, menorrhagia & cyclic painAppearance on u/s, irregular lesion with ill defined border and presence of endometriotic inclusion cystsOperatively irregular thickening of the myometrium with an off-white fibrotic appearance, firmly attached to the serosa and endometrium hard and difficult to grasp and suture
![Page 41: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/41.jpg)
Sclerotic adenomyosis
Intact lesion After lesion was excised
![Page 42: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/42.jpg)
Sclerotic adenomyosis
Excised fibrotic areas Final result, significant reduction of posterior uterine wall
![Page 43: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/43.jpg)
Sclerotic adenomyosis
![Page 44: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/44.jpg)
Surgery for sclerotic adenomyosis
![Page 45: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/45.jpg)
C) Adenomyotic cyst or cystic adenomyosistwo types: juvenille and adultType I - juvenile cystic adenomyoma (<20 years)Type II - adult cystic adenomyoma (>20 years)
Presenting in young women with severe dysmenorrhoeaAppearance on US, cystic appearance within the myometriumOperatively a distinct endometriotic cyst in the myometrium
![Page 46: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/46.jpg)
Adenomyotic cyst or cystic adenomyosis
![Page 47: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/47.jpg)
Iatrogenic cystic adenomyosis
![Page 48: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/48.jpg)
D) Diffuse adenomyosis
• Presenting mainly with menorrhagia more often in older age groups (>40)
• Appearance on vaginal U/S symmetric or more frequently asymmetric thickening of the uterine wall, inclusion cysts
• Operatively, uniformly thickening of the myometrium with a soft,spongiform texture of the uterus
![Page 49: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/49.jpg)
Other surgical methods
• Fujishita compared two adenomyomectomy techniques. The classic adenomyomectomy with a transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared with 0% of the older method.
A Fujishita et al 2004. Gynecol Obstet Invest
Takeuchi H et al 2006
![Page 50: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/50.jpg)
100% (3)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Diffuse
Sclerotic
Nodular
Cystic
Total
Adenomyomectomy Hysterectomy
Operative outcome in patients with adenomyosis
54.5% (37)
100% (19)
89% (8)
19% (7)
45.4% (31)
11% (1)
81% (30)
![Page 51: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/51.jpg)
Surgery for adenomyosis
• Nodular and cystic can has been removed in all cases laparoscopically
• In eight cases of sclerotic adenomyosis (89%) the major part of the lesion was resected. In some cases Complete Uterine Reconstruction Surgery was necessary (CURES)
• In only 7 (19%) cases of diffuse adenomyosis was cyto-reduction feasible.
![Page 52: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/52.jpg)
Italian multicenter study on complications of laparoscopic myomectomy
Sizzi O et al 2007 1998 -2004 four centres 2050 laparoscopic myomectomies Myoma size 1-20 cm
Complications in 38 (2.02 %) women 14 cases of haemorrhage (3 blood transfusion) 10 postoperative haematomas 1 bowel injury 1 postoperative kidney failure 2 unexpected sarcomas 7 converted to laparotomy 2 readmitted for surgery 1 laparoscopic hysterectomy 386 pregnancies, 1 case (0.26%) of ruptured uterus at 33 weeks ATTENTION! That one case had adenomyosis!
![Page 53: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/53.jpg)
Conclusions: Adenomyosis
• There is a strong association between adenomyosis , endometriosis and fibroids. • Sclerotic or focal adenomyosis can present a diagnostic dilemma as it resembles uterine
myomas• However, the majority of women with sclerotic lesions, in contrast with similar size myomas,
complain of dysmenorrhea and menorrhagia• Moreover, sclerotic adenomyosis lacks the peripheral vasculature and the pseudocapsule
seen on vaginal U/S• Nodular adenomyosis commonly occurs in the fundal uterine area near the R. ligaments• Further, nodular adenomyosis, in contrast with similar size small myomas, resembles deep
endometriotic nodules• When sclerotic lesion affects less than 50% of the uterine wall, and is circumscribed, resection
is possible (this is arbitrary)• Part, and not whole resection of adenomyotic lesion, should be avoided, especially in the
younger patient• Diffused adenomyosis is not surgically correctable• Prolonged down regulation is recommended in women with diffused lesion requesting
fertility
![Page 54: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/54.jpg)
Miss you all, have a great time and a great meeting
![Page 55: Technique of Cytoreductive Surgery in Patients with Myomas ... · transverse H incision step wise resection of abnormal tissue. The newer technique yielded 50% pregnancy rate compared](https://reader035.vdocuments.us/reader035/viewer/2022071007/5fc52ef91845aa682043ddff/html5/thumbnails/55.jpg)