treating the untreatable : surgery on adenomyosis 1 2016 adeno (english).pdf · surgery on...
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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.
Management of adenomyosis by the triple-flap method
• 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.
Management of adenomyosis by the triple-flap method
• 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.
Reconstruction of the uterine wall
Overlapping the 2nd layer of the uterine wall
Reconstruction 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 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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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
6 months after surgery
Contrast-MRI
At this point the women
may be allowed conceive
MRI
Case 1: Recovery of blood flow After surgery ?
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
Case 2: Recovery of blood flow After surgery ?
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
Case 2: Recovery of blood flow After surgery ?
avascular area
柳昭子6月MRI
6 months
after surgery
MRI
Case 2: Recovery of blood flow After surgery ?
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
Case 2: Recovery of blood flow After surgery ?
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
Case 2: Recovery of blood flow After surgery ?
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