Treating the untreatable : Surgery on adenomyosis 1 2016 Adeno (English).pdf · Surgery on adenomyosis Hisao OSADA, MD, PhD. Director, Natural ART Clinic, Nihombashi, Tokyo Former

Treating the untreatable : Surgery on adenomyosis

Hisao OSADA, ＭＤ, ＰｈＤ.

Director, Natural ART Clinic, Nihombashi, Tokyo

Former Prof. Nihon University

Ovarian Club VII, Hong Kong on May 21-22 2016

Video Presentation

1.Ante. and post. wall of the

uterus

2.Anterior wall of the uterus

3.Ante. and post. wall of the

uterus

永友美輝

Severe Cases of Adenomyosis

2. Include severe dysmenorrhea / severe hypermenorrhea and thus may also interfere with a woman’s well being.

3. Management may include long term usage hormonal or analgesic therapy.

4. May in the end possible need for hysterectomy for adequate relief.

1. A cause of infertility

Main Purpose for

Conservative Procedure for Adenomyosis

1. Retention of tubal patency

The tubal patency must be retained

in order to assure fertilization.

2. Retention of a functional uterine cavity The uterine cavity environment must be retained in order to assure implantation.

3. Adequate reconstruction of the uterine wall The uterine wall must be constructed property so that it can sustain a normal pregnancy.

4 4

Surgery for Severe cases of Adenomyosis

Wedge-resection of the uterine tissue, followed

by the approximation of the remaining myometrium and serosa.

3

1 Options for conservarive prosedure

Ｗedge-resection

l Park WH. Et al : Uterine rupture after laparoscopic removal of a pedunculated myoma. J Minim

Invasive Gynecol. 2007 May-Jun;14(3):362-4.

l Grande N. et al : Spontaneous uterine rupture at 27 weeks of pregnancy after laparoscopic

myomectomy. J Minim Invasive Gynecol. 2005 Jul-Aug;12(4):301.

l Banas T. et al : Spontaneous uterine rupture at 35 weeks' gestation, 3 years after laparoscopic

myomectomy, without signs of fetal distress. J Obstet Gynaecol Res. 2005 Dec;31(6):527-30 .

l Malberti S. et al : Spontaneous uterine rupture in the third trimester of gestation after

laparoscopic myomectomy. A case report. Minerva Ginecol. 2004 Oct;56(5):479-80. Italian.

l Lieng M. Et al : Uterine rupture after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc.

2004 Feb;11(1):92-3.

l Oktem O. Et al : Spontaneous uterine rupture in pregnancy 8 years after laparoscopic

myomectomy. J Am Assoc Gynecol Laparosc. 2001 Nov;8(4):618-21.

l Nkemayim DC. Et al : Uterine rupture in pregnancy subsequent to previous laparoscopic

electromyolysis. Case report and review of the literature. Arch Gynecol Obstet. 2000

Nov;264(3):154-6.

l Pelosi MA. 3rd et al : Spontaneous uterine rupture at thirty-three weeks subsequent to previous

superficial laparoscopic myomectomy. Am J Obstet Gynecol. 1997 Dec;177(6):1547-9.

l J.-B.Dubuisson et al : Uterine rupture during pregnancy after laparoscopic myomectomy Human

Reproduction vol.10 no.6 pp.1475-1477, 1995

l Wesley J. et al : Uterine dehiscence following laparoscopic myomectomy Obstetrics and

Gynecology Vol.80,No.3 part 2, Sep;1992

l Asakura H, et al : A case report : Change in fetal heart rate pattern on spontaneous uterine

rupture at 35 weeks gestation after laparoscopically assisted myomectomy, J Nippon Med Sch

2004;71 : 69-72

l Hockstein S. : Supontaneous uterine rupture in the early third trimester after laparoscopically

assisted myomectomy, J Reprod Med 2000;45 : 139-141

Uterine rupture during pregnancy after myomectomy/Adenomyomectomy

M.I. 35yrs Spont.abortion x3

Conservarive Prosedure：Ｗedge-resection

after a wedge-resection

Thin 1ayer of

uterine wall

After Wedge-resection

The approximated site is depressed.

4 4

1) Wide complete excision of affected tissues

to assure adequate removal

2) Triple-flap reconstruction of the uterine wall

to assure adequate uterine wall strength,

to allow potential future pregnancies.

Surgery for Severe Cases of Adenomyosis

1. Options for conservarive prosedure 1) Wedge-resection of the uterine tissue,

2) Followed by the approximation of the remaining

myometrium and serosa.

3

2. Our proposed procedure

3. Laparoscopic procedure Hemostasis of incised surfaces.

Application of hemostatic barriers for the inhibition of adhesions

2. Adenomyomectomy under minimal abd. incision Three main purposes for preserving reproductive functions. ;

1) Resection and removal of all adenomyosis tissue

while retaining tubal patency

2) Retaining a functional uterine cavity

3) Adequate reconstruction of the uterine wall

Strength adequate to experience normal pregnancy

1. Laparoscopic procedure 1) Observation of pelvic organs and their configuration 2) The adhesions frequently seen in the pouch of Douglas are laparoscopically lysed.

Surgical Management of Severe Cases of Adenomyosis by the Triple-flap method

2. For cases of severe dysmenorrhea

necessitating administration of more than 5 days

of analgesics or more than 1 day of bed rest

per menstrual cycle

Indications for Surgery by the Triple-flap method

1. For cases of severe adnomyosis

involving more than 80% of the anterior

and or posterior wall of the uterus

and enlargement of 6cm or more.

3 . For cases of patients under 45 years of age

who desire to conceive or to preserve uterine function

永友美輝 MRI

Case 1.

Ａdenomyosis involving more than 80% of the

anterior and/or posterior wall of the uterus

Pre-surgical H S G

Expanded uterine cavity

and vascularization

The artery and vein circulation of the uterus

The artery and vein circulation of the uterus is mainly in the

bi-lateral wall． Therefore, it is clearly to do medial vertical-incision

of the uterine wall to prevent interruption of blood circulation.

• The tissue is adequately dissected with scissors, with care taken to retain

a serosal flap with myometrium.

Management of adenomyosis by the triple-flap method

• The affected tissue is vertically incised to split the area to be excised

into two, and the incision is extended to the uterine cavity.


• The tissue is adequately dissected with scissors, with care taken to retain a

serosal flap with myometrium.

• The tissue to be excised is grasped and placed under tension with Martin forceps

• Also, special care must be taken to prevent damage to the Fallopian tubes.


• The adenomyosis had been completely excised with scissors or scalpel

and by palpitation, if hard adenomyosis tissue is inadequately excised should

be caried out additional excision.

The endometrial flaps,

5-7 mm in thickness.

The serosal flaps,

5-7 mm in thickness.

• It is essential to introduce a index finger into the uterine cavity to assure the

maintenance of an adequate endometrial flaps, to allow a safe margin of

tissue for reconstructing the uterine wall.

Reconstruction of the uterine wall

• The endometrium reconstruction is carried out by

approximating the endometrium.

The first layer of uterine wall,

• Adapting the 2nd layer of the uterine wall by Overlapping on the first layer.


Overlapping the 2nd layer of the uterine wall


• Muscle fibers in the reconstructed uterine wall is abundant.

• Therefore, by triple overlap, more muscle fibers will be

gathered for strength. This is the benefit of this method.

Overlapping the 3rd layer of the uterine wall

• TachoComb® , a Fibrin Adhesive in Sheet Form is applied

to the uterine surface for the control of oozing.

Hemostasis and prevention Adhesion

Video

Ｃase 1.

2 weeks after surgery

2 months after surgery


3 months post surgery

A post-operative MR showed that the majority of the affected tissues

had been removed and the reconstructed posterior wall of the uterus

had been formed to the same thickness as the anterior wall.

Hysterosalpingography

3 months post surgery

Perfusion

the uterine cavity was maintained.

as was patency in both fallopian

tubes.

And Perfusion of contrast medium

was normal, which meant no adhesion

was formed.

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伊藤麻衣子

The patient became pregnant after 3 months post surgery naturally.

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0602

18

The patient delivered a twinat 34 weeks by elective Cesarean section.

Video

Ｃase 2

Video

Ｃase 3

Prevention Adhesion

2nd Look Laparoscopy

Recovery of blood flow After surgery ?

永友美輝 MRI

Recovery of blood flow After surgery ?

MRI

1 month after surgery

Contrast-MRI

Case 1: Recovery of blood flow After surgery ?

avascular area


Contrast-MRI

At this point the women

may be allowed conceive

MRI


avascular area

The Uterine blood flow has come back,

and no avascular area is visible.

ヤナギアキコ

ホサカミナコ

MRI


This case is a case of longest cases that is needed about

20 months untill is recovered uterine blood flow

柳昭子2ヶ月MRI②

柳昭子2ヶ月MRI②

2 months

after surgery

MRI

Contrast-MRI


avascular area

柳昭子６月MRI

6 months

after surgery

MRI


Contrast-MRI

avascular area

柳 20ヶ月子宮内膜柳昭子１２ヶ月ｘ MRI

Contrast-MRI

12 months

after surgery

avascular area


柳 20ヶ月子宮内膜

20 months

after surgery

MRI

At this point the women

may be allowed conceive Contrast-MRI

avascular area


After the uterine blood flow is recovered

untill almost normal flow

may be allowed conceive

The uterine blood flow of almost cases

is recovered within 6 months after surgery

However, in a few cases （5/104, 4.8%）

the blood flow took nearly a year to return.

Method；

1. Visual Analog Scale (VAS)

2. Numerical rating scale (NRS)

3. Visual rating scale (VRS)

10 9 8 7 6 5 4 3 2 1 0

Dysmenorrhea

Clinical post operative Efficacy for Dysmenorrhea and Hypermenorrhea

N=104 casess

Mean± SD

Pre-surgery 3 months 6 months 12 months 24 months

post surgery

Menstrual volume

10

9 8

7

6

5

4

3

2

1

1.61 1.54 1.44 1.67

Dysmenorrhea

V

A

S 3.27 2.89 2.63 2.87

Clinical post operative Efficacy for

Dysmenorrhea and Hypermenorrhea

6. 1998 - 8. 2008

Birth and pregnancy outcome :

Elective Caesarean section : 29 cases

Clinical pregnancies(on going) : 0 case

Abortion (5 , 8, 16 weeks) : 7 cases(14times)

No. of patients who become pregnant : 34/ 52 (65.3%)

Spontaneous pregnancies : 6/34 cases(17.6%)

I V F-ET 28/34 cases(82.4%)

No. of patients : 113

No. of patients who desired to conceive : 52/ 113 (46.0%)

Outcome after surgical Treated by the triple-flap method of severe cases of adenomyosis Jun. 1998 - Dec. 2015

2015.12

1. A wider and more complete excision of adenomyosis

2. A reconstruction of the uterine wall strength enough to sustain normal pregnancy

3. No complications as yet experiment

The triple-flap method can achieve:

Conclusions

The three-flap reconstruction of the uterine wall following wide adequate excision of adenomyosis tissue in women with hyper-dysmenorrhea

and in women who desired to conceive, allowed them to go to term without rupturing the uterine wall.

resulted in a dramatic reduction in both menstrual cramping and menstrual flow volume post surgically,

Internet: Adenomysis Osada prodcedure

or RBMOnline

Thank you for your attention

Documents

Treating the untreatable : Surgery on adenomyosis 1 2016 Adeno (English).pdf · Surgery on adenomyosis Hisao OSADA, MD, PhD. Director, Natural ART Clinic, Nihombashi, Tokyo Former