Efficacy of laparoscopic adenomyomectomy using double-flap method for diffuse uterine adenomyosis

Huang et al. BMC Women's Health Efficacy of laparoscopic adenomyomectomy using double-flap method for diffuse uterine adenomyosis Xiufeng Huang Qiongshi Huang Shuyi Chen Jing Zhang Kaiqing Lin Xinmei Zhang Background: Adenomyomectomy has recently been considered the priority option for the treatment of adenomyosis, however, the surgical efficacy and modes are still debated. We aimed to evaluate the efficacy of laparoscopic adenomyomectomy using a double-flap method for the treatment of uterine diffuse adenomyosis when compared with conventional laparoscopic adenomyomectomy. Methods: Laparoscopic adenomyomectomy using the conventional method (group A, n = 48) and the double-flap method (group B, n = 46) to treat diffuse uterine adenomyosis, respectively. Visual analog scale (VAS), menstrual amount, serum CA125 levels, and uterine volume were comparatively analyzed in both groups. Results: The VAS scores, menstrual amount, serum CA125 levels, and uterine volume at 12 or 24 months after surgery significantly reduced in group B than in group A (P < 0.05); these parameters were statistically decreased in both groups after surgery compared with those obtained before surgery (P < 0.001). Moreover, serum CA125 levels and uterine volume at six months of follow up were significantly lower in group B than in group A (P < 0.01). In addition, blood loss during surgery was similar in groups A and B (P > 0.05), although the operative time was significantly longer in group B than that in group A (P < 0.05). Conclusions: Laparoscopic adenomyomectomy using the double-flap method may be an effective technique to treat uterine diffuse adenomyosis. Adenomyosis; Adenomyomectomy; Dysmenorrhea; Double flap method; Surgery - Background Adenomyosis is a benign gynecologic disorder characterized by the invasion of endometrial glands and stroma in the uterine myometrium, resulting in dysmenorrhea, hypermenorrhea, and infertility [1]. Although adenomyosis may be treated with several methods, such as hysterectomy, conservative surgery, drug therapy such as gonadotropin-releasing hormone agonist therapy (GnRHa), and uterine artery embolization, complete hysterectomy can thoroughly treat this disease [2-9]. However, total hysterectomy is not suitable for women with adenomyosis who want to preserve their uteri and/or require fertility in the future. As such, these women prefer uterus-sparing surgery. Although many uterus-sparing surgical techniques have been developed to treat adenomyosis, adenomyomectomy is considered as the most feasible and efficacious; adenomyomectomy has also been considered as the first-line approach to treat adenomyosis, particularly focal adenomyosis [10]. Partial adenomyomectomy including wedge resection of the uterine wall, transverse H incision technique, and asymmetric dissection of uterus to treat diffuse adenomyosis, can improve clinical symptoms; however, these techniques are frequently associated with adenomyosis recurrence and spontaneous uterine rupture in pregnancy [2,11-14]. The complete excision of adenomyosis by employing several techniques, such as overlapping flaps and triple-flap method to treat diffuse adenomyosis, can achieve good results; nevertheless, these techniques are difficult to implement, particularly laparoscopy [15-17]. These findings suggest that the development of a new surgical technique is a major concern to improve the convenience of laparoscopic conservative surgery to treat diffuse adenomyosis; with these novel techniques, adenomyotic lesions should be excised during surgery and uterine wall integrity should be retained. Therefore, this study aimed to modify the technique of Osada et al. to perform laparoscopic adenomyomectomy by using a double-flap method for the treatment of uterine diffuse adenomyosis [16]. This study was also designed to evaluate the surgical efficacy of laparoscopic adenomyomectomy with the modified doubleflap method for women with uterine diffuse adenomyosis, particularly those who manifested severe clinical symptoms and wished to preserve their uteri, but their reproductive capacity was not a priority request, compared with conventional laparoscopic adenomyomectomy. Methods Patients The Ethics Committee of the Womens Hospital, Zhejiang University School of Medicine approved this study. Written informed consent for participation in the study was obtained from participants. A total of 129 patients who were referred to our hospital and underwent laparoscopic adenomyomectomy for uterine diffuse adenomyosis between March 2011 and February 2014 were recruited in this study. The inclusion criteria were listed as follows: women had severe dysmenorrhea with and without menorrhagia (hypermenorrhea), but failed to undergo drug therapy, including GnRHa, Mirena and oral contraceptives; women wished to preserve their uteri, but their reproductive capacity was not a priority request; Pure adenomyosis for all the study subjects was preoperatively verified by ultrasound and magnetic resonance imaging according to the previous reported diagnostic criteria [16-26], and affected more than 70% of the anterior and/or posterior wall of the uterus with an enlargement of >5 cm in thickness. The exclusion criteria were listed as follows: women presenting with a contraindication to laparoscopy because of severe medical illness. The patients who were recruited in this study were all interviewed by Dr. Huang. During her interview, each patient was in detail told about the advantage and disadvantage of the conventional method and the double-flap method (for example, less time and blood loss but less adenomyotic lesions excised may be in the former, whereas more time and blood loss but more adenomyotic lesions excised may be in the latter), and decide whether to participate in the study, and which method to take. Consquently, thirty-five among 129 patients who were invited to participate refused treatment. The 94 remaining patients with diffuse adenomyosis who were included in this study were assigned to undergo laparoscopic adenomyomectomy by using the conventional method (group A, n = 48) and the double-flap method (group B, n = 46) based on patient requirements. After surgery was completed, all of the patients received GnRHa for six months. None of the study patients revoked their consent, failed to undergo follow up, or received sexhormone therapy six months before surgery. Surgical procedure All surgical procedures were performed under general anesthesia in the Trendelenburg position with four-port laparoscopy. One 10 mm port was inserted through the umbilicus for the zero-degree laparoscope, and two lateral 5 mm ports were inserted above and medial to each anterior superior iliac spine. A second left sided 5 mm port was inserted between the left lateral port and the umbilical port. The surgeon (XZ and XH) used the two left sided ports to perform most of the surgical procedures. The technique of resection of adenomyotic lesions u (...truncated)