Case report #1

Dr. Harald Krentel – Clinic for Gynecology, Obstretrics, Gynecological Oncology and Senology, Bethesda Hospital Duisburg, Germany   ❓ Anamnesis: The 40-year old patient presented with dysmenorrhea, dyspareunia and pelvic pain. She reported bleeding disorders with hypermenorrhea and brownish spotting. Her family planning was completed. No previous surgeries and one vaginal birth in her history.   🩺 Gynecological examination: Vulva, Vagina and Portio without findings. Painful uterus in bimanual examination. No adnexial findings. No visible or palpable DE.   TVS: Anteflexio uteri, normal anterior uterine wall, endometrium 8 mm, large transmural cystic lesion in the posterior uterine wall (3,5 cm), no liquid in POD, normal adnexial anatomy.   Abdominal ultrasound: normal kidneys.

Fig.1: TVS with cystic lesion of the posterior uterine wall.

❗ Diagnosis: Cystic uterine adenomyosis Treatment options: ⁉️ What would be your approach to solve this problem? Dienogest? COC? Surgery? And if surgery, which type of surgery? Laparoscopic resection with suture? Hysteroscopic resection? Hysterectomy? Subtotal or total? HIFU? RFA? Laparoscopy in order to treat possible peritoneal endometriosis?   πŸ‘¨β€βš•οΈTreatment: You can find the video of our surgical approach following this link:
βœ… Result: We realized an ambulatory bipolar hysteroresectoscopy. The procedure was carried out with no complications. The patient recovered without any problems. At follow-up after 7 days, three and six months, the patient was satisfied with the result of the intervention and reported a dramatic improvement of her symptoms. πŸ’¬ Discussion: A good and efficient solution in these cases could be minimal access hysterectomy. Our patient refused this approach. She wished to save the uterus. An alternative to hysterectomy is the resection of the cystic adenomyosis. This can be performed by hysteroscopy or laparoscopy. In case of completed family planning we opted for the bipolar hysteroscopic approach. As you can see in the video this technique is related to a minimal blood loss and easy to perform. The laparoscopic approach would be appropriate in case of ongoing family planning, as the resection of the adenomyotic lesion leaves a large wall defect which should be sutured in patients who still wish to conceive. As the main treatment approach was by hysteroscopy, we discussed with our patient whether a combined laparoscopy would be useful or not. In case of additional peritoneal or deep endometriosis a combined laparoscopic treatment could help to avoid persistent pain due to intrabdominal lesions. However this patient refused laparoscopy and she also refused hormonal treatment options. In this case a LNG-IUD could have been an option instead of surgery, or as a postsurgical prophylaxis.   πŸ”† Another type of cystic adenomyosis: In this case we presented large myometrial cystic adenomyosis. A more common ultrasound sign of adenomyosis are very small subendometrial cystic lesions with a diameter of 3-4 mm.

Fig.2: Subendometrial micro cysts in 2D TVS.

Fig.3: Native tissue sample with microcyst.

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