Surgical Tutorial 2: Complicated Endometriosis - aagl.org · STRANGE DISEASE CALLED ADENOMYOSIS:...

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Surgical Tutorial 2: Complicated Endometriosis

PROGRAM CHAIR

Antonio Setubal, MD

Leila V. Adamyan, MDJa Hyun Shin, MD, MS

Horace Roman, MD, PhDErrico Zupi, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 A Strange Disease Called Adenomyosis: Diagnosis and Management L.V. Adamyan ................................................................................................................................................ 3 Adenomyosis: Impact on Sub‐Fertility E. Zupi ........................................................................................................................................................... 7 Rare Cases of Endometriosis J.H. Shin ...................................................................................................................................................... 16 Conservative Surgery in Advanced Deep Endometriosis of Mid and Low Rectum: Feasibility and Advantages H. Roman .................................................................................................................................................... 21 Cultural and Linguistics Competency ......................................................................................................... 24

Surgical Tutorial 2: Complicated Endometriosis

Antonio Setubal, Chair

Faculty: Leila V. Adamyan, Horace Roman, Ja Hyun Shin, Errico Zupi This session provides a discussion on complicated endometrisis, including recto-‐vaginal and rare cases of the disease. A special focus on Adenomyosis and the impact on sub-‐fertility will be presented. Quality of life related to the treatment of endometriosis is another important issue that will be discussed. Finally, the need for protective stoma on deep endometriosis surgery will be presented. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Explain the best approach to treating complicated endometriosis.

Course Outline 12:05 Welcome, Introductions and Course Overview A. Setubal

12:10 A Strange Disease Called Adenomyosis: Diagnosis and Management L.V. Adamyan

12:20 Adenomyosis: Impact on Sub-‐Fertility E. Zupi

12:30 Rare Cases of Endometriosis J.H. Shin

12:40 Conservative Surgery in Advanced Deep Endometriosis of Mid and Low Rectum: Feasibility and Advantages H. Roman

12:50 Questions & Answers All Faculty

1:05 Adjourn

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Leila V. Adamyan* Horace Roman Consultant: IPSEN, Plasma Surgical Speakers Bureau: Nordic Pharma Antonio Setubal* Ja Hyun Shin* Errico Zupi* Asterisk (*) denotes no financial relationships to disclose.

2

STRANGE DISEASE CALLED ADENOMYOSIS:

DIAGNOSIS AND MANAGMENT

Leila V. AdamyanProfessor, Academician of RAS

Russian Scientific Center for Obstetrics, Gynecology and PerinatologyMoscow, Russia

I have no financial relationships to disclose

• Discuss the diagnosis and management of adenomyosis

Adenomyosis is a common condition among women of reproductive age.

Management with hormonal treatment that aims to reduce the proliferation of endometrial cells is promising, but there is a paucity of welldesigned studies to guide treatment. Hysterectomy or use of the levonorgestrel intrauterine system (LNG‐IUS) remains the mainstay of treatment.

The common presenting symptoms are: painful and heavy periods, infertility, many women are asymptomatic

The aetiology is unclear, and until recently a diagnosis was made only after invasive and destructive surgery

It is defined as the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia.

With the advent of improved imaging of the pelvic organs, and in particular MRI, the diagnosis of adenomyosis is being made more frequently.

Unfortunately, because the disease has been infrequently diagnosed prior to hysterectomy, there are few well‐designed studies of medical or surgical management

56341

HysteroscopyHysteroscopy

LaparoscopyLaparoscopy

LaparotomyLaparotomy

Vaginal approachVaginal approach

3990 op – endometriotic cyst

2640 op – external genital endometriosis & adenomyosis

242 – endometriotic cyst rupture in adolescents 6‐7% malformations

92 nodule adenomyosis

1370 op – retrocervical endometriosis

II st - 750 III st - 370 IV st - 250

75% of patients with privies surgery

35‐40% of patients with combined forms (external+adenomyosis+cyst)

1‐2% of patients with genital malformations

Scientific Center+University

Hospitals #15 & #50Adolescent department

Adenomyosis

Classification and staging-based strategies

Stage I – endometriotic lesions are within submucouse layer

Stage III – involvement of entire myometrium up to serosa

Stage IV – involvement of pelvic peritoneum and adjacent organs

Stage II – endometriotic lesions penetrate into myometrium

Adenomyosis may be diffuse or focal (nodular or cystic) Crucial difference from myoma is absence of distinct borders of the lesion. Adamyan L., 1993

3

vaginal endometriosis

cervical endometriosis

vaginal endometriosis

cervical endometriosis

Increase of uterus size

Thickening or deformation of uterus wall

«Marble» serosa

Increase of uterus size

Thickening or deformation of uterus wall

«Marble» serosa

AdenomyosisAdenomyosisLaparoscopyLaparoscopy

Genital endometriosisGenital endometriosis

Endometriosis of ovaries

More than 20 forms of peritoneal lesions

Deep infiltrative forms

Combined forms

Endometriosis of ovaries

More than 20 forms of peritoneal lesions

Deep infiltrative forms

Combined forms

ColposcopyColposcopy Hysterospopy (adenomyosis)Hysterospopy (adenomyosis)

Additional methods of visualization: US, MRI, SCTAdditional methods of visualization: US, MRI, SCT

Final diagnostics – hystological investigation!!!Final diagnostics – hystological investigation!!!

Extrusion of wall

Visualisation of endometrioid holes

Complicated dilation of uterus cavity

Extrusion of wall

Visualisation of endometrioid holes

Complicated dilation of uterus cavity

Diagnostics – identification of anatomo-morphologic formDiagnostics – identification of anatomo-morphologic form

Modern diagnosis of adenomyosis

USI – 2D/ 3D/4DMRI

Hysteroscopy

1

23

4

3 32

3

1

Enlarged uterus with asymmetric walls (1), poordifferentiation of the uterine walls layers (2); tubularstructures in myometrium (3), local thickening oftransitional‐connective zone (over half of uterine wallthickness) (4).

Adenomyosis II-III stage

4

52

1

3

1

3

2

14Adenomyosis IV stage

Endometriotic lesions involving peritoneum (1),thickening of transitional‐connective zone (2);endometriotic lesions in myometrium(3), right ovary withfollicular cyst is adherent to posterior uterine wall (4).

Adenomyosis – nodule and diffuse form

MR-image of adenomyosis

Adenomyosis treatment strategyAdenomyosis treatment strategy

Medical treatment (danazol, a-GnRH, levonorgestrel-IUS), if ineffective – surgeryMedical treatment (danazol, a-GnRH, levonorgestrel-IUS), if ineffective – surgery

Uterus preserving surgery in patients willing to have pregnancy is possible in nodular form of the disease –but both the doctor and the patient should be aware of high risk of recurrence

Uterus preserving surgery in patients willing to have pregnancy is possible in nodular form of the disease –but both the doctor and the patient should be aware of high risk of recurrence

Excision or FUS-ablation- Hysterectomy is the only radical treatment- Laparoscopy is used for removal of nodular of cyst forms- Hysteroscopic resection of endometrium and myometrium for

excision because of bleedings is possible with LNG-IUS insertion thereafter

Excision or FUS-ablation- Hysterectomy is the only radical treatment- Laparoscopy is used for removal of nodular of cyst forms- Hysteroscopic resection of endometrium and myometrium for

excision because of bleedings is possible with LNG-IUS insertion thereafter

Rehabilitation with different antirecurrency treatmentRehabilitation with different antirecurrency treatment

Spontaneous pregnancy or ARTSpontaneous pregnancy or ART

Alternative technologiesUAE, FUS-ablation

a‐GnRH COCNSAD

Dienogest???Ulipristal acetate?!

S. Gordts, R. Campo, I. Brosens Hysteroscopic diagnosis and excision of myometrial cystic adenomyosis Gynecol Surg (2014)

CAMPO Compact Hysteroscope TROPHYSCOPE®

Introduction of compact hysteroscopes

Operative hysteroscopy and hysteroresectoscopy in the treatment of adenomyosis

Exision of cystic adenomyosis under US‐control

Classification of cystic adenomiosis based on hysteroscopic findings (MUSCLE)

Uterine Cystic Adenomyosis: A Disease of Younger WomenIvo Brosens, Stephan Gordts et al Pediatr Adolesc Gynecol, 2014

Type I complete and total eradication of

adenomyosis

The technique includes the following : 1. careful and thorough recognition of the adenomyotic foci and their borders by inspection and/or

palpation (possible only in exploratory laparotomy); 2. longitudinal incision of the uterine wall along the lesion; 3. sharp and delicate dissection of the adenomyoma from the surrounding relatively healthy

myometrium tissue using diathermy (the bipolar coagulator system is preferred or scissor or knife, and preservation of maximal residual serosa or serosa‐muscular layer;

4. closure and reconstruction of the uterine cavity using 4‐0 absorbable suture if the uterine cavity was opened;

5. closure of the uterine wall with 1‐0 absorbable sutures layer by layer; 6. closure of the serosa layers with 4‐0 or 5‐0 absorbable sutures

Laparoscopic adenomyomectomy has been successfully performed by some groups with excellent outcomes. Laparoscopy is feasible either for ablation of the adenomyotic foci or for

excision of adenomyomas, and laparoscopic suturing presents no more difficulty than suturing alone after myomectomy.

Grimbizis et al Uterus‐sparing operative treatment for adenomyosis. Fertil Steril 2014;101:472Laparoscopic resection of cystic adenomyosis in a teenager with arcurate uterusElizabeth Ball et al Gynecol Surg (2009)

Two types of surgery for adenomyosis

• Barbed sutures• Antiadhesive materials• Hemostatic sponge/Surgicel

4

The main components of the three interconnecting “H” incision are:1. a vertical incision with a 5‐mm resection of the uterine serosae‐myometrium layer and two transverse

incisions perpendicular to the vertical incision along the upper and lower edges of the uterus 2. removal of slices of adenomyotic tissue by serial resection; 3. performing repeated chromopertubation tests by injecting indigo carmine solution during the

operation to minimize the risk of entering the uterine cavity; 4. avoiding tension to the sutured tissue closing the defect to minimize the risk of hematoma; 5. preferred use of antiadhesive material

Type II - cytoreductive surgery of adenomyosis.

Hisao Osada et al Surgical procedure to conserve the uterus for future pregnancy inpatients suffering from massive adenomyosisReproductive BioMedicine Online (2011)

Nishida et al Conservative surgery for adenomyosis. Fertil Steril 2010.

• The laparoscopic approach might be possible, although laparotomy is much more feasible that the surgeon can palpate and recognize the adenomyotic lesions intraoperatively.

• There is no doubt that the technique might be more complicated because the disease hasinvaded the myometrium, and suturing the remaining uterine wedges after resection is difficult .

• Use of intracorporeal absorbable barbed suture

A. Saremi t al Treatment of adenomyomectomy in women with severe uterine adenomyosis using a novel technique Reproductive BioMedicine Online (2014)

Different modifications of type II surgery

• The effectiveness of conservative uterine‐sparing surgery for adenomyosisand/or adenomyoma is promising

• The main problem secondary to uterine adenomyosis is dysmenorrhea, which can be improved significantly, up to 80%.

• Menorrhagiawas also improved in more than two‐thirds of patients after type I uterine‐sparing surgery, and nearly half of the patients had improvement in their symptoms after type II uterine‐sparing procedures.

• The pregnancy rate was also acceptable or good, ranging from 21‐47‐61 %.

Therapeutic effects of surgery

Because of the limited amount of data available, the use of uterine-sparing surgery in the management of uterine adenomyosis and/or adenomyoma is still controversial.

Fabiana F. et al Effectiveness of Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) in the uterine adenomyosis treatment: technical approach and MRI evaluation Radiol med2015

Decrease of uterine volume on 13%

Ultrasound-guided high intensity focused ultrasound

Ultrasound-guided high intensity focused ultrasound for the treatment of gynaecological diseases: A review of safety and efficacy Lian Zhang et al, International Journal of Hyperthermia 2015

Retrospective analysis of ultrasound‐guided high intensity focused ultrasound (USgHIFU) for the treatment of adenomyosis: 2549 patients sufficient relieve of symptons

MRI-FUS ablation in the treatment of adenomyosis

Alternative methods of adenomyosistreatment

92 patients with adenomyosis were enrolled in the study. Average age was of 33,5 ± 2,6 years

• Laparoscopic excision of adenomyotic lesion with subsequent hormonal therapy with GnRH agonists was performed in all patiеnts. All underwent a careful excision of the adenomyosis tissue without damage to the uterine cavity*.

• Mean visual analog scale score of dysmenorrhea and menorrhagia after a 3‐month follow‐up was measured.

• After surgery, the mean visual analog scale score of dysmenorrhea decreased from 9.4 to 0.8, and anemia due to menorrhagia improved in all women.

• 76 women conceived spontaneously or after ART at 12‐18 months after surgery, the pregnancies were uneventful, and healthy infants were delivered via cesarean section at term. In 10 patients pregnancy loss occurred.

• Our data support the opinion of the beneficial role of the combination of cytoreductive surgery and GnRH agonist treatment in managing infertile women with adenomyosis.

• Laparoscopic cytoreductive surgery can be an alternative treatment to the use of hypoestrogenic agents or hysterectomy in women with localized adenomyosis, especially for those who want to maintain their fertility and achieve successful pregnancies.

OUR EXPERIENCE

Perspectives • FUS‐ablation • Antiapoptotic drugs

• Destructive surgery

• Ulipristal acetate???

Crio‐Radiofriquency

Preliminary results (7 patients)

for nodule adenomyosis

Insert Video

5

• Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing operative treatment for adenomyosis. Fertil Steril 2014; 101:

• Smeets A. J. et al. Cardiovasc Intervent Radiol (2012) 35:815–819

• Gordts S. , Campo R. , Brosens I. Hysteroscopic diagnosis and excision of myometrial cystic adenomyosisGynecol Surg (2014)

• Brosens I., Gordts S. et al Uterine Cystic Adenomyosis: A Disease of Younger Women Pediatr Adolesc Gynecol, 2014

• Hisao Osada et al Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis Reproductive BioMedicine Online (2011)

• Nishida et al Conservative surgery for adenomyosis. Fertil Steril 2010.

• Fabiana F. et al Effectiveness of Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) in the uterine adenomyosis treatment: technical approach and MRI evaluation Radiol med 2015

• Lian Zhang et al Ultrasound-guided high intensity focused ultrasound for the treatment of gynaecological diseases: A review of safety and efficacy, International Journal of Hyperthermia 2015

• Adamyan L. Additional internatinal perspectives/ in Nichols D.H. ed Genecologic and Obstetric Surgery, 1993, 1167-1182

XXIX International Congress New Technologies for Diagnosis and Treatment of Gynecologic Diseases June 2016, Moscow, Russia

X International Congress on Reproductive Medicine19‐22 January 2016, Moscow, Russia

6

Adenomyosis: Impact on Sub-Fertility

Errico Zupi

University of Tor Vergata Rome

Disclosure

I have no financial relationships to disclose.

Objective

Discuss adenomyosis and the impact on

Sub‐Fertility

endometriomadeep

endometriosis

Endometriosis

Similar pathogenesis

Different clinical management

peritonealendometriosis

Different symptoms

adenomyosis

Endometriosis represents: 15-20% of causes of women infertility

30-35% of women with endometriosis is infertile 25-40% of infertile women have endometriosis

Halis G, Arici A; Ann N Y Acad Sci. 2004

Endometriosis and infertility

Women with stage III-IV

the monthly probability to conceive is

2-10% vs 15-25% in “healthy” couples

Halis G, Arici A; Ann N Y Acad Sci. 2004

ESHRE guidelines 2007

Women with stage I-II

pregnancy rates increase after

ablation of endometriotic lesionsendometrioma

deependometriosis

Endometriosis

peritonealendometriosis adenomyosis

7

Destruction of germinal epithelium, abnormal rates of follicular development and premature follicular rupture with asynchrony of oocyte maturation

Doody MC et al, Fertil Steril 1988

Haney AF et al, JCEM 1996

Anovulation may occur in 15-25% of patients with endometriosis

Ovarian endometriomas occur in 17– 44% of patients with endometriosis

Redwine DB et al, Fertil Steril 1999

Increased tissue oxidative stress inducing oocyte apoptosis and necrosis

Inflammatory reaction and fibrosis in surrounding normal ovarian cortex

Donnez J. et al, Fertil Steril 2011

Donnez J. et al, Fertil Steril 2011

Endometrioma and infertility

.

. Donnez J. et al, Fertil Steril, 2011

The follicular density in cortex from ovaries with endometriomasless than 4 cm in size is significantly lower than in cortex from

contralateral normal ovaries

Histologic alterations in cortical tissue, such as formation of fibrosis and concomitant loss of cortex-specific stroma, were found to significantly correlate

with follicular density in cortex from ovaries with endometriomas

Endometrioma and ovarian reserve

Surgical treatment of endometrioma-associated infertility

The problem of co-existing endometriomas in a context of infertility raises two main questions:

1. Is there a conservative laparoscopic procedure that offersbetter fertility outcomes?

2. Should we, or should we not, operate on endometriomas inpatients scheduled for ART?

Chapron C. et al. Hum Reprod Update, 2002

Laparoscopic cystectomy for ovarian endometriomas is better than drainage and ablation

Muzii et al, Hum Reprod 2005

Consistent amount of ovarian tissue containing follicles is unintentionally removed during cystectomy

Cystectomy results in a lower recurrence rate (6.4%), higher cumulative pregnancy rate and greater pain relief than ablation (18.4%)

Bipolar coagulation at bleeding sites close to ovarian hilusleads to destruction of the ovarian blood supply

Muzii L. et al, Hum Reprod 2005

Vercellini P. et al, Am J Obstet Gynecol 2003

Donnez J. et al, Best Pract & Res Clin Obst Gyn, 2004Hart et al. Cochrane Database Syst Rev 2008

1. Is there a conservative laparoscopic procedure that offers better fertility outcomes?

The post-operative serum AMH levels significantlydecreased in comparison to the preoperative levels

in patients with endometriomas

Hwu et al, Reprod Biol Endocr, 2011


Bilateral/unilateral localization

rASRM score

Age

Hirokawa W. et al, Hum Reprod, 2011

Hwu et al, Reprod Biol Endocr, 2011


Decresing AMH after surgery are influenced by:

Surgical tecnique

8

no significant change in the

mean AFC was observed after

surgery

Hum Rep 2014 Hum Rep 2014

non-excisional techniques appeared not to affect AFC values after surgery

affected ovary, either with the endometrioma present before surgery, or after surgical excision, showed reduced AFC compared with the contralateral ovary supporting the hypothesis of damage to the ovarian tissue that is

already present before surgery, and therefore due to the disease itself, and not to the surgical procedure

Hum Rep 2014 Muzii et al 2014

Comparison between the Stripping Technique and the Combined Excisional/Ablative Technique for the Treatment of Bilateral Ovarian

Endometriomas: A Multicentric, Randomized Study

36 patients of reproductive age with pelvic pain and/or infertility affected by bilateral endometriomas larger than 3 cm

complete removal by stripping on one side versus the combined technique, consisting of partial excisional cystectomy followed by ablative surgery with bipolar coagulation of the final part on the

hilus, on the other side

Ovarian volume and AFC 1/3/6 months after surgery

Muzii et al 2014

Comparison between the Stripping Technique and the Combined Excisional/Ablative Technique for the Treatment of Bilateral Ovarian

Endometriomas: A Multicentric, Randomized Study

10.2±5.6 for the stripping technique versus

7.5±4.2 for the combined technique

The stripping technique and the combined technique for the treatment of endometriomas appear to be similar in terms of

postoperative ovarian reserve.

Ovarian volume AFC

3.9±1.9 for the stripping technique versus

4.4±2.3 for the combined technique

the differences were not significantly different also at 3 and 6 months

Expectant Surgery

The impact of ovarian endometriomas onassisted reproductive technology (ART) outcomes is controversial

The management of an asymptomatic ovarian endometrioma in a woman with infertility is controversial

2. Should we, or should we not, operate on endometriomas in patients scheduled for ART?

9

Garcia-Velasco JA. et al. Fertil Steril, 2004Garcia-Velasco JA. et al. Curr Opin Obstet Gynecol. 2012

Laparoscopic cystectomy for ovarian endometriosis does not offer any additional benefit in terms of fertility outcomes

1. The quality of the oocytes retrieved in IVF cycles is not improved after surgery

2. Patients going through an operative procedure might extend the time to pregnancy


In vitro fertilization outcomes were similar in women undergone to cystectomy compared with women with tubal

factor infertility

No reduction in the number of oocytes retrieved and embryos obtained are observed after cystectomy

Donnez J. et al. Fertil Steril, 2001

Canis M. et al. Hum Reprod, 2001

Careful laparoscopic surgery in experienced hands does not impair ovarian function in women committed to ART treatment


Falcone T. et al. Semin Reprod Med, 2011

Outcomes from ART were not affected by the time interval between surgery and ART

Falcone T. et al. J Reprod Med, 2008

After surgery, couples must attempt to conceive naturally for at least 1 year, in women

younger than 35 years

De Ziegler D. et al, Lancet 2010

If this attempt fails, it is recommended to go directly to ART


De Ziegler D. et al, Lancet 2010


Medical treatment with 3–6 months of gonadotropin-releasinghormone analogues improves the outcome of ART

in women with endometriosis

Ovarian suppression before ART augments outcome by correction of endometrial alterations encountered in

endometriosis, thus, amplifying endometrial receptivity

Results from large randomized trials are needed to elucidatewhether or not ovarian endometriomas should be treated

before undergoing an IVF–ICSI cycle and which treatment is more suitable

Somigliana E. et al. Hum Reprod Update, 2006


Expectant Surgery

There are strong indications to surgical removal of the ovarianendometrioma, particularly in case of associated pain or infertility

The best available evidence recommends complete excison of the cyst (stripping) as opposed to alternative techniques

Good surgical technique is pivotal to reduce the damage to the healthy ovarian tissue

The damage may be due to the disease itself, to the surgery, or to the surgeon himself: it may be the singer, not only the song…

J Minim Invasive Gynecol. 2011

10

Somigliana E. et al. Hum Reprod Update, 2006

1. Risk of pelvic abscess and cyst rupture

2. Risk of occult malignancy3. Retrieval difficulties4. Contamination with

endometrioma content5. Endometriosis progression

1. Surgical‐related damage2. Surgical complications3. Economic costs4. Lack of evidence that

surgery improve IVF pregnancy rates

Expectant Surgery

Endometrioma and infertility

Age

Symptoms

Volume/Size

Desire of pregnancy

c

Previoussurgery

JMIG 2014

endometriomadeep

endometriosis

Endometriosis

peritonealendometriosis

adenomyosis

Adenomyosis and reproductive performance after surgery for rectovaginal and colorectal endometriosis: a systematic review and meta-analysis

Vercellini et al. Reprod Biomed Online 2014

Adenomyosis and infertility

coexistence of adenomyosis and deep endometriosis was associated with a 68%

reduction in the likelihood ofpregnancy

women with rectovaginal/colorectal endometriosis and concomitant uterine adenomyosis should be informed thatsurgery may not have an appreciable

effect on the likelihood of conception and that the same or possibly better chances of pregnancy could be obtained through

IVF/ICSI

Uterine adenomyosis and in vitro fertilization outcome: a systematic review and meta-analysis

Vercellini et al. Hum Rep 2014

Adenomyosis and infertility

adenomyosis was associated with a 28% reduction in the likelihood of clinical

pregnancy in infertile women who underwent IVF/ICSI with autologous oocytes

adenomyosis was associated with a more than doubled risk of miscarriage

suppression of adenomyosis by long-term down-regulation with GnRH agonists might

improve IVF/ ICSI outcome

Treatment for adenomyosis

1. GnRH agonist treatment

2. Progestins

3. Surgery

Garcia L et al, J Minim Invasive Gynecol. 2011

11

Surgical treatment

The treatment for severe adenomyosis has usually been hysterectomy,

because there is no line of demarcation between diseased and normal tissue

Adenomyosis is diagnosed with increasingfrequency in women attending infertility clinics

Pepas L. et al, Curr Opin Obstet Gynecol. 2012

For patients who wish to preserve their fertility, conservative surgery has been proposed

The adenomyotic tissues are radically excised and the uterine wall is reconstructed to prevent uterine rupture in subsequent pregnancies

Nishida M et al, Fertil Steril 2010

The procedure resulted in a dramatic reduction in symptoms and allowed to conceive without uterine rupture

Osada H et al, Reprod BioMed, 2011

Adenomyomectomy

Kinoshita K et al, J Minim Invasive Gynecol. 2006

There is no uniform standard to measure the efficacy of adenomyomectomy therapy (relief of symptoms or a pregnancy rate)

Lang J et al, Chin Med J 2011

Conservative surgery for adenomyosis

Three case series evaluated the effect of conservative surgery alone in women with adenomyosis

conservative surgical techniques described involve excision of the adenomyotic tissue or adenomyoma

and hysteroplasty either laparoscopically or via laparotomy

2012

there are no fertility-sparing treatments of proven effectiveness

there is no indication for finding or treating adenomyosis in women who wish to conceive

30% successful pregnancy rate;

decrease of 65%in the number of patients with

a heavy menstrual bleeding

decrease of 41% in the number of patients with

dysmenorrhea

Rep BioMed 2014

1. Complete excision of adenomyosis.a. Adenomyomectomy.

b. Cystectomy

2. Cytoreductive surgery/partial adenomyomectomy

3. Nonexcisional techniques

Uterine-sparing operative treatment of adenomyosis and its variants appears to be feasible and efficacious. Control of dysmenorrhea is

achieved in more than 81% and menorrhagia in 50% of patients

pregnancy rates appear to be higher than 46%.

2014

12

Global endometrial ablation has also proved successful in treatment of excessive bleeding in women with

adenomyosis

1.5-fold increased risk of failure requiring subsequent hysterectomy or repeat ablation

Garcia et al 2011

Endometrial ablation/resection

before After 6 monts

Rabinovici et al 2006

Uterine artery embolization

Popovic et al 2011

Although the level of evidence of available studies is only fair sustained clinical and symptomatic improvements were reported

utero

ultrasuoni focalizzati

ultrasuoni focalizzati guidati da risonanza magnetica (MRgFUS)

before after

Rabinovici et al 2006

• It is mandatory to search and find adenomyosis in approaching patients with a suspicion of endometriosis

• Nowadays we have to consider adenomyosis as an emergent and specific disease

• It is not only detectable in older and multiparous women

• Its diagnosis allows a more appropriate counselling with patients

• Individualization of surgical treatment

Adequate management

The present study aimed to investigate the possible presence of adenomyosis by TVS in a group of women with DIE and its

impact on pre- and postoperative symptoms

multicenter study 121patients with confirmed hystological diagnosis of DIE

counselling

Lazzeri et al. 2014

Results

TVS features of adenomyosis were found in 59/121 patients

DIE group: n=62

DIE+ adeno group: 5

No statistically significant difference was found in clinical characteristics

between the 2 groups

The 2 groups were homogeneous for the distribution of different

sites of DIE lesions confirmed at surgery

13

endometrioma

deep endometriosis

Endometriosis

peritonealendometriosis adenomyosis

Infertility 18 mo

o Dysmenorrhea: 9o Dyschezia: 5o Dysuria: 0o Dyspareunia: 4o Rectal bleeding

D. V. 32 yrs

3 PMA (FIVET)

Ultrasound evaluation 2D/3D, Power Doppler

Case 1

Laparoscopy

Sponteneous pregnancy 6 mo after surgery

Infertility 30 mo

o Dysmenorrhea: 7o Dyschezia: 4o Dysuria: 8o Dyspareunia: 4o Hematuria

B.E. 33 yrs

Ultrasound evaluation 2D/3D, Power Doppler

Case 2

Laparoscopy

Hystology

Sponteneous pregnancy 2 mo after surgery Fertil Steril 2009

patients may require infertility treatment, particularly when aged >35 years at the time of surgery

1. age >35 years2. uterine adenomyosis3. longer duration of infertility before surgery

are associated with decreased pregnancy rate.

14

Stepniewska A et al, Hum Reprod 2009

seems to negatively influence the reproductive outcome

the complete removal of endometriosis with bowel segmental resection seems to offer better results in terms

of post-operative fertility

Surgical treatment in endometriosis-associated infertility

Ballester M et al, Hum Reprod 2012

Patient age over 35 years and AMH serum level under 2 ng/ml were associated with a decreased CPR per patient

Adenomyosis was associated with a decreased CPR

The combined strategy of endoscopic surgery and subsequent IVF led to a higher clinical pregnancy rate (65.8%) than that obtained with

surgery alone or IVF alone, especially in patients younger than 35 years

Barri PN et al, Reprod Biomed Online 2010

Ballester M et al, Hum Reprod 2012

Conclusions

15

Rare Cases of Endometriosis: Management of Extrapelvic Disease

Ja Hyun Shin, MD Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York

Objective: Discuss diagnosis and management of extrapelvic endometriosis.

Design: Surgical case presentations of abdominal scar, perineal, and primary umbilical endometriosis.

Setting: Extrapelvic endometriosis is rare. The true incidence of these conditions is yet to be defined

since most of the literature is based on small case reports. Diagnosis and management of extrapelvic

disease can be a challenge to gynecologists as there is not a standard approach. All 3 patients presented

with a palpable nodule that was exacerbated during menses. Imaging supported these findings

suggestive of endometriosis. Two patients had chronic pelvic pain and also experienced symptoms

suggestive of interstitial cystitis/painful bladder syndrome.

Interventions: Each of these patients underwent diagnostic laparoscopy and had an excisional

procedure for their extrapelvic disease. Histopathology confirmed endometriosis in both intracavitary

specimens and the excised masses for all 3 cases. Patients with painful bladder symptoms

demonstrated global glomerulations during cystoscopy with hydrodistention.

Conclusion: Gynecologists should have a high index of suspicion for extrapelvic endometriosis based on

a thorough physical exam and history. Imaging can aid in the diagnosis. The role of routine laparoscopy

needs further investigation in this population of patients as they may also have intracavitary disease. All

associated symptoms, including genitourinary complaints, should also be explored.

16

Rare Cases of Endometriosis

Ja Hyun Shin, MDDirector, Pelvic Pain Clinic

Division of Minimally Invasive Gynecologic Surgery

I have no financial relationships to

disclose

Objective

• Discuss and Present 3 cases of extrapelvicendometriosis:

1. Abdominal wall cesarean scar2. Perineal 3. Primary umbilical

• Identify management issues1. History and physical exam2. Preoperative planning3. Role of diagnostic laparoscopy

Abdominal Wall C/S Scar Endometriosis

• Incidence (0.03-1%)

• Iatrogenic seeding of endometrial cells

• Palpable nodular mass with cyclic or noncyclic pain in or near cesarean scar

• Reports of malignancy

Abdominal Wall C/S Scar Endometriosis

Case 1:• 27 yo P3 with c/s x3

- 3rd c/s complicated by retained POC and hemorrhage

-> D&C and transfusion

• CPP, dysmenorrhea

• Pain and growth of “ball” on left aspect of c/s scar during menses

MRI

17

Perineal Endometriosis

• Literature based on case reports

• Most commonly reported with history of episiotomy

• Typically present with cyclic pain and nodule

• Delay in treatment with misdiagnosis- Abscess/infection, condyloma, Bartholin’s cyst

• Full excision may not be possible depending on location- anal sphincter involvement, periclitoral

Perineal Endometriosis

Case 2:• 34 yo P1 with hx of left

mediolateral episiotomy

• Multiple ED visits for cyclic perineal “lump” pain

• CPP, Dysmenorrhea

• Urinary frequency, urgency, nocturia, pain with full bladder

18

Interstitial Cystitis/Painful Bladder

Syndrome

• The “evil twin” of endometriosis

- >80-90% of patients

• No gold standard for diagnosis

• Consider cystoscopy with hydrodistention at time of surgery

Primary Umbilical Endometriosis

• Literature based on case reports

• May present with cyclic pain, nodule, bleeding

• Delay in treatment with misdiagnosis

- Melanoma

- Keloid

- Fistula/abscess

Primary Umbilical Endometriosis

Case 3:

• 30 yo P1 with no prior surgeries

• Cyclic umbilical pain and bleeding

• Dysmenorrhea

• Painful bladder symptoms

scope

19

Summary: Recommendations for

Management of Extrapelvic Endometriosis

1. Thorough physical exam and history- Painful cyclic palpable mass - Surgical/Obstetric history - Systems evaluation (including GU for IC/PBS in patients with endometriosis)

2. Preoperative planning- Imaging

1) Aid in diagnosis2) Evaluate involvement of surrounding tissue

- Consult with other surgical services

3. Consider diagnostic laparoscopy- Can guide future management

References

• Leyla O, Julide S, Aysun U, et al. Abdominal wall endometriosis in the cesarean. section surgical scar: A potential diagnostic pitfall. Obstet Gynecol Res. 2012; 38(3): 526-530.

• Mert I, Semaan A, Kim S, et al. Clear cell carcinoma arising in the abdominal wall: two case reports and literature review. Am J Obstet Gynecol. 2012;207(2):e7-e9.

• Chen N, Zhu L, Lang J, et al. The clinical features and management of perineal endometriosis with anal sphincter involvement: a clinical analysis of 31 cases. Hum Reprod. 2012 Jun;27(6):1624-1627.

• Li J, Shi Y, Zhou C, et al. Diagnosis and treatment of perineal endometriosis: review of 17 cases. Arch Gynecol obstet. 2015. [Epub ahead of print].

• Chung MK, Chung RP, Gordon D. Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The “Evil Twins: syndrome. JSLS. 2005 Jan-Mar;9(1):25-9.

• Minaidou E, Polymeris A, Vassilliou J, et al. Primary umbilical endometriosis: case report and literature review. Clin Exp Obstet Gynecol. 2012;39(4):562-564.

• Ecker A, Donnellan N, Shepherd J, Lee T. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol. 2014;211(4):363(e1-5).

20

Conservative Surgery in Advanced Deep Endometriosis of Mid and Low Rectum:

Feasibility and Advantages

Horace ROMAN, MD PhD

Rouen University Hospital, France

• Consultant: IPSEN, Plasma Surgical

• Speakers Bureau: Nordic Pharma

Deep infiltrating endometriosis (DIE) of mid and low rectum (M/LR)

• To discuss the role of conservative surgery (CS) in DIE of M/LR• Avoid major functional troubles following low colorectal resection

(CRR): anal incontinence, low anterior rectal resection syndrome (LARS)

• Discuss conservative procedures: disc excision or shaving

Outline

Conservative surgery in DIE of the M/L R (<=10 cm height):

1. Why?

2. How?

3. In whom?

4. What results?

Background

• Historically, first articles (1991/92) reported conservative laparoscopic management of DIE of the R

• Then, progressive involvement of general surgeons in multidisciplinary teams has raised the rate of patients undergoing colorectal resection (CRR)

• 2011: 71% of patients with colorectal DIE are managed by CRR

• However, DIE of the M/LR is completely different from any other benign ormalign rectal diseases, which are usually managed by CRR

Inwards vs. OutwardsDIE

Cancer

Crohn

50‐60% of patients with low CRR for cancer present with LARS (low anterior rectal resection syndrome)

• anal incontinence,

• frequent bowel movements (up to 10‐20/day),

• bowel emptying difficulties,

• Urgency

Very few series focus on only M/LR DIE! = lack of specific information in DIE

Why?

21

961 patients with CRR for cancer

‐mean height of CR anastomosis: 10 cm

‐ mean age 63 years

‐ 20% postoperative radiotherapy

Impact of LARS on QoL:

‐ 25% no impact

‐ 34.3% minor impact

‐ 40.4% some/major impact

Could we afford it in a benign disease?

CRR in DIE of M/LR may result in :

1. Rectal denervation: due to the section of the mesocolon

2. Stenosis of the colorectal anastomosis : up to 15‐19%

3. Dramatic reduction of rectal reservoir

4. Risk for faecal incontinence and urgency – hence, high intracolic pressures directly impact on anal sphincter

Avoiding postoperative rectal dysfunction = challenging, because multifactorial

Patients managed by low CRR for DIE may experience daily bowel dysfunction:

‐ Several symptoms are not solved: constipation, dyschesia, tenesmus

‐ New symptoms may occur: LARS

Why?

Comparison of CRR to conservative surgery• Only a couple of comparative studies + ongoing randomized trial (ENDORE)

• Attempting conservative surgery was related to better functional outcomes and improvement of gastrointestinal scores: KESS, GIQLI, FIQL, Wexner

• CS: How? In which patients? What results?

• 2 major techniques:

1. Rectal shaving

2. Rectal shaving + disc excision of shaved area

How?Shaving:

• Excision of macro/microscopic lesions is likely to be incomplete

• Good results in terms of complications (no R suture) and R function

• Long term recurrences should better be assessed

• Good technique in elderly women / postoperative long term amenorrhea

Disc excision:

• The suture may be challenging into the deep pelvis: improved by the use of transanal staplers

• Incomplete resection of microscopic foci in 27‐44%

• Preservation of mesorectum and overall R wall length: no LARS

How?The Rouen technique

In whom?

• Feasibility: 93% of patients with DIER enrolled in ENDORE randomized trial

• In multifocal colorectal DIE: Preferring CS M/LR associated to CS / CRR on sigmoid colon, instead of long CRR with low colorectal / coloanal anastomosis

• In DIE of M/LR with stenosis: shaving + in situ ablation enable CS

• CRR: circumferential DIE + advanced stenosis

YESYES YES

22

Which results?

Retrospective comparative study in 75 women with >2 ys follow up:

• The results of gastrointestinal scores: systematically better after CS

Prospective series of 30 patients: the Rouen technique for M/LR DIE (unpublished data):

• ‐ no anal incontinence

• ‐ overall improvement of rectal function

• ‐ no patient underwent an impairment of the QoL and gastrointestinal scores

ENDORE randomized controlled trial : 60 patients with R DIE (44 M/L R):

• Last 2‐yr follow up visit: September 2015

• Database is actually frozen

• Full report expected in March 2016

“The surgeons who had so painstakingly created the world of radical surgery had no incentive to change it.”

Siddhartha Mukherjee

‐ The statement concerns Halsted’s school impact on breast cancer surgery

It only depends on us that deep endometriosis surgery does not follow the same path

Surgical management of colorectal DIE :

•Meuleman C, Tomassetti C, D'Hoore A, Van Cleynenbreugel B, Penninckx F, Vergote I, et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011;17: 311–26.

•Donnez J, Nisolle M, Gillerot S, Smets M, Bassil S, Casanas‐Roux F. rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynecol 1997; 104: 1014‐8.

•Reich H, McGlynn F, Salvat J. laparoscopic treatment of cul‐de‐sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 1991; 36: 516‐22.

•Donnez J. Excision of deep endometriotic nodules by laparoscopy. In Donez J, ed Laser surgery. Leuven: Nauwelaerts Printing, 1991: 148.

•Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study. Hum Reprod 2005;20: 2317–20.

•Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C. Deep endometriosis infiltrating the recto‐sigmoid: critical factors to consider before management. Hum Reprod Update 2015; 21: 329‐39.

•Nezhat C, Nezhat F, Ambroze W, Pennington E. Laparoscopic repair of small bowel and colon. A report of 26 cases. Surg Endosc 1993;7:88–9.

Functional outcomes of rectal surgery:

•Emmertsen KJ, Laurberg S. Low anterior resection syndrome score. Development and validation of a symptom‐based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg 2012;255:922‐8.

•Roman H, Vassilieff M, Tuech JJ, Huet E, Savoye G, Marpeau L, Puscasiu L. Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril 2013; 99: 1695‐704.

•Roman H, Bridoux V, Tuech JJ, Marpeau L, da Costa C, Savoye G, Puscasiu L. Bowel dysfunction before and after surgery for endometriosis. Am J Obstet Gynecol 2013;209:524–530.

•Maytham GD, Dowson HM, Levy B, Kent A, Rockall A. Lapraoscopic excision of rectovaginal endometriosis : report of a prospective study and review of the literature. Colorectal Dis 2010; 12: 1105‐12.

•Knowles CH, Scott SM, Legg PE, Allison ME, Lunniss PJ. Level of classification performance of KESS (symptom scoring system for constipation) validated in a prospective series of 105 patients. Dis Colon Rectum 2002; 45: 842‐3.

•Slim K. First validation of the French version of the Gastrointestinal Quality of Life Index (GIQLI). Gastroenterol Biol Clin 1999; 23: 25‐31.

•Lee WY, Takahashi T, Pappas T, Mantyh CR, Ludwig KA. Surgical autonomic denervation results in altered colonic motility: an explanation for low anterior resection syndrome? Surgery 2008; 143: 778‐83.

Disc excision and shaving in DIE of the M/LR:

•Roman H, Abo C, Huet E, Bridoux V, Auber M, Oden S, Marpeau L, Tuech JJ. Full thickness disc excision in deep endometriotic nodules of the rectum. A prospective cohort. Dis Colon Rectum 2015; In press.

•Roman H, Tuech JJ, Slim K, Canis M. Functional Outcomes of Surgical Management of Deep Endometriosis Infiltrating the Rectum (ENDORE). NCT01291576 Available on http://clinicaltrials.gov/ct2/show/NCT01291576?term=NCT01291576&rank=1; 2011. Access the August 9, 2014.

•Roman H, Tuech JJ, Arambage K. Deep rectal shaving followed by transanal disc excision in large deep endometriosis of lower rectum. J Minim Invasive Gynecol 2014; 21: 730‐1.

•Roman H, Tuech JJ. Laparoscopic and transanal excision of large lower and mid‐rectal deep endometriotic nodules: the Rouen technique. Fertil Steril 2014; 102: e7.

•Roman H. Deep shaving using PlasmaJet in deep endometriosis of the rectum. Fertil Steril 2013; 100: e33.

•Roman H. Deep rectal shaving using plasma energy for endometriosis causing rectal stenosis. Colorectal Dis. 2014 Jul 12. doi: 10.1111/codi.12720.

•Roman H, Abo C, Huet E, Tuech JJ. Deep shaving and transanal disc excision in large endometriosis of mid and lower rectum: the Rouen technique. Surg Endosc 2015; In press.

•Roman H, Darwish B. How I do… conservative rectal surgery in multifocal colorectal endometriosis instead large low colorectal resection. Gynecol Obstet Fertil 2015; In press.

Thank you

23

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

24

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

Surgical Tutorial 2: Complicated Endometriosis - aagl.org · STRANGE DISEASE CALLED ADENOMYOSIS:...

Documents

Transcript of Surgical Tutorial 2: Complicated Endometriosis - aagl.org · STRANGE DISEASE CALLED ADENOMYOSIS:...