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Total Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring
May 2003, Vol. 10, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
Total Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring Hiroshi Nabeshima, M.D., Takashi Murakami, M.D., Ph.D., Yukihiro Terada, M.D., Ph.D., Takahiro Noda, M.D., Nobuo Yaegashi, M.D., Ph.D., and Kunihiro Okamura, M.D., Ph.D. Abstract
(J Am Assoc Gynecol Laparosc 10(2):195–199, 2003)
A 19-year-old-woman had a cystic adenomyoma located within the myometrium. She complained of severe dysmenorrhea. Gonadotropin-releasing hormone agonist therapy was administered, but her dysmenorrhea was more pronounced than before treatment. Therefore, total laparoscopic resection of the lesion was performed. The external appearance of the patient’s uterus was almost normal. A hydroultrasonographic monitoring method was devised (transvaginal ultrasonography with peritoneal hydration of physiologic saline) that proved useful in locating the adenomyoma. The patient’s dysmenorrhea disappeared postoperatively.
Adenomyosis is a benign proliferative disease of the uterus characterized by contiguous spread of endometrial glands and stroma into the myometrium. It may be associated with cystic spaces filled with blood. However, such spaces are typically small, less than 0.5 cm in diameter.1 Large adenomyotic cysts, referred to as cystic adenomyomas, are rare.2 They often cause severe pain,3 and as drug therapy is usually only marginally effective, surgical treatment is recommended.
peritoneum. Because the uterine shape was almost normal and the location of the cystic adenomyoma could not be detected precisely (Figure 2), we devised a hydroultrasonographic monitoring method to determine an incision point. The pelvic cavity was filled with physiologic saline up to top of the uterus. The intramural cyst and forceps were clearly imaged, and the point of incision was determined with certainty with ultrasound monitoring (Figure 3). Excessive water was suctioned, vasopressin with saline was injected into the uterine muscle layer, and uterine serosa and myometrium were cut with a harmonic scalpel (Ethicon EndoSurgery, Inc.). The adenomyotic region was resected with the harmonic scalpel; however, as is uncommon in myomectomy, the adenomyotic cyst was not clearly distinguished from normal myometrium. It proved impossible to carry out intact resection of the entire adenomyotic region. When the scalpel reached the intramural cyst, chocolate-like fluid was expressed from the cyst. We therefore resected the area surrounding the cyst using a special tension device. The cyst was removed through the 12-mm left umbilical incision using a morcellation cutter. After resection of the entire adenomyotic portion of the uterus, the cavity was repaired with interrupted 0 polyglactin suture of the muscle layer, and with continuous 4-0 polypropylene suture of the serosal layer. Total operating time was 234 minutes, and blood loss was less than 100 ml. The woman’s postoperative course was uneventful and she was discharged 4 days after surgery. Her dysmenorrhea totally disappeared, and she became pregnant 3 months later. The pregnancy was in progress at time of writing.
Case Report A 19-year-old nulligravida woman had a history of severe dysmenorrhea for which she had received gonadotropin-releasing hormone (GnRH) agonist therapy. After menstruation resumed, dysmenorrhea was worse than before. Transvaginal ultrasonography revealed a 3-cm cystic-like region located within the myometrium. Magnetic resonance images of the pelvic cavity revealed a 3-cm structure (T1- and T2-weighted images were of high signal intensity) involving the right side of the uterus (Figure 1). On hysterosalpingogram, the uterine cavity was pushed to the left, which suggested a cyst on right side of uterus, and that the cyst had no communication with the uterine cavity. Laboratory test results were unremarkable except for a slightly elevated serum CA 125 of 40.9 U/ml (normal <35 U/ml). In view of progressive dysmenorrhea, laparoscopic resection of the cystic region was planned. Operative Technique Laparoscopic surgery was performed with fourpuncture technique and carbon dioxide (CO2) pneumo-
From the Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Miyagi, Japan (all authors). Address reprint requests to Hiroshi Nabeshima, M.D., Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan; fax 81 22 717 7258. Submitted May 10, 2002. Accepted for publication September 27, 2002. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, May 2003, Vol. 10 No. 2 © 2003 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
195
Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring Nabeshima et al
FIGURE 1. (A) Magnetic resonance images of pelvic cavity in an axial position. CA = cystic adenomyoma; EM = normal endometrium. (B) Hysterosalpingogram shows uterine cavity pushed to left side, which suggested a cyst on right side of the uterus, and that the cyst had no communication with the uterine cavity.
Histologic Examination Microscopic examination showed the cyst wall lining to be abraded in most areas (Figure 4). Exfoliation was most likely the effect of the GnRH agonist. Very few areas on the cyst were lined with endometrial-type epithelium. There were diffuse adenomyotic areas, and overgrowth of myometrium-like uterine myoma in the muscle layer below the cyst was observed.
This type of adenomyoma has chocolate- or tar-colored, thick viscous contents, and contains various amounts of endometrial stroma below the glandular epithelium. Diffuse hyperplasia and overgrowth of the myometrium are present.4–6 Clinical symptoms are menorrhagia, dysmenorrhea, and abdominal cramps,6 which are resistant to drug therapy. Many reports recommended resection of cystic adenomyomas due to this resistance, but these studies reported the need for laparotomy for curative treatment, after which dysmenorrhea is reduced or absent.2, 6,7 We believe this is the first report of total laparoscopic resection of a cystic adenomyoma. It should be noted that a few problems were encountered during the procedure. The
Discussion Cystic adenomyomas are rare and are usually associated with diffuse adenomyosis uteri, as determined histologically. 196
May 2003, Vol. 10, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 2. (A) Uterine surface appeared normal. (B) Chocolate-like fluid flowed from the cyst. (C) Cystic adenomyoma was removed with the harmonic scalpel and a special tension device. (D) Wound was repaired as after myomectomy.
FIGURE 3. Hydroultrasound monitoring. Arrows point to celiac cavity, cystic adenomyoma, and forceps.
197
Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring Nabeshima et al
FIGURE 4. Photomicrographs. (A) Cyst wall lining was abraded in almost all areas. (B) Few parts of the cyst were lined with endometrial-type epithelium (hematoxylin & eosin; original magnification 200 ×).
first was determining the optimal uterine incision point. The tumor was so small that no atypical finding on the uterine surface was initially seen laparoscopically. The second problem was finding a method of distinguishing the diseased region from normal myometrium. Because the adenomyotic region had spread diffusely around the cyst, the layer between that region and myometrium was diffuse, therefore rendering it difficult to separate out only the cyst. We overcame these problems by performing hydroultrasonographic monitoring. The problems were due to lack of sense of touch, which is peculiar to laparoscopic surgery; thus, finger-assisted laparoscopy may be an alternative.8 Hydroultrasonographic monitoring does not allow for tactile access to the surgical site; however, it does produce a useful visual image of the
area. It can be applied in any hospital, as the contrast material is physiologic saline; it is only necessary to exchange CO2 for saline solution. In general, borders between gas and solid matter cannot be described clearly by ultrasound due to low acoustic impedance for gaseous bodies, yet with our new technique, the border between liquid and solid matter was well enhanced. This effect promised to be useful for this laparoscopic surgery, and thus the pelvis was filled with physiologic saline. Using this simple method, the border between the position of the forceps and the intramural cystic area was clearly recognized. Intermittent monitoring by ultrasound facilitated recognition of the division between adenomyotic foci and normal myometrium. Physiologic saline contrast material was helpful in locating the disease within the myometrium. Typically, this
198
May 2003, Vol. 10, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
is very difficult to achieve laparoscopically, as the surface of a uterus with an intramural disorder usually appears normal; this is especially the case in women with adenomyosis or small intramural or submucosal myomal nodes.
3. Tamura M, Fukaya T, Takaya R, et al: Juvenile adenomyotic cyst of the corpus uteri with dysmenorrhea. Tohoku J Exp Med 178:339–344, 1996 4. Neri A, Bahary C, Eckerling B, et al: Serosal (subperitoneal) cysts of the uterus. Am J Obstet Gynecol 102:612–614, 1968
Conclusion Total laparoscopic resection of a cystic adenomyoma was performed successfully under hydroultrasonographic monitoring. This appears to be a good approach, because it is minimally invasive and it relieves the typically severe symptoms of menorrhagia, dysmenorrhea, and abdominal cramps associated with this disorder.
5. Keating S, Quenville NF, Korn GW, et al: Ruptured adenomyotic cyst of the uterus—A case report. Arch Gynecol 237:169–173, 1986
References
7. Kammerer-Doak DN, Magrina JF, Nemiro JS, et al: Benign gynecologic conditions associated with a CA-125 level >1,000 U/mL. A case report. J Reprod Med 41:179–182, 1996
6. Ejeckam GC, Zeinab OA, Salman M, et al: Giant adenomyotic cyst of the uterus. Br J Obstet Gynaecol 100:596–598, 1993
1. Slezak P, Tillinger KG: The incidence and clinical importance of hysterographic evidence of cavities in the uterine wall. Radiology 118:581–586, 1976
8. Terada Y, Murakami T, Noda T, et al: Finger-assisted laparoscopy to remove a noncommunicating uterine horn. J Am Assoc Gynecol Laparosc 8:594–596, 2001
2. Kataoka ML, Togashi K, Konishi I, et al: MRI of adenomyotic cyst of the uterus. J Comput Assist Tomogr 22:555–559, 1998
199
The Journal of the American Association of Gynecologic Laparoscopists
Total Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring Hiroshi Nabeshima, M.D., Takashi Murakami, M.D., Ph.D., Yukihiro Terada, M.D., Ph.D., Takahiro Noda, M.D., Nobuo Yaegashi, M.D., Ph.D., and Kunihiro Okamura, M.D., Ph.D. Abstract
(J Am Assoc Gynecol Laparosc 10(2):195–199, 2003)
A 19-year-old-woman had a cystic adenomyoma located within the myometrium. She complained of severe dysmenorrhea. Gonadotropin-releasing hormone agonist therapy was administered, but her dysmenorrhea was more pronounced than before treatment. Therefore, total laparoscopic resection of the lesion was performed. The external appearance of the patient’s uterus was almost normal. A hydroultrasonographic monitoring method was devised (transvaginal ultrasonography with peritoneal hydration of physiologic saline) that proved useful in locating the adenomyoma. The patient’s dysmenorrhea disappeared postoperatively.
Adenomyosis is a benign proliferative disease of the uterus characterized by contiguous spread of endometrial glands and stroma into the myometrium. It may be associated with cystic spaces filled with blood. However, such spaces are typically small, less than 0.5 cm in diameter.1 Large adenomyotic cysts, referred to as cystic adenomyomas, are rare.2 They often cause severe pain,3 and as drug therapy is usually only marginally effective, surgical treatment is recommended.
peritoneum. Because the uterine shape was almost normal and the location of the cystic adenomyoma could not be detected precisely (Figure 2), we devised a hydroultrasonographic monitoring method to determine an incision point. The pelvic cavity was filled with physiologic saline up to top of the uterus. The intramural cyst and forceps were clearly imaged, and the point of incision was determined with certainty with ultrasound monitoring (Figure 3). Excessive water was suctioned, vasopressin with saline was injected into the uterine muscle layer, and uterine serosa and myometrium were cut with a harmonic scalpel (Ethicon EndoSurgery, Inc.). The adenomyotic region was resected with the harmonic scalpel; however, as is uncommon in myomectomy, the adenomyotic cyst was not clearly distinguished from normal myometrium. It proved impossible to carry out intact resection of the entire adenomyotic region. When the scalpel reached the intramural cyst, chocolate-like fluid was expressed from the cyst. We therefore resected the area surrounding the cyst using a special tension device. The cyst was removed through the 12-mm left umbilical incision using a morcellation cutter. After resection of the entire adenomyotic portion of the uterus, the cavity was repaired with interrupted 0 polyglactin suture of the muscle layer, and with continuous 4-0 polypropylene suture of the serosal layer. Total operating time was 234 minutes, and blood loss was less than 100 ml. The woman’s postoperative course was uneventful and she was discharged 4 days after surgery. Her dysmenorrhea totally disappeared, and she became pregnant 3 months later. The pregnancy was in progress at time of writing.
Case Report A 19-year-old nulligravida woman had a history of severe dysmenorrhea for which she had received gonadotropin-releasing hormone (GnRH) agonist therapy. After menstruation resumed, dysmenorrhea was worse than before. Transvaginal ultrasonography revealed a 3-cm cystic-like region located within the myometrium. Magnetic resonance images of the pelvic cavity revealed a 3-cm structure (T1- and T2-weighted images were of high signal intensity) involving the right side of the uterus (Figure 1). On hysterosalpingogram, the uterine cavity was pushed to the left, which suggested a cyst on right side of uterus, and that the cyst had no communication with the uterine cavity. Laboratory test results were unremarkable except for a slightly elevated serum CA 125 of 40.9 U/ml (normal <35 U/ml). In view of progressive dysmenorrhea, laparoscopic resection of the cystic region was planned. Operative Technique Laparoscopic surgery was performed with fourpuncture technique and carbon dioxide (CO2) pneumo-
From the Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Miyagi, Japan (all authors). Address reprint requests to Hiroshi Nabeshima, M.D., Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan; fax 81 22 717 7258. Submitted May 10, 2002. Accepted for publication September 27, 2002. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, May 2003, Vol. 10 No. 2 © 2003 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
195
Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring Nabeshima et al
FIGURE 1. (A) Magnetic resonance images of pelvic cavity in an axial position. CA = cystic adenomyoma; EM = normal endometrium. (B) Hysterosalpingogram shows uterine cavity pushed to left side, which suggested a cyst on right side of the uterus, and that the cyst had no communication with the uterine cavity.
Histologic Examination Microscopic examination showed the cyst wall lining to be abraded in most areas (Figure 4). Exfoliation was most likely the effect of the GnRH agonist. Very few areas on the cyst were lined with endometrial-type epithelium. There were diffuse adenomyotic areas, and overgrowth of myometrium-like uterine myoma in the muscle layer below the cyst was observed.
This type of adenomyoma has chocolate- or tar-colored, thick viscous contents, and contains various amounts of endometrial stroma below the glandular epithelium. Diffuse hyperplasia and overgrowth of the myometrium are present.4–6 Clinical symptoms are menorrhagia, dysmenorrhea, and abdominal cramps,6 which are resistant to drug therapy. Many reports recommended resection of cystic adenomyomas due to this resistance, but these studies reported the need for laparotomy for curative treatment, after which dysmenorrhea is reduced or absent.2, 6,7 We believe this is the first report of total laparoscopic resection of a cystic adenomyoma. It should be noted that a few problems were encountered during the procedure. The
Discussion Cystic adenomyomas are rare and are usually associated with diffuse adenomyosis uteri, as determined histologically. 196
May 2003, Vol. 10, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 2. (A) Uterine surface appeared normal. (B) Chocolate-like fluid flowed from the cyst. (C) Cystic adenomyoma was removed with the harmonic scalpel and a special tension device. (D) Wound was repaired as after myomectomy.
FIGURE 3. Hydroultrasound monitoring. Arrows point to celiac cavity, cystic adenomyoma, and forceps.
197
Laparoscopic Surgery of Cystic Adenomyoma under Hydroultrasonographic Monitoring Nabeshima et al
FIGURE 4. Photomicrographs. (A) Cyst wall lining was abraded in almost all areas. (B) Few parts of the cyst were lined with endometrial-type epithelium (hematoxylin & eosin; original magnification 200 ×).
first was determining the optimal uterine incision point. The tumor was so small that no atypical finding on the uterine surface was initially seen laparoscopically. The second problem was finding a method of distinguishing the diseased region from normal myometrium. Because the adenomyotic region had spread diffusely around the cyst, the layer between that region and myometrium was diffuse, therefore rendering it difficult to separate out only the cyst. We overcame these problems by performing hydroultrasonographic monitoring. The problems were due to lack of sense of touch, which is peculiar to laparoscopic surgery; thus, finger-assisted laparoscopy may be an alternative.8 Hydroultrasonographic monitoring does not allow for tactile access to the surgical site; however, it does produce a useful visual image of the
area. It can be applied in any hospital, as the contrast material is physiologic saline; it is only necessary to exchange CO2 for saline solution. In general, borders between gas and solid matter cannot be described clearly by ultrasound due to low acoustic impedance for gaseous bodies, yet with our new technique, the border between liquid and solid matter was well enhanced. This effect promised to be useful for this laparoscopic surgery, and thus the pelvis was filled with physiologic saline. Using this simple method, the border between the position of the forceps and the intramural cystic area was clearly recognized. Intermittent monitoring by ultrasound facilitated recognition of the division between adenomyotic foci and normal myometrium. Physiologic saline contrast material was helpful in locating the disease within the myometrium. Typically, this
198
May 2003, Vol. 10, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
is very difficult to achieve laparoscopically, as the surface of a uterus with an intramural disorder usually appears normal; this is especially the case in women with adenomyosis or small intramural or submucosal myomal nodes.
3. Tamura M, Fukaya T, Takaya R, et al: Juvenile adenomyotic cyst of the corpus uteri with dysmenorrhea. Tohoku J Exp Med 178:339–344, 1996 4. Neri A, Bahary C, Eckerling B, et al: Serosal (subperitoneal) cysts of the uterus. Am J Obstet Gynecol 102:612–614, 1968
Conclusion Total laparoscopic resection of a cystic adenomyoma was performed successfully under hydroultrasonographic monitoring. This appears to be a good approach, because it is minimally invasive and it relieves the typically severe symptoms of menorrhagia, dysmenorrhea, and abdominal cramps associated with this disorder.
5. Keating S, Quenville NF, Korn GW, et al: Ruptured adenomyotic cyst of the uterus—A case report. Arch Gynecol 237:169–173, 1986
References
7. Kammerer-Doak DN, Magrina JF, Nemiro JS, et al: Benign gynecologic conditions associated with a CA-125 level >1,000 U/mL. A case report. J Reprod Med 41:179–182, 1996
6. Ejeckam GC, Zeinab OA, Salman M, et al: Giant adenomyotic cyst of the uterus. Br J Obstet Gynaecol 100:596–598, 1993
1. Slezak P, Tillinger KG: The incidence and clinical importance of hysterographic evidence of cavities in the uterine wall. Radiology 118:581–586, 1976
8. Terada Y, Murakami T, Noda T, et al: Finger-assisted laparoscopy to remove a noncommunicating uterine horn. J Am Assoc Gynecol Laparosc 8:594–596, 2001
2. Kataoka ML, Togashi K, Konishi I, et al: MRI of adenomyotic cyst of the uterus. J Comput Assist Tomogr 22:555–559, 1998
199