- Surgical treatment of uterine adenomyosis - the cardinal approach
Adenomyosis of the uterus - is a very common disease, which in some women does not cause any symptoms at all, while others greatly complicates life. For its treatment can be used surgery or drug therapy. Surgical treatment of uterine adenomyosis preferred for very strong symptoms of adenomyosis, which can not cope with other methods.
Throughout more than a century hysterectomy remains the main method of diagnosis and treatment of uterine adenomyosis. Vaginal hysterectomy is preferable to abdominal (first performed through the vagina, the second - through an incision in the abdominal cavity), because it is safer and the recovery process after such an operation is much faster. However, a decision in favor of one or another type of hysterectomy may be made not only on the basis of medical evidence and safety reasons, but also from the experience of the surgeon who will perform the operation.
In a comparative analysis of several hundred cases of vaginal hysterectomy in patients with uterine leiomyoma and adenomizom, it was found that hysterectomy is appointed for the treatment of adenomyosis is associated with an increased risk of bladder injury. Blood loss in the surgical treatment of both diseases are approximately the same. The exact reason why there is an increased likelihood of damage to the bladder is unknown, but presumably this is due to the fact that with adenomyosis can be harder to detect certain patterns of the reproductive system in most cases failed vaginal hysterectomy is associated with a deep germination of endometrial tissue outside of the inner shell wall uterus. Laparoscopy substantially facilitates operation and reduces the risk of bladder injury.
Speaking of conservative surgical treatment of uterine adenomyosis, you must take into account the differences between the two main forms of this disorder: a diffuse adenomyosis, where the disease affects the myometrium is more or less evenly, and adenoma or focal adenomyosis, which is characterized by local emergence of endometrial tissue in the myometrium. There are also some subtypes of these forms of adenomyosis, the peculiarities of the treatment which we discuss below. Conservative surgery was made possible thanks to modern methods of medical imaging. It is not suitable for all patients, but many women use it to manage to get rid of the symptoms of adenomyosis
Adenomyosis: Symptoms - what to expect from the body?
Without resorting to hysterectomy.
Symptomatic superficial adenomyosis typically affects the entire upper layers of the myometrium. Analysis results of ultrasound and magnetic resonance imaging (MRI) of many patients has shown that diffuse adenomyosis, typically the strongest strikes the back wall of the uterus. For the treatment of superficial adenomyosis can be used transcervical coagulation or resection of the endometrium. Unsuccessful ends 8-10% of such operations (a failure they say always, if symptoms persist after surgery adenomyosis, deteriorates or there are serious complications). During the ablation analysis 305 cases it was found that about 75% of patients who failed due to the ablation of the endometrium
Endometrial ablation - an alternative curettage
It required a hysterectomy - a woman who was appointed ablation for the treatment of uterine adenomyosis. Similar results were given another study: in seven of the eight cases, in women who required a hysterectomy was adenomyosis and endometrial ablation failure experience. The authors of both studies point out that the re-emergence of symptoms and, especially, the need for a hysterectomy is correlated to how deep into the myometrium sprouted endometrial tissue.
Doctors believe that in many cases the effects of endometrial ablation failure can be eliminated with the help of therapeutic hysteroscopy. In 26 women whose medical records were studied in the analysis of cases of surgical treatment of adenomyosis, after endometrial ablation were unbearable pain, which could not cope with the help of analgesics, bleeding and asymptomatic hemometra (accumulation of blood in the uterus). In all these cases hysteroscopy gave excellent results - amenorrhea and severe pain in the lower abdomen have passed, and most of the patients able to avoid hysterectomy. The experts who conducted the study, concluded that if a couple of decades ago when adenomyosis hysterectomy was almost inevitable, today superficial adenomyosis can be successfully treated using hysteroscopy and the latest methods of endometrial ablation.
On the other hand, when a deep germination endometrial tissue (greater than 2.5 cm) in the case of an unsuccessful endometrial ablation is usually necessary to resort to a hysterectomy. To determine the degree of damage of the myometrium and choose the most suitable kind of surgery, MRI may be used in high-resolution ultrasound or - one of the most effective methods for diagnosis of uterine adenomyosis.
Recently published results of a small study in which examined the use of laparoscopic uterine artery ligation (LPMA) in 20 women with deep adenomyosis. Six months after surgery 15% of patients evaluated the results LPMA satisfactory, but 45% of patients were dissatisfied with the results of the operation. The low degree of satisfaction among patients with a high probability says that this kind of operation is not suitable for the treatment of deep adenomyosis, although research in this area will still continue.
In another study, researchers analyzed the 44 cases where women with deep diffuse adenomyosis
Diffuse adenomyosis - common disease of women
We wanted to avoid hysterectomy, and doctors tried to use for their treatment conservative surgery. During the operation, carried out a longitudinal incision of the uterus, removing the most affected parts of the front and back walls of the uterus, after which the remaining fabric sewn. After surgery, a significant proportion of patients have no pain in the lower abdomen during menstruation, and all 44 women passed the anemia caused by menorrhagia
Menorrhagia (menorrhagia) - excessive blood loss
(very heavy menstrual bleeding). After some time after the operation the patient became pregnant two: one of them had a normal pregnancy, the other - interstitial tubal pregnancy.
Conservative surgery can be used in the treatment of deep diffuse adenomyosis as an alternative to hysterectomy.
The most appropriate conservative surgical treatment for uterine adenomyoma a laparotomy, but its implementation may be difficult because the surgeon uses this kind of surgery, it is extremely difficult to detect lesions of the myometrium and the depth of infiltration of tissues. Adenomyoma can germinate in areas located close to the fallopian tubes or major blood vessels. Furthermore, adenomyoma themselves may be many blood vessels. Often, before the operation is carried out medical treatment agonist of gonadotropin-releasing hormone.
A team of scientists to investigate the case of transactions with a cross-sectional view of the abdominal wall that allows the surgeon a better view of the uterus, to conduct palpation, and remove the affected tissue adenomyosis. Compared to traditionally used for the treatment of adenomyosis laparotomy using a cross-section of the risk of uterine perforation has decreased from 40% to 17%.
In the other study involved 26 patients with adenomyoma; all they wanted after removing adenomyoma maintain reproductive function. Complete removal adenomyoma was only possible in ten cases, and at sixteen patients received only partially remove the adenoma. However, operation in all cases resulted in a significant relief of symptoms adenomyosis, dysmenorrhea like (severe pain and cramps during menstruation) and menorrhagia. Three patients failed to get pregnant without serious problems to bear and raise children. In the other three patients it was observed re-occurrence of the symptoms of adenomyosis, on average, after 50 months after surgery.
The medical literature describes and cases of laparoscopic removal of the adenoma patients with chronic pelvic pain, despite the fact that the precise location of adenomas using laparoscopy can be quite frustrating
. In some cases, the diagnosis and determine the location of adenomas used MRI, then held laparoscopy
. In one study, seven out of ten reported cases has been successfully used laparoscopic coagulation - patients adenomyoma uterus removed, after which many of the symptoms disappear or become much less pronounced
. In the other three cases, one patient had a deletion adenomyoma through abdominal incision, the other needed a hysterectomy, and the third patient refused further treatment
. Another study was used for detection of adenomas gidrosonografiya before being successfully removed using laparoscopy