Role of Conservative Surgical Treatment

in Adenomyosis


Achmad Kemal Harzif


Department of Obstetrics and Gynecology
Faculty of Medicine Universitas Indonesia
Jakarta Indonesia


Outline

Introduction
Health problems related to adenomyosis
Surgical Management in Adenomyosis
Whats the current evidence
Take Home Messages


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




A surgeon is someone who does everything and
knows nothing

Anonymous


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Adenomyosis is defined by the presence of islands of
ectopic endometrial tissue within myometrium


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




EPIDEMIOLOGY
Prevalence reported to range from 5-70%
Adenomyosis at hysterectomy is approximately
20-30%
Five to 25% of adenomyosis are observed in
patient younger than 39 yo
Garcia L, Isaacson K
Journal of Minimally Invasive Gynecology, Vol 18, No 4, July/August 2011
It can be
focal


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Or dIffuse


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Symptoms of Adenomyosis
Symptoms N (%)
Dysmenorrhea 34 (69,39%)
Pelvic pain 7 (14,29%)
Dysmenorrhea and dyspareunia 4 (8,16%)
Dysmenorrhea and pelvic pain 3 (6,12%)
Abnormal uterine bleeding 1 (2,04%)
Legiantuko A, Wiweko B. Presented at Annual POGI meeting 2013
Not only gynecological symptoms
Taran FA, et al. Fertil Steril, 2010;94:12238


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Reproductive BioMedicine Online (2012) 24, 3546
Factors that may contribute
1. Altered uterine peristaltic activity
2. Altered endometrial function and receptivity
3. Impaired implantation
4. Altered decidualization




Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Placenta 34 (2013) 100-105
Adenomyosis
Endometriosis
Miscarriage Preterm birth
PPROM IUGR Preeclampsia
Progesterone
resistance
Defective deep
decidualization
Vascular resistance in JZ
Defective trophoblastic
invasion
Thickened
JZ
Endothelial
Dysfunction ?
Treatment Options


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




1. Definitive treatment : Hysterectomy
2. Medical treatment
Combined oral contraceptive
Progestins
LNG-IUS
GnRH agonist
3. Conservative surgery

Garcia L, Isaacson K
Journal of Minimally Invasive Gynecology, Vol 18, No 4, July/August 2011
Classification of Uterine-Sparing Techniques


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




1. Complete excision
2. Partial excision
3. Non excisional technique (high frequency
ultrasound, radiofrequency, artery
occlusion

Curr Opin Obstet Gynecol 2012, 24:259 264
Adenomyosis Resection


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Refers to the surgical excision of myometrial
tissue affected with adenomyosis in patients
wishing to retain their uterus

Curr Opin Obstet Gynecol 2012, 24:259 264
Difficulties in conservative management


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Grimbizis G, et al. Fertil Steril 2013, Article in Press
1. Complete excision of lesion remains
inaccurate
2. Excision of adenomyotic tissue is always
accompanied by excision of myometrium
3. High recurrence rate


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Nishida M, et al. Fertil Steril 2010;94:7159


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Nishida M, et al. Fertil Steril 2010;94:7159


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Reproductive BioMedicine Online (2011) 22, 9499


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




RESULTS OF CONSERVATIVE SURGERY IN ADENOMYOSIS
NISHIDAS TECHNIQUE
n = 44
Mean operative time 159 + 43,7 minutes
Mean blood loss 745 + 56 ml
Preoperative VAS 9,4 + 1,0
Postoperative VAS 0,8 + 1,0
Pregnancy 2 patients
Recurrence after
surgery
3 patients
Nishida M, et al. Fertil Steril 2010;94:7159


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




RESULTS OF CONSERVATIVE SURGERY IN ADENOMYOSIS
OSADAS TECHNIQUE
Reproductive BioMedicine Online (2011) 22, 9499


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




RESULTS OF CONSERVATIVE SURGERY IN ADENOMYOSIS
OSADAS TECHNIQUE
Reproductive BioMedicine Online (2011) 22, 9499


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




RESULTS OF CONSERVATIVE SURGERY IN ADENOMYOSIS
Legiantuko A, Wiweko B. Presented at Annual POGI meeting 2013
49%
32%
19%
Operative Management
Hysterectomy
Conservative
resection
Osada's
techique
Operative method Mean Age
Hysterectomy 45,52 + 3,612
Conservative resection 35,83 + 3,505
Osadas technique 33,63 + 3,483


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages



Legiantuko A, Wiweko B. Presented at Annual POGI meeting 2013
One year follow up
82%
18%
0%
Pain
No Symptoms
Reduced Pain
Persistent
symptoms


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Mrs I, 35 years old

Osada adenomyosis resection in 2010
By c-section born 2770 gram baby boy AS 9/10


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages



Legiantuko A, Wiweko B. Presented at Annual POGI meeting 2013
Fertility outome
Natural
conception
8 patients
IVF
2 patients
Elective CS
2 patients
Elective CS
2 patients
Ongoing
pregnancies
2 patients
Miscarriage
2 patients


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Human Reproduction Update, Vol.18, No.4 pp. 374392, 2012
No randomized controlled trials were found
We have refrained from doing any meta-analysis due to
the study designs


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Fertil Steril 2013, Article in Press
Systematic literature review
64 studies dealing with 1,049 patients were
identified

Conservative uterine-sparing surgery for
adenomyosis classified as
(1) complete excision of adenomyosis,
(2) incomplete removal of the lesion
(3) nonexcisional techniques




Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




FERTILTIY OUTCOME
Wish to concieve
182 patients
Total conception
107 patients
(58,79 %)
Full term
deliveries
79 patients
(73,83 %)
Preterm
7 patients
(6,54 %)
Ongoing
2 patients
(1,87 %)
90 patients natural
17 patients IVF
Miscarriage 19 patients (17,76 %)


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Laparotomy or Laparoscopy
Laparotomy has been used for the surgical treatment of
adenomyosis because of the extension of the disease
within the myometrium and the difficulty in suturing the
remaining uterine wedges after the excision.

Adenomyotic foci or for excision of adenomyomas
Laparoscopy ?


Grimbizis G, et al. Fertil Steril 2013, Article in Press


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




Fertil Steril 2013, Article in Press
Which technique is better ?

There is no strong evidence to indicate a
technique that secures the best clinical and
reproductive performance

Important aim of surgery
maximize the amount of adenomyosis excised
empower the uterine wall integrity so that a
future pregnancy can be sustained




TAKE HOME MESSAGES


Introduction


Health
problems
related to
adenomyosis


Surgical
Management in
Adenomyosis


Whats the
current
evidence


Take Home
Messages




1. Conservative surgery is an option for
adenomyosis in which preservation of uterus is
still needed
2. No technique proven to be superior in
adenomyosis resection
3. The aim of surgery is maximize excision while
maintaining uterine wall integrity

Indonesian Reproductive Medicine
Research and Training Center (INA REPROMED)
Ali Baziad, Andon Hestiantoro, Muharam Natadisastra, Kanadi Sumapraja,
Gita Pratama, Herbert Situmorang Eliza Mansyur, Tita Yuningsih, Dyah Pitha, Siti Mariam, Endang Kurdiningsih,
M Priangga, Valencia Yuwono, Nadia Safira
Acknowledgement