Even though uterine-sparing surgery is being increasingly recommended as a mainstay treatment for adenomyoma14–16, conservative surgical interventions cannot be the sole therapeutic measure for adenomyoma, especially since it can prove a challenge to excise all the ectopic uterine tissue. Adenomyotic tissue has the pathological propensity to invade the uterine muscle layer without leaving clear lesion border markings, so we believe that resection of adenomyosis tissue should be as complete as possible, and that comprehensive therapy is essential to achieve a clinically successful outcome for the patient.
In the current study, 4 of the 21 patients with fertility requirements and 3 of the 120 patients without fertility requirements were found to have a relapse on ultrasound examination. At 48 months after the operation, only 19.0% of patients with fertility requirements and 2.5% of patients without fertility requirements were found to have relapses. This indicates that laparoscopic adenomyomectomy with complete resection of adenomyosis, including part of the endometrium, can be expected to produce a significant decline in the relapse rate.
The results of the present study demonstrated a marked reduction in VAS scores, menorrhagia, and serum CA125 levels, together with a rise in blood hemoglobin level, after the surgery. Dysmenorrhea and menorrhagia are both hallmark symptoms of adenomyosis, and their degree of severity is directly related to the surgical efficacy of laparoscopic adenomyomectomy17. Serum CA125 level is deemed to be a reliable diagnostic biomarker and is suitable for monitoring the efficacy of adenomyosis therapies and detecting possible recurrences2, 17. It is apparent that laparoscopic adenomyomectomy combined with GnRH agonists can effectively treat adenomyoma patients.
Our group has already reported the advantage of modified laparoscopic myomectomy using manual assistance for the comprehensive and systematic palpation of the uterus for multiple uterine myomas12. In the current study, this method was used to perform adenomyomectomy for patients with multiple foci of adenomyosis or suspicious lesions.
The 23 patients who did not use contraception in our study included 5 patients without preservation of endometrial integrity and 18 patients with preservation of endometrial integrity. Among these patients, 12 patients (52%) had a total of 14 clinical pregnancies during 48 months of postoperative follow-up. Among the 18 patients with preserved endometrial integrity, 7 patients had 9 clinical pregnancies; 7 of the 18 infertile women (38.9%) succeeded in conceiving after the operation, but 1 of them underwent elective termination because she no longer had any fertility requirements. None of the patients had another pregnancy during the rest of the follow-up period. The 5 patients without preserved endometrial integrity who became pregnant also opted for elective termination under hysteroscopy because they had no fertility requirements. Thus, if the patient has no fertility requirements, contraception should be used after this procedure. This study had no uterine rupture. In infertile women, if a pregnancy fails to result after conservative therapy, laparoscopic adenomyoma resection may be considered.
Research has proved that the high-intensity-focused ultrasound method (HIFU) and combined treatment before assisted reproductive techniques can prove beneficial in adenomyosis patients18.
Of the 21 patients with fertility requirements, 3 patients were treated with an LNG-IUS, as they had no short-term fertility requirements. Indeed, for some patients with no desire for fertility, laparoscopic adenomyoma resection can be followed by combined treatment with the LNG-IUS and GnRH agonists. Research has proved that laparoscopic adenomyoma resection and GnRH agonist treatment can be of great therapeutic benefit in symptomatic adenomyoma and that the LNG-IUS can improve the efficacy of this novel combination therapy14.
However, the number of patients with fertility requirements was limited and the study lacked a control group. Further studies are needed to investigate the pregnancy outcomes and relapses.
Laparoscopic adenomyomectomy combined with GnRH agonist therapy can effectively treat uterine adenomyoma. In the case of patients with no fertility requirements, complete resection of the adenomyosis tissue (including part of the endometrium) can be expected to result in a significant decline in the relapse rate.