What does adenomyosis mean?
Adenomyosis is known as the cancer that doesn’t die, and it’s not a name you just get. Most medical scholars believe that it is related to genetics, damage to the uterus (whether you don’t want to have an abortion, or want to have a natural flow, or a cesarean section, multiple pregnancies, multiple deliveries, the uterus will have some damage), chronic endometritis, high estrogen and progesterone level stimulation, etc. Adenomyosis is highlighted by dysmenorrhea and abnormal aunt, serious pain to the end just want to hit the wall, adenomyosis and aunt have a certain correlation, aunt did not come (puberty and before), or aunt never come (after menopause) few people have, so that it is easy for girls of childbearing age to get, in addition to physical pain, another psychologically painful problem also came: easy infertility. The most common question is, “Doctor, I have adenomyosis, what should I do?
What can I do?
After all, adenomyosis is also considered a major problem among benign gynecological diseases, if the past, the problem is a problem, everything is done, never to suffer. Now this way is not everything. In line with the trend of the times, girls are getting married later and later, adenomyosis is found in girls who are relatively young, the state encourages the second child, coupled with infertility, there are girls who are not born but have a desire to preserve the integrity of the uterus, all sides collided with the fierce sparks, to preserve the uterus of the surgical methods have emerged and flourished, in the end, what are they? Let’s list them in a row.
Table 1 Surgical approaches to preserve the uterus and their surgical evolution
Type of surgery
Surgical technique
Different evolutionary types
Complete excision of the lesion
Adenocystectomy
Partial excision of the lesion (cytoreductive surgery)
No excision of the lesion
Excision of adenomyosis lesions
Traditional surgery
Partial excision of adenomyosis lesions
Partial excision of adenomyosis foci combined with other techniques
Non-excision alone
Hysteroscopic technique
Other
1. Conventional open/laparoscopic complete excision of adenomyosis lesions or intraoperative ultrasound-guided excision. Uterine reconstruction can be performed with direct sutures or modified U-shaped sutures/overlapping muscle flap sutures
2. Tri-muscle flap technique.
1. conventional open/laparoscopic partial excision of the adenomyosis lesion
2. transverse H-shaped resection at the lesion
3. Wedge resection of the uterus
4. Asymmetric hysterectomy
Partial adenomyosis resection combined with uterine artery block
1. Uterine artery ligation
2. Myometrial electrocoagulation
1. Endometrial resection
2. Endometrial ablation
3. Hysteroscopic resection of intracapsular lesions
1. High frequency ultrasound (HIFU)
2. Intracapsular anhydrous alcohol infusion for adenomyosis
3. Non-hysteroscopic endometrial ablation
Radiofrequency technology
Microwave technology
Thermal balloon endometrial ablation, etc.
A new problem has arisen, the existence is reasonable. How to choose from so many different methods?
What is it like to be a doctor and a good doctor drifting apart? It’s the feeling that a girl asks you “What should I do, doctor” and you can only answer “I don’t know”. To alleviate this feeling, let’s talk about the advantages and disadvantages of various uterus-preserving surgeries.
Advantages and disadvantages of various uterus-preserving surgeries for adenomyosis.
(1) Complete focal excision: similar to myoma stripping, followed by various methods of suturing, including U-shaped sutures, overlapping muscle flap sutures, triple muscle flap technique sutures, etc. (the latter two are illustrated below).
Mainly for focal adenomyosis (adenomyoma), diffuse adenomyosis is generally difficult to completely cut or remove the lesion (because adenomyosis and our useful normal uterine muscles do not have boundaries, in layman’s terms completely is the ideal completely, technically difficult to implement. (Digging a root out of the ground can not bring a bit of soil, the root is also intact out?) (The root can be dug out from the ground without any soil and the root is intact? According to recent statistics, the overall pregnancy rate after complete focal resection reached 60.5%, miscarriage rate 16.9%, pain relief rate 82%, and menstrual flow reduction rate 68.8%.
(2) Partial focal resection/cytoreductive surgery: It is mainly indicated for the resection of diffuse adenomyosis. Clinical validation showed that the postoperative outcome was poor because of incomplete lesion excision, with only 50.0%-54.6% relief of menorrhagia/dysmenorrhea and 46.9% postoperative pregnancy rate. According to Fujishita [10] et al. the disadvantages of laparoscopy for this type of surgery include bleeding and difficulty in assessing the extent of diffuse adenomyosis more accurately by palpation intraoperatively, so open surgery remains the dominant surgical approach. These surgical approaches cannot be accurately distinguished between adenomyosis lesions and normal myometrium by the clinical eye, and removal of the lesions also results in the absence of some of the normal myometrium, reducing uterine volume and predisposing the pregnancy to miscarriage or preterm delivery in the postoperative period, and the scar formed after removal of the lesions and the residual lesions within the myometrium affect the tone and strength of the uterus, leading to the risk of uterine rupture in late pregnancy.
(3) Non-excision of lesions: mainly uterine artery ligation, myometrial electrocoagulation, endometrial resection, endometrial ablation, hysteroscopic excision of intracapsular lesions, and some new treatment techniques are also used for adenomyosis to do “lesion removal” treatment: high frequency ultrasound, anhydrous alcohol infusion in the capsule of adenomyosis, non hysteroscopic endometrial ablation, radiofrequency and microwave techniques, etc., but the overall efficacy of these methods is not optimistic.
(4) Laparoscopic uterine artery occlusion (LUAO) can be combined with laparoscopic uterine artery occlusion and other surgical options depending on the patient’s disease, age and fertility requirements. 1) Partial adenomyectomy for limited adenomyosis (adenomyoma) and 1) partial adenomyosis resection for patients with limited adenomyosis (adenoma) and diffuse adenomyosis with significant increase in uterine volume; 2) resection of endopathic pelvic lesions; 3) pelvic adhesion release; 4) presacral neurectomy for patients with significant symptoms of dysmenorrhea and pelvic pain caused by adenomyosis. A retrospective analysis of the outcomes of 182 cases of LUAO-based combined surgical protocols for adenomyosis at our hospital, after 36-month follow-up, showed that patients had significantly reduced menstrual flow, effective improvement of dysmenorrhea symptoms, significant reduction in uterine volume, significantly better postoperative quality of life than before surgery, no serious surgical complications or postoperative complications, and 3 cases had recurrence of postoperative symptoms and requested hysterectomy (1.6%) . Preliminary clinical validation showed that this approach was safe and effective in the treatment of adenomyosis, and the treatment outcome was significantly better than that reported in the literature.
The mechanism of treatment is the “single organ shock doctrine”, in which the uterine arteries are blocked bilaterally by laparoscopic surgery, resulting in a rapid reduction of uterine blood flow by about 90% and the onset of shock in the uterus (single organ). During this pathophysiological stage, the “good boy” uterus survives because of its physiological peculiarities, while the “bad boy” myometrium dies a great deal of necrosis and apoptosis, and the recurrence rate is greatly reduced.