Application of modified subtotal resection of adenomyosis combined with LNG-IUS and GnRH-a sequential therapy in severe adenomyosis: A case series

Abstract

Background and objective: Adenomyosis focus resection has always been the main surgical method for patients with uterine preservation, but its curative effect and surgical method are still controversial. We improved this method on the basis of the "double-flap method" and combined it with the levonorgestrel intrauterine delivery system (LNG-IUS) and gonadotropin-releasing hormone agonist (GnRH-a) sequential treatment to determine the clinical effect and feasibility of this scheme in the treatment of severe adenomyosis.

Methods: This is a retrospective review. A total of 64 patients with severe adenomyosis were treated in the Department of Gynecology of Changzhou Second People's Hospital, which is affiliated to Nanjing Medical University, from December 2017 to September 2021. The transabdominal approach and laparoscopic approach were adopted for the purposes of treatment in this study. Hence, the patients were subdivided into the transabdominal approach subgroup and the laparoscopic approach subgroup. The hemoglobin, visual analog score (VAS) score, menstruation score, and other indices of each patient before and after treatment were observed, recorded, and analyzed.

Results: All 64 patients underwent the operation successfully. After the completion of sequential treatment, the CA125 decreased significantly 1 month after the operation, the average uterine volume significantly reduced, the hemoglobin value increased to a certain extent 3 months after the operation, and the menstrual score and dysmenorrhea during the first menstruation were significantly lower than they were before the operation. After the treatment, the therapeutic results of the transabdominal approach subgroup and endoscopic approach subgroup were compared on the basis of the observed indices, and no significant difference was observed (P > 0.05). Only one patient had a downward movement of the LNG-IUS, and the vaginal ultrasound showed that the upper end of the LNG-IUS was approximately 1.5 cm from the bottom of the uterine cavity. The average follow-up period was 24.02 ± 11.77 months, and no lesion progression was found in any patients.

Conclusion: For patients suffering from severe adenomyosis who have no pregnancy plans and require uterine preservation, transabdominal or laparoscopic subtotal resection of the focus of adenomyosis, combined with the LNG-IUS + GnRH-a sequential treatment, may be a safe and effective alternative when conservative treatments such as drugs fail.

Keywords: dysmenorrhea; gonadotropin-releasing hormone agonist; levonorgestrel intrauterine delivery system; severe adenomyosis; subtotal resection of adenomyosis.

Figure 1

Procedure diagram of a transabdominal operation. (A) Inject diluted pituitrin; (B) remove uterine fibroids; (C) make a longitudinal incision of adenomyosis lesions to reach the uterine cavity; (D) Resect the lesion as much as possible (preserving approximately 0.5–1 cm of the plasmomuscular layer flaps); (E) treat the contralateral lesions with the same method; (F) gradually subtract the lesion to the uterine cavity and excise a part of the uterine cavity to reduce the uterine volume; (G) treat the contralateral lesions with the same method; (H) remodel the myometrium; (I) place the LNG-IUS (Manchester ring) and reshape the depth of the uterine cavity again based on the LNG-IUS length; (J) Mattress-suture the uterine cavity continuously; (K) align the sarcoplasmic layers and reduce the extra length; (L,M) suture the bilateral seromuscular layers with the “baseball stitching technique”; (N) repair the sutured uterus; (O) uterine fibroids and adenomyosis specimens resected during the operation.