Role of Conservative Surgery in Adenomyosis

8/11/2019 Role of Conservative Surgery in Adenomyosis

1/34


2/34

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


3/34

A surgeon is someone who does everything and

knows nothing

Anonymous


4/34

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


5/34

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 inpatient younger than 39 yo

Garcia L, Isaacson KJournal of Minimally Invasive Gynecology, Vol 18, No 4, July/August 2011


6/34

It can be

focalIntroduction

Health

problems

related to

adenomyosis

Surgical

Management in

Adenomyosis

Whats the

current

evidence

Take Home

Messages

Or dIffuse


7/34

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


8/34

Not only gynecological symptoms

Taran FA, et al. Fertil Steril, 2010;94:12238


9/34

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 activity2. Altered endometrial function and receptivity

3. Impaired implantation

4. Altered decidualization


10/34

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

EndothelialDysfunction ?


11/34

Treatment OptionsIntroduction

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 KJournal of Minimally Invasive Gynecology, Vol 18, No 4, July/August 2011


12/34

Classification of Uterine-Sparing TechniquesIntroduction

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, 24:259264


13/34

Adenomyosis ResectionIntroduction

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 patientswishing to retain their uterus

Curr Opin Obstet Gynecol 2012, 24:259264


14/34

Difficulties in conservative managementIntroduction

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 alwaysaccompanied by excision of myometrium

3. High recurrence rate


15/34

Introduction

Health

problems

related to

adenomyosis

Surgical

Management inAdenomyosis

Whats the

current

evidence

Take Home

Messages

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


16/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages



17/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages



18/34

Introduction

Health

problems

related to

adenomyosis

Surgical


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 patientsRecurrence after

surgery

3 patients



19/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages


OSADAS TECHNIQUE



20/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages


OSADAS TECHNIQUE



21/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages



49%

32%

19%

Operative Management

Hysterectomy

Conservative

resection

Osada'stechique

Operative method Mean Age

Hysterectomy 45,52 + 3,612

Conservative resection 35,83 + 3,505

Osadastechnique 33,63 + 3,483


22/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages


One year follow up

82%

18%

0%

Pain

No Symptoms

Reduced Pain

Persistent

symptoms


23/34


24/34

Introduction

Health

problems

related to

adenomyosis

Surgical


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


25/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages


Fertility outome

Natural

conception

8 patients

IVF

2 patients

Elective CS

2 patients

Elective CS

2 patients

Ongoing

pregnancies

2 patients

Miscarriage

2 patients


26/34

Introduction

Health

problems

related to

adenomyosis

Surgical


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 refrainedfrom doing any meta-analysis due to

the study designs


27/34

Introduction

Health

problems

related to

adenomyosis

Surgical


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


28/34


29/34


30/34

Introduction

Health

problems

related to

adenomyosis

Surgical


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 %)


31/34

Introduction

Health

problems

related to

adenomyosis

Surgical


Whats the

current

evidence

Take Home

Messages

Laparotomy or Laparoscopy

Laparotomy has been used for the surgical treatment ofadenomyosis 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


32/34

Introduction

Health

problems

related to

adenomyosis

Surgical


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


33/34

TAKE HOME MESSAGESIntroduction

Health

problems

related to

adenomyosis

Surgical


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 inadenomyosis resection

3. The aim of surgery is maximize excision while

maintaining uterine wall integrity


34/34

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

Role of Conservative Surgery in Adenomyosis

Documents

Transcript of Role of Conservative Surgery in Adenomyosis