Adenomyosis is identified by uterine enlargement secondary to areas of endometrium (both glands and stroma) located deep in the myometrium. These areas cause hyperplasia and hypertrophy of the surrounding myometrium which causes an enlarged uterus. Ectopic areas of the endometrium can be diffusely present throughout the myometrium or focal forming a nodular adenomyoma .{1) Levgur et al created the grading system to describe the depth of adenomyotic foci;deep(>80%) ,intermediate (40-80%) and superficial(<40 %) (2).

Etiology: The exact etiology of adenomyosis is not known hence at least 4 theories have been postulated.
a).The first and most popular theory is that adenomyosis develops from the invagination of endometrium into the myometrium . Steriod hormone studies have shown that adenomyotic tissue exhibits higher expression of estradiol receptors than does eutopic  endometrium.The increased response to estrogen may facilitate the overall invagination of endometrium .

b).A second theory is that adenomyosis develops denovo from embryologically misplaced
pleuripotent mullerian remanants . Extra uterine sites for adenomyosis such as that in the rectovaginal septum supports this theory.

  1. c) Theory of intralymphatic intramyometrial spread.d) Bone marrow stem cell origin of adenomyosis.

Classification; The surgical /histological classification of adenomyosis was given by grimbiz et al(3) in 2014,describe adenomyosis into  5 categories.

Diffuse (wherein the adenomyosis is present diffusely all over the myometrium), Focal (wherein only an adenomyotic nodule is present and rest of the myometrium is normal),  Cystic Adenomyosis (wherein the adenomyotic nodule has cystic contents) ,uterine adenomyomatous Polyp, and some special categories like Rectovaginal Endometriosis which he classified as a form of adenomyosis as the features of RV endometriosis histologically and behaviourally are closer to adenomyosis than to endometriosis.

Diffuse Adenomyosis . Smooth Muscle Hyperplasia with ectopic endometrium.
Focal Adenomyosis. Adenomyoma, Adult /juvenile Cystic Adenomyoma.
Polypoidal Adenomyosis. Typical or Atypical.
Special Categories Adenomyosis of Endocervical Type.
Retroperitoneal  Adenomyosis OR Rectovaginal Endometriosis.

 

MECHANISMS OF RECURRENT PREGNANCY LOSS IN ADENOMYOSIS;

The identification of the myometrial junctional zone and of its distruption and thickening has been linked to the poor reproductive performance, mainly thru the perturbed uterine peristalisis a phenomenon that originates exclusively from the junctional zone in non pregnant women.(4)
Additionally a number of biochemical and functional alterations in both the eutopic and heterotopic endometrium in women with adenomyosis have now been found to lower endometrial receptivity known as “implantation marker defects ’.In these patients there is also altered decidualization and abnormal concentrations of intrauterine free radicals.

Also recent evidence suggests that adenomyosis in addition to causing the symptoms of menorrhagia ,dysmenorrhea,dyspareunia,dyschezia(in rectovaginal endometriosis) subfertility and recurrent pregnancy loss is also associated with adverse pregnancy outcomes like preterm labour , fetal growth restriction ,pregnancy induced hypertension,intrauterine infections and mysteriously even cervical incompetence.(5)(6)(7).

IMAGING;

ULTRASOUND;A Transvaginal ultrasound forms a very important tool in the diagnosis of adenomyosis with the suggestive signs of an asymmetrically and diffusely enlarged uterus with increased myometrial echogenicity or linear hyperechoic bands extending deep into the myometrium and the presence of myometrial cysts.

MRI; On T2 weighted images a large asymmetrically enlarged uterus along with myometrial heterogenicity, and presence of myometrial cysts along with enlargement of the junctional zone (the innermost myometrial layer] can be seen in adenomyosis. Mri has very high specificity and positive predictive value{more than 90 percent}and is especially useful if fibroids coexist in the same patient to differentiate between the two.

HYSTEROSCOPY;In adenomyosis irregular endometrium with pitting endometrial defects altered vascularisation and cystic haemmorhagic lesions maybe observed on hysteroscopy.

A Gordts spirotome maybe used to get a hysteroscopic biopsy from the suspicious areas.

TREATMENT

The basic principle of medical management is by means of hormonal treatment which only work as agents for ‘Suppression of the Disease’ and Surgery and Excision of the lesions form the mainstay for the treatment of the disease. Hence continous oral contraceptive pills, Depoprovera, Levonorgestrel iucd ,danazol iucd and Gnrh agonists all work as temporary methods for suppression of the disease.

Alternative methods; Treatments such as high frequency ultrasound [HIFU] and uterine artery embolisation [UAE] have been proposed for treatment of selective cases of adenomyosis their role is still controversial and data on pregnancy outcome scanty. Therefore presently alternate treatments should be proposed in women with no desire for future pregnancy Also UAE for adenomyosis is technically different from when it is performed for fibroids as at angiography adenomyosis shows a reduction in arterial pattern but increase in microvessel density making the use of polyvinyl alcohol particles less effective. Hence, the absence of a good embolic agent suited to adenomyosis currently makes this procedure less effective than when it is used for fibroids.

FERTILITY SPARING  LAPAROSCOPIC SURGERIES;
Classification  of uterus sparing surgical techniques;

Surgical Category. Technique Described Variant
Complete Excision Adenomyomectomy Classical Technique
Modifications; Ushaped adenomyomectomy, Triple flap, Overlapping flaps.
Partial Excision Partial Adenomyomectomy. Classical Technique
Modifications; Transverse H incision, Asymmetric dissection.

As women with adenomyosis suffer not only from an increased incidence of infertility but also from an increased incidence of recurrent miscarriages , along with menorrhagia and dysmenorrhoea women desirous of future pregnancy have been treated by Extensive Radical Adenomyomectomies for symptom relief and to achieve a good pregnancy outcome. With Extensive radical adenomyomectomies the resultant scars were not strong enough to withstand subsequent pregnancy hence several surgeons like Osada came up with special techniques like Triple Flap technique where after a radical adenomyomectomy the myometrium is sutured back as overlapping flaps to ensure stronger scars that can withstand subsequent pregnancy. This procedure results in more than 70 percent spontaneous conception rate . Also along with good reproductive outcome women get a lot of relief from the dysmennorhea and menorrhagia. It is recommended that subsequent pregnancies should be delivered by Elective caesarean section only.

THE SUNRISE LAPAROSCOPIC FLAP ADENOMYOMECTOMY;

The Procedure;

a)The primary trocar is inserted at the modified Palmers point  and then 3 secondary trocars are placed under vision lateral to the inferior epigastric vessels on each side and one supra pubic.

b)Dilute Vasopressin is then infiltrated into the uterus

c)A vertical incision is then given over the uterus upto the endometrial cavity 1 cms of margin of myometrium is left over the basalis layer of endometrium .

d)On the serosal layer side 1cms of margin of myometrium is left inside by tunneling. All the in between myometrium is then excised.

e)The end result is thus that the uterus is left with 1 cm myometrium over the endometrium and another 1 cm myometrium under the serosa.

f)To make this remaining myometrium withstand subsequent pregnancy the uterus is then sutured with barbed continous sutures as reinforcing flaps.

INCISION BEING GIVEN ON THE UTERUS AFTER INJECTING VASOPRESSIN.

1CM MYOMETRIUM BEING LEFT BEHIND WITH SEROSA BY TUNNELLING.

1CM MARGIN OF MYOMETRIUM LEFT OVER THE ENDOMETRIUM

FLAP SUTURING BEING DONE.

Technical challenges of this procedure

Compared to myomas there are no distict planes /capsule hence the excision of tissue is entirely arbitrary and left to the discretion of the surgeon. Also the adenomyomatous tissue is difficult to hold and manipulate compared to normal myometrium .

Secondly the surgeon has to have good experience with laparoscopic suturing as extensive flap suturing is mandatory for the success of this procedure. Also the surgeon has to be good at lateral pelvic wall dissection laparoscopically as uterine artery clipping at origin maybe required in some cases for adequate haemostasis  . All these challenges make this procedure a very advanced laparoscopic procedure .

THE T SHAPED ADENOMYOMECTOMY;
During this procedure certain changes have been made in order to overcome the technical challenges  faced at Flap  Adenomyomectomy  .This procedure is designed by Dr Hafeez Rahman at Sunrise Hospital.

a) A deliberate uterine perforation is made with a uterine sound;
This perforation of the uterus is done with a uterine sound so as the clearly know where the uterine cavity is located. (As in adenomyosis  the myometrial tissue is pulled inside known as the octopus sign hence at visual inspection although the adenomyotic tissue may appear predominantly anterior in position it may in fact actually be posteriorly located)
This is in fact the most important step of the surgery as it avoids accidental excision of part or whole of the uterine cavity. Also a clear margin of 1 to 2 cms from the endometrial cavity should be maintained to avoid ashermanns syndrome  in the future .

T shaped Incision being given on the Uterus

b)A “T shaped “ incision is made on the adenomyotic tissue to be excised maintaining  a clear 1 to 2 cms margin  from the endometrial canal.
1 cms myometrium is maintained under the uterine serosa .All the remaining Myometrium in between is excised.

c) The vertical and horizontal stems of the T shaped incisions aid in getting the remaining  tissue close to each other  eliminating the need for overlapping flaps. The edges of the T are then sutured with Barbed sutures. The end result of the procedure is the formation of a strong scar that can withstand subsequent pregnancy and removal of  a large part of the adenomyotic  pathology .

RECTOVAGINAL ENDOMETRIOSIS
This form of adenomyosis deserves special mention as not only does it cause severe symptoms like dyspareunia ,dyschezia ,and dysmenorrhea but it is also an individual cause of infertility and recurrent pregnancy loss(34 )(35). Ironically almost 70 percent  gynaecologists do not recognize it and hence do not treat it.
Rectovaginal endometriosis once suspected by the symptomatology of the patient can be diagnosed by  a number of imaging modalities .

IMAGING;

The transvaginal ultrasound can give a number of indications to the presence of rv endometriosis when needed this can be supplemented with a transrectal ultrasound. Using this sonography an accurate assessment of the vagina, particularly the areas of the posterior and lateral fornices, the retrocervical area with torus uterinum the uterosacral area and the recto vaginal septum can be evaluated along with the presence of rectal nodules .Adherance of the rectum and vagina can be seen as the ‘Sliding sign’..Intestinal nodules detected below the level of uterosacralsare considered to be low rectal lesions, while the ones above this level are considered upper rectal or rectosigmoid in location. This  differentiation is important as low rectal lesion surgeries are associated with higher complication rates including higher chances of fistula formation and abscess formation and hence this difference will help in adequate preoperative counseling of the patient. Nowadays  MRI is another tool extensively used for diagnosing rectovaginal  endometriosis with a high positive predictive value of 95 percent.(38)Additionally a CT enteroclysis and a CT scan “The Virtual Colonoscopy” are  additional tools used for an accurate preoperative assessment.

It is extremely important to make an accurate preoperative assessment so as to to clarify the involvement of specific site (ureter, bowel stenosis, upper intestinal localization)
to establish a correct tailored management of the disease,
to properly inform patients of the extent of their disease and therapeutic options the best surgical approach and the potential need to involve other surgical specialists than a gynaecologic surgeon (e.g. colorectal surgeon or urologist). Depending on these factors the adequate preoperative counseling of the patient remains the most important aspect of the treatment of the patient.

The Treatment;
The treatment modality for rectovaginal endometriosis is decided upon the depth of involvement of the nodule(mucosa involved or not), the size of the lesion(if more than 3cms size lesion or more than 50 percent circumfrential bowel involvement segmental resection of the bowel may be preffered) .Also as the ureters get pulled in medially by the rectovaginal nodule it is important to know the location of the ureters at all times by either performing a ureterolysis  or using lit ureteric stents.

Shaving/ Mucosal Skinning Mucosa of the Bowel is not entered .The  Recto vaginal nodule on the bowel is shaved off from the serosa and muscularis areas of the bowel. Reinforcing  sutures may be taken on the bowel.
Discoid Resection Transanal Circular Stapler is used for anterior/anterolateral bowel resection.
Segmental Resection Full thickness Bowel resection with natural orifice specimen retrieval thru the vagina or anus.
Placement of Omental patches is done wherever 2 staple lines are present.

REFERENCES.

(1) Garcia L, Isaacson K. Adenomyosis: review of the literature. J Minim Invasive Gynecol. 2011;18:428–437.

(2) LevgurM,AbadiMA,TuckerA.Adenomyosis:symptoms,histology, and pregnancy terminations. Obstet Gynecol. 2000;95:688–691.

  1. (3) Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing operative treat- 
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