A Case of Elastography-Assisted Laparoscopic Fertility Preservation for Severe Deep Endometriosis Causing Ureteral Stenosis and Subtype II Adenomyosis

Abstract

Adenomyosis is commonly treated by total hysterectomy. Adenomyomectomy is considered for women of reproductive age who wish to preserve their fertility. However, a high recurrence rate following adenomyomectomy has been reported because complete removal of the lesion is difficult, and uterine rupture during pregnancy remains a complication. We previously reported that laparoscopic adenomyomectomy using a cold knife prevented thermal damage to the myometrium and elastography to avoid residual lesions. Here, we report the case of a patient who underwent complete resection of a subtype II adenomyosis and resection of deep endometriosis (DE) with the closure of the pouch of Douglas. The patient was 31 years old, had severe dysmenorrhea, and had left ureteral stenosis and subtype II adenomyosis associated with the closure of the pouch of Douglas by the DE. After resection of the DE posterior wall adenomyosis, residual lesions were confirmed by laparoscopic real-time elastography. Eight weeks after surgery, postoperative transvaginal ultrasound showed that the myometrium had shrunk from 28 to 22.7 mm, and the hydronephrosis had disappeared, although a stent remained necessary. In this study, we report the complete resection of subtype II adenomyosis and DE, combined with elastography to visualize the lesions during resection.

Laparoscopic Adenomyomectomy under Real-Time Intraoperative Ultrasound Elastography Guidance: A Case Series and Feasibility Study

“…Therefore, we decided to perform resection using intraoperative ultrasound, which is used in myomectomy of uterine fibroids [20]. Since it is difficult to distinguish the normal muscle layer from the adenomyosis area using conventional ultrasonography, we proposed the use of ultrasonic elastography [10,11].…”

“…One gynecologic surgeon (YO) performed all the surgeries. Surgical procedures for laparoscopic adenomyomectomy under ultrasonic elastography guidance have been described in our previous reports [10,11]. A 10-mm port (ENDOPATH XCEL ® , Ethicon Endo-Surgery, Cincinnati, OH, USA) for the zero-degree laparoscope was introduced intra-umbilically, and three additional 5-mm lateral ports (ENDOPATH XCEL ® , Ethicon Endo-Surgery) were placed under vision, centrally, and on the left and right lateral sides.…”

“…Additionally, intraoperative elastography has been used to detect focal lesions in breast and brain tumors [5,9]. One of our recent studies reported successful laparoscopic excision of an adenomyotic lesion, using intraoperative ultrasound elastography [10,11].…”