The benefit of adenomyomectomy on fertility outcomes in women with rectovaginal endometriosis with coexisting adenomyosis.

STUDY OBJECTIVE: To evaluate the effect of removal of coexisting adenomyosis on fertility outcomes in women with rectovaginal endometriosis. DESIGN: A retrospective cohort study. SETTING: A general hospital. PATIENTS: A total of 190 women who underwent laparoscopic nodule excision surgery for rectovaginal endometriosis between April 2007 and December 2012. INTERVENTIONS: Surgical excision of the rectovaginal endometriosis and coexisting uterine adenomyosis. Statistical analysis for fertility outcomes. MEASUREMENT AND MAIN RESULTS: A total of 119 women desired postoperative pregnancy. Coexisting adenomyosis was found in 21% of the women. The overall clinical pregnancy rate was 41.2%. The only determining factor associated with a successful pregnancy was "age at surgery". Clinical pregnancy rates with or without adenomyosis were 36.0% and 42.6%, respectively. We found no significant difference in clinical pregnancy rates between the groups. CONCLUSION: There is a possibility that surgical removal of coexisting adenomyosis positively effects fertility outcomes in women with rectovaginal endometriosis. However, it is also important to note that the age at surgery was a critical factor for successful pregnancy.

An evaluation of laparoscopic hysterectomy alone versus in combination with laparoscopic myomectomy for patients with uterine fibroids.

OBJECTIVE: The purpose of this study was to compare surgical outcomes following conventional laparoscopic hysterectomy (LH) (C-LH) versus the combination method of LH plus laparoscopic myomectomy (LM) (LH+LM) for the treatment of large uterine fibroids. STUDY DESIGN: This study was performed in 56 patients (uterine weights ≥500g) who underwent either C-LH or LH+LM performed by the same surgeon between May 2010 and May 2016. LH+LM was performed when C-LH was problematic because of poor visibility and/or mobility due to uterine fibroids. RESULTS: The C-LH and LH+LM groups consisted of 27 (48%) and 29 (52%) patients, respectively. The clinical characteristics of patients differed significantly only in the median sizes of the dominant fibroid. The sizes of the dominant fibroid in the C-LH and LH+LM groups were 9.5cm and 10.7cm (P=0.04), respectively. Regarding the surgical outcomes for the C-LH and LH+LM groups, the median uterine weights were 558g and 737g (P=0.03), respectively, the median operating times were 156min and 173min (P=0.23), respectively, and the median intraoperative blood losses were 150g and 300g (P=0.0004), respectively. In all patients, LH was performed without conversion to laparotomy and there were no cases of bladder, ureteral, or gastrointestinal tract injury. There were no postoperative complications of Clavien-Dindo scale≥III in either group. CONCLUSIONS: When C-LH cannot be performed because of large uterine fibroids that cause poor visibility and/or mobility, LH+LM may allow the procedure to be successfully completed without conversion to laparotomy. However, the latter approach increases the risk for intraoperative blood loss.

Who will benefit from uterus-sparing surgery in adenomyosis-associated subfertility?

OBJECTIVE: To analyze the determinants of successful pregnancy following laparoscopic adenomyomectomy. DESIGN: Retrospective cohort study. SETTING: A general hospital. PATIENT(S): A total of 102 women who had a desire for pregnancy underwent laparoscopic adenomyomectomy from 2007 to 2012. INTERVENTION(S): Surgical excision of the uterine adenomyosis; statistical analysis for fertility outcomes. MAIN OUTCOME MEASURE(S): Pregnancy rates and the results of univariable and multivariable analyses. RESULT(S): When the women were divided into ≤39 years and ≥40 years age groups, clinical pregnancy rates were 41.3% and 3.7%, respectively. Factors associated with clinical pregnancy were: history of IVF treatments, posterior wall involvements, and age, with odds ratios of 6.22, 0.18, and 0.77, respectively. In the younger group, 60.8% of women with history of IVF failure showed successful pregnancy after surgery. We experienced 2 cases of placenta accreta in far advanced cases. CONCLUSION(S): This study demonstrated age as a determinant in fertility outcomes. Surgery could be a beneficial treatment for women who experienced IVF treatment failures, especially at ages of ≤39 years. We could not show a clear benefit of the surgery on fertility outcomes of the group aged ≥40 years. Extremely severe adenomyosis affecting a broad range of the uterine subendomerial myometrium should be treated carefully on a pregnancy course.

Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification.

OBJECTIVE: The aim of the present study was to differentiate and specify the subtypes of adenomyosis. STUDY DESIGN: Surgically treated adenomyosis (n = 152) was subcategorized retrospectively into 4 subtypes on the basis of magnetic resonance imaging geography. Subtype I (n = 59) consisted of adenomyosis that occurs in the uterine inner layer without affecting the outer structures. Subtype II (n = 51) consisted of adenomyosis that occurs in the uterine outer layer without affecting the inner structures. Subtype III (n = 22) consisted of adenomyosis that occurs solitarily without relationship to structural components. Adenomyosis that did not satisfy these criteria composed subtype IV (n = 20). Stepwise logistic regression analysis was used for specification of the subtypes. RESULTS: Subtypes I-III were suggested as a product of direct endometrial invasion, endometriotic invasion from the outside, and de novo metaplasia, respectively. Subtype IV was a heterogeneous mixture of far advanced disease. CONCLUSION: Adenomyosis appears to consist of 3 distinct subtypes of different causes and an additional subtype of indeterminate cause.

Acute urinary retention caused by endometrial carcinoma with large cystic cervix.

INTRODUCTION: Several pelvic masses have been known to cause urinary retention due to a mass effect with the bladder being obstructed secondary to compression of the urethra or bladder neck. MATERIALS AND METHODS: We report the extremely rare case of endometrial carcinoma with an enlarged cystic cervix which resulted in acute urinary retention. A 92-year-old woman was referred for acute urinary retention. Vaginal ultrasound revealed a 70 × 70 × 65 cm-sized cystic lesion in the cervix. Voiding became normal immediately after the incision and drainage of the mass. Ultrasound performed after the incision revealed a hyperechogenic mass with a honeycomb appearance in the uterine cavity. Endometrial biopsy revealed well-differentiated adenocarcinoma of the endometrium. Total hysterectomy and bilateral salpingo-oophorectomy was performed. CONCLUSION: The possible existence of endometrial carcinoma should be considered when the enlargement of cervix is clinically suspected in an elderly woman even if there is no vaginal discharge or bleeding.