Clinical Outcomes of Conservative Surgery for Diffuse Uterine Leiomyomatosis: Preliminary Experience of 17 Cases in a Single Center.

This study aimed to introduce the clinical outcomes of conservative surgery for diffuse uterine leiomyomatosis, which also included the specialized surgical technique. All patients with diffuse uterine leiomyomatosis underwent conservative surgery such as transient occlusion of the uterine arteries (TOUA) adenomyomectomy. All 17 surgeries were performed by a single surgeon between 2018 and 2021. The mean age of the 17 patients was 36.12 years old (range 29-48, SD = 5.4). Fourteen of the 17 patients received a previous myomectomy via a laparotomic (6, 35.3%), laparoscopic (6, 35.3%), or hysteroscopic (2, 11.8%) approach. The major symptom was menorrhagia (94.1%); the mean operation time was 97.06 min (70-160, SD = 22.71), and the mean estimated blood loss was 283.53 mL (20-1000, SD = 273.72). The mean hemoglobin level one day after the operation was 9.64 g/dL (7.2-13.1, SD = 1.85). The mean hospital stay was 6.47 days (6-8, SD = 0.62). The mean follow-up duration was 116.41 weeks (32-216, SD = 50.88). The recurrence rate was 5/17 (29.4%), and the recurrence-free interval was 50.6 weeks (27-87, SD = 23.71). In patients with diffuse uterine leiomyomatosis, who want fertility preservation and relief of disease-related symptoms, conservative surgery such as TOUA adenomyomectomy could be a good option to preserve the uterus. However, further studies are required to assess fertility outcomes with a long-term follow-up.

Advanced Laparoscopic Adenomyomectomy Technique for Focal Uterine Adenomyosis by Three-step Approach.

Background and Objective: Owing to the increasing trend of preserving fertility in adenomyomectomy, the need for laparoscopic adenomyomectomy has increased. This study aimed to introduce a new surgical technique, an advanced laparoscopic adenomyomectomy technique, and to evaluate its efficacy, benefits, and safety in focal uterine adenomyosis. Methods: From February 1, 2019 to February 29, 2020, 47 patients who underwent laparoscopic adenomyomectomy using the new surgical technique were enrolled in the study. The inclusion criteria were: (1) Focal-type adenomyosis, diagnosed by ultrasound or magnetic resonance imaging that was refractory to medical treatments. (2) A strong desire to preserve the uterus. All the operations were performed by a single surgeon with a uniform technique. Results: The mean patient age was 40.53 ± 5.93 years (median 38.5, range 32-47). The mean diameter of the adenomyoma lesions was 4.57 ± 1.21 cm and the mean weight of the excised lesions was 40.53 ± 35.65g (range, 15-209 g). The mean total operation time was 70.11 ± 15.05 minutes. The mean estimated blood loss was 88.88 ± 20.0 mL (20 - 500 ml). There was no conversion to laparotomy or major complications requiring reoperation. At the seven-month follow-up, there was complete remission of dysmenorrhea and menorrhagia in 97.4% and 88.9% of the patients, respectively. Conclusions: The new advanced laparoscopic adenomyomectomy technique with a three-step approach could be a safe and effective therapeutic method.

Pregnancy and delivery outcomes in the women who have received adenomyomectomy: Performed by a single surgeon by a uniform surgical technique.

OBJECTIVE: Although adenomyomectomy for fertility-sparing is an expanding procedure worldwide, there is no guideline or consensus about how to manage the pregnant women who have previously received conservative surgery for adenomyosis. The aim of this study is to evaluate antenatal care and delivery outcomes in pregnant women after adenomyomectomy. MATERIALS AND METHODS: Between May 2011 and May 2019, the medical record was reviewed in all delivery of pregnant women received adenomyomectomy performed by a single surgeon by a uniform surgical technique. The evaluating parameters consisted of antenatal care outcomes, delivery outcomes, intrapartum outcome, and neonatal outcomes. RESULTS: Twenty-two patients were evaluated to monitor pregnancy and delivery outcomes after the adenomyomectomy. Mean age of delivery was 37.0 years old (SD = 3.1, range 32-45, median 37). All were delivered by cesarean section. Mean gestational age was 36.2 weeks (SD = 3.6, range 27.4-39.4, median 37.3). The mean birth weight was 2560.9 g (SD = 771.8, range 1100-3920, median 2550) and the number of preterm births admitted for prematurity care was seven (31.8%, 7/22). Placental abnormality was found in the four cases, which included two placenta accreta and two previa. However, there were no cases of hysterectomy or intervention. We identified one case of uterine rupture during pregnancy (4.5%, 1/22) at 27 weeks of gestation. Except for preterm birth, adverse neonatal outcomes were not found in this study. CONCLUSION: Delivery of pregnant women who received adenomyomectomy can obtain safe perinatal outcomes under close monitoring of preterm labor and surveillance of catastrophic pregnancy related complications.

Granulomatous peritonitis caused by iatrogenic spillage of ovarian dermoid cystectomy: a case report and literature review.

A 39-year-old nulliparous woman experienced continuous mild fever and abdominal pain since undergoing laparoscopic ovarian dermoid cystectomy 3 months previously in a local hospital. Abdominal computed tomography revealed diffuse heterogeneous fat infiltrations with numerous micronodules in the greater and lesser omentum, combined with ascites with thickening of the parietal peritoneum. The patient underwent exploratory laparoscopy, which included partial pelvic peritonectomy, excision of granulomas, and adhesiolysis with massive irrigation. The patient was treated successfully with laparoscopic surgery and all reproductive structures were spared without operative complications. To avoid peritonitis, complete removal of cyst contents and massive irrigation should be performed during ovarian dermoid cystectomy. Conservative surgical treatment may be a good choice for treating granulomatous peritonitis induced by iatrogenic rupture.

Postoperative pain control with ropivacaine following laparoscopic myomectomy: A randomized double-blind, pilot study.

AIM: The aim of this study was to evaluate immediate pain control in patients who underwent laparoscopic myomectomy (LM) by intraoperative injection of ropivacaine into both uterosacral ligaments. METHODS: The study was a prospective, double-blind, randomized study. We analyzed 46 cases of LM performed between July 2015 and November 2016 by a single surgeon. We randomized the enrolled patients into either a ropivacaine or a saline injection group. Before the surgeon closed the abdominal wall, each 7.5% ropivacaine (5 mL) or saline (5 mL) was administered into both uterosacral ligaments through laparoscopic injection needle. We compared the pain intensity scores 2, 6, 12, and 24 h after injection between the two groups. RESULTS: The pain intensity scores were not significantly different. However, the ropivacaine group requested less of the analgesic than the placebo-injected group requested (P = 0.035). No patient in the ropivacaine group reported any side effects. CONCLUSION: Intraoperative ropivacaine injection into both uterosacral ligaments during LM can reduce the dosage of opioid analgesics.

Immediate postoperative pain control with ropivacaine following laparoscopic-assisted vaginal hysterectomy: A randomized double-blind pilot study.

OBJECTIVE: Although laparoscopic hysterectomy, a worldwide popular surgery, ensures faster recovery and less postoperative pain than with laparotomic hysterectomy, immediate pain control still improving postoperative care. We introduce an effective method, intraoperative injection of ropivacaine into both uterosacral ligaments, to control immediate postoperative pain. MATERIALS AND METHODS: We performed a prospective, double-blind, and randomized study. We analyzed 40 cases of laparoscopic vaginal hysterectomy performed between July 2015 and November 2016 by a single surgeon (Y.S.K.). We randomized the enrolled patients into the ropivacaine injection group and the saline injection group. Before the vaginal stump was closed, 7.5% ropivacaine or saline (10 mL) was administered into both uterosacral ligaments, 5 mL each. In all cases, the medicine was injected transvaginally before the vaginal stump was closed. The primary outcome was the postoperative pain intensity expressed by numeric ranking scale (NRS) scores at 2, 6, 12, and 24 h after injection. The secondary outcome was the amount of analgesics demanded for pain control during the 24 h after the surgery. RESULTS: The pain intensity at 2 h after injection was significantly lower in the ropivacaine-injected group (p = .0234). There was no difference in pain intensity at 6, 12, and 24 h after injection and the amount of analgesics used. However, the total amount of opioid analgesic used was lower in the ropivacaine-injected group than in the placebo-injected group. (p = .0251). CONCLUSION: Intraoperative ropivacaine injection into both uterosacral ligaments during laparoscopic hysterectomy can reduce early postoperative pain and consumption of analgesics to improve postoperative care.

Conservative surgery of uterine adenomyosis via laparoscopic versus laparotomic approach in a single institution.

AIMS: To evaluate the surgical outcomes of both approach methods (laparoscopy vs laparotomy) and to suggest the proper surgical approach according to type of uterine adenomyosis (focal vs diffuse). METHODS: We retrospectively analyzed 224 cases of uterine adenomyomectomy, 116 laparotomic and 108 laparoscopic, performed between July 2011 and June 2016 by a single surgeon (Y. S. K.). In all 224 cases, the surgeon had used transient occlusion of the uterine artery (TOUA). Surgical outcomes included weight of specimen, operating time, estimated blood loss and intraoperative injury to other organs. Postoperative clinical outcomes included symptom improvement (dysmenorrhea, menorrhagia and others) and recurrence. RESULTS: All patients in the laparoscopic group had been diagnosed with focal uterine adenomyosis, and most in the laparotomic group (85.3%) had been diagnosed with diffuse type. The largest lesion diameters were 6.48 cm in the laparotomic group and 4.34 cm in the laparotomic group. Operation time and estimated blood loss were 116.12 min and 222.67 mL in the laparotomic group and 75.09 min, respectively, and 155.33 mL in the laparoscopic group. There was no case of laparotomic conversion in patients with laparoscopic adenomyomectomy. CONCLUSION: Conservative surgery is effective to reduce the symptoms of adenomyosis regardless of approach method. For near-complete excision of adenomyosis, the diffuse type is recommended to be treated with laparotomic adenomyomectomy, and focal lesions less than 5 cm can be treated with laparoscopic conservative surgery.

Conservative surgery of diffuse adenomyosis with TOUA: Single surgeon experience of one hundred sixteen cases and report of fertility outcomes.

The aim of this study is to evaluate the clinical outcomes of conservative adenomyomectomy with TOUA for diffuse uterine adenomyosis and to determine the feasibility and safety. One hundred and sixteen patients with symptomatic diffuse uterine adenomyosis underwent adenomyomectomy with TOUA by a single surgeon at Ulsan University Hospital between May 2011 and March 2016. Surgical outcomes included operative time, intraoperative injury and operative blood loss. We assessed the degree of improvement in dysmenorrhea and menorrhagia at the 7-month follow-up visit after the operation. The mean age of patients was 37.49 years (range: 26-49). The mean total surgical time was 116.12 min (range: 60-300, SD: 37.27). The mean estimated blood loss was 207.22 mL (range: 30-1200, SD: 161.08) and there were no cases of injury to the uterine arteries or pelvic nerves. The mean duration of hospital stay was 5.05 days (range: 4-7, SD: 0.68) and the mean follow-up period of 16.67 months (range: 6-49, SD: 12.77). At the 7-month follow-up after adenomyomectomy with TOUA, dysmenorrhea and menorrhagia were improved in 100% and 89% of the patients, respectively. In patients with diffuse uterine adenomyosis, even when the whole uterus is involved, for relief of severe adenomyosis-related symptoms, adenomyomectomy with TOUA could be a safe and effective surgical treatment option for those who want to preserve their fertility.

Laparoscopic Surgery for Focal Adenomyosis.

BACKGROUND AND OBJECTIVES: For conservative surgical treatment of focal uterine adenomyosis, laparoscopic adenomyomectomy has been increasingly performed, so that reassessment to determine the safety and efficacy of the laparoscopic surgical technique in a larger number of cases and reevaluation for reproducibility for laparoscopic adenomyomectomy is needed. We evaluate the clinical outcomes of laparoscopic adenomyomectomy with transient occlusion of uterine arteries (TOUA) for focal uterine adenomyosis performed by a single surgeon at a single institute. METHODS: Patients (N = 105) with symptomatic focal uterine adenomyosis underwent laparoscopic adenomyomectomy with TOUA by a single surgeon at Ulsan University Hospital from May 1, 2011, through September 30, 2016. Surgical outcomes included operative time; intraoperative injury to blood vessels, nerves, and pelvic organs; and intraoperative blood loss. We assessed the degree of improvement in dysmenorrhea and menorrhagia and relapsing or remnant adenomyosis lesion by ultrasonography at the 7-momth follow-up after the operation. Then, all patients were followed up at 6-month intervals at the outpatient clinic. RESULTS: The mean patient age was 41.98 ± 4.73 years. The mean TOUA and operative times were 4.46 ± 2.68 and 75.14 ± 20.56 min, respectively. The mean estimated blood loss was 148.19 ± 101.69 mL. No conversion to laparotomy or major complications occurred. At the 7-month follow-up, complete remission of dysmenorrhea and menorrhagia had occurred in 93.02% and 76.92% of patients, respectively. CONCLUSIONS: Laparoscopic adenomyomectomy with TOUA is a safe and effective surgical treatment modality for women with symptomatic focal uterine adenomyosis who want to preserve fertility.

Monochorionic twin delivery after conservative surgical treatment of a patient with severe diffuse uterine adenomyosis without uterine rupture.

A 31-year-old nulliparous woman with severe diffuse uterine adenomyosis, which replaced nearly the whole uterine myometrium, visited our hospital due to severe dysmenorrhea, menorrhagia, and a desire to have a baby. The patient had a history of two spontaneous abortions. Laparotomic adenomyomectomy with transient occlusion of uterine arteries (TOUA) was performed safely and the patient tried in vitro fertilization and achieved a intrauterine twin pregnancy after recovery time of the operation. At 31+6 weeks of gestation, a male neonate baby weighing 1,620 g and a male neonate baby weighing 1,480 g were born by transverse lower segment cesarean delivery. There was no complication after the operation. The babies were discharged after receiving routine neonatal intensive care for neonatal respiratory distress syndrome. Adenomyomectomy with TOUA technique would be an option for conservative surgical treatment in patients with severe diffuse whole uterine adenomyosis. This is the first report of twin pregnancy after diffuse whole uterine adenomyomectomy with TOUA.

Successful term delivery cases of trans-abdominal cervicoisthmic cerclage performed at more than 18 weeks of gestation.

A 38-year-old nulliparous woman was referred to our clinic because of cervical incompetence at 19 weeks of gestation. Trans-abdominal cervicoisthmic cerclage was performed after failure of modified Shirodkar cerclage operation in the patient at 21 weeks of gestation via a laparotomic approach. Another 38-year-old patient, who underwent loop electrosurgical excision procedure conization for treatment of cervical dysplasia 4 years ago, presented for cervical incompetence. At 18 weeks of gestation, we performed trans-abdominal laparotomic cervicoisthmic cerclage without any post-operative complications. During antenatal follow-up, there were no obstetrical co-morbidities and finally she gave birth to a healthy infant at full term by cesarean section. We report two cases of women who underwent trans-abdominal cervicoisthmic cerclage surgery because of cervical incompetence as they were not suitable for transvaginal cervical cerclage. Both patients successfully maintained their pregnancy until full term after undergoing transabdominal cervicoisthmic cerclage at more than 18 weeks of gestation.

Diagnosis and surgical treatment of isolated rectal endometriosis: long term complication of incomplete treatment for pelvic endometriosis.

A 40-year-old woman visited our hospital with cyclic hematochezia for four months. The patient had the history of laparoscopic-assisted vaginal hysterectomy because of severe dysmenorrhea two years ago at another tertiary hospital. According to the medical records, the past surgical treatment was incomplete excision of pelvic endometriotic lesions, especially in rectal serosal lesions. A colonoscopy and abdominopelvic computed tomography showed an isolated tumor mimicking neoplasm, in which a biopsy under colonoscopy was performed and the lesion was endometriosis pathologically. Laparoscopic anterior resection (LAR) was performed. There were no complications during intraoperative and postoperative period and the patient was discharged 7 days after the LAR. It is important for reducing of long-term complication like rectal endometriosis that complete and safe excision of pelvic endometriosis with expert surgical strategy.

Intraoperative bleeding control during cesarean delivery of complete placenta previa with transient occlusion of uterine arteries.

There are few methods to control heavy intra-operative bleeding during cesarean delivery of placenta previa. Transient occlusion of uterine arteries (TOUA) during operation has previously been reported as a quick and safe method to control intra-operative uterine bleeding. We reported 2 cases of cesarean delivery with complete placenta previa in which TOUA was performed to safely reduce intra-operative complication, especially heavy intra-operative bleeding. In the 2 cases, cesarean deliveries were safe and without any complications under the TOUA method. TOUA can be a good method to control heavy intra-operative bleeding during cesarean delivery of complete placenta previa with risk of heavy bleeding.

Subclinical hypothyroidism diagnosed by thyrotropin-releasing hormone stimulation test in infertile women with basal thyroid-stimulating hormone levels of 2.5 to 5.0 mIU/L.

OBJECTIVE: To investigate the prevalence of subclinical hypothyroidism (SH) diagnosed by thyrotropin-releasing hormone (TRH) stimulating test in infertile women with basal thyroid-stimulating hormone (TSH) levels of 2.5 to 5.0 mIU/L. METHODS: This study was performed in 39 infertile women with ovulatory disorders (group 1) and 27 infertile women with male infertility only (group 2, controls) who had basal serum TSH levels of 2.5 to 5.0 mIU/L and a TRH stimulating test. Serum TSH levels were measured before TRH injection (TSH0) and also measured at 20 minutes (TSH1) and 40 minutes (TSH2) following intravenous injection of 400 µg TRH. Exaggerated TSH response above 30 mIU/L following TRH injection was diagnosed as SH. Group 1 was composed of poor responders (subgroup A), patients with polycystic ovary syndrome (subgroup B) and patients with WHO group II anovulation except poor responder or polycystic ovary syndrome (subgroup C). RESULTS: The prevalence of SH was significantly higher in group 1 of 46.2% (18/39) compared with 7.4% (2/27) in group 2 (P=0.001). TSH0, TSH1, and TSH2 levels were significantly higher in group 1 than the corresponding values in group 2 (P<0.001, P<0.001, P<0.001). In group 1, TSH1 and TSH2 levels were significantly lower in subgroup C compared with those in subgroup A and B (P=0.008, P=0.006, respectively). CONCLUSION: TRH stimulation test had better be performed in infertile women with ovulatory disorders who have TSH levels between 2.5 and 5.0 mIU/L for early detection and appropriate treatment of SH.