Objective

To equip reproductive surgeons with an approach to the Osada procedure and critical prophylactic hemostatic measures that optimize perioperative outcomes.

Design

Stepwise demonstration of the Osada procedure with narrated video footage.

Setting

Definitive management of symptomatic adenomyosis requires hysterectomy. However, adenomyomectomy can improve symptoms and restore anatomy while maintaining fertility potential. Limited but comparable perioperative outcomes exist for minimally invasive methods of adenomyomectomy, and most involve resection of focal, not diffuse, adenomyosis. Among the literature involving resection of diffuse adenomyosis using minimally invasive methods, relatively small volumes of resected tissue are reported and none include obstetric outcomes. Most published reports for excision of diffuse adenomyosis involve laparotomic resection, likely because of specific intraoperative challenges curtailed by this approach. In response, a laparoscopic-assisted laparotomic approach was developed in 2011 by Dr. Hisao Osada, a reproductive surgeon in Japan. This procedure involves aggressive excision of adenomyotic tissue with prophylactic hemostatic techniques and subsequent uterine wall reconstruction using a triple-flap method. Compared with other excisional methods for diffuse adenomyomectomy, the Osada procedure has the best reported obstetric outcomes.

Patient(s)

A 37-year-old nulliparous female presented with pelvic pain, bulk symptoms, abnormal uterine bleeding, and infertility. Physical examination demonstrated a 20-week, bulky uterus with limited bimanual mobility. Her endometrial cavity was inaccessible because of marked anatomic distortion. Magnetic resonance imaging revealed marked abnormality of her endometrial contour because of a 15 cm adenomyoma with diffuse adenomyomatous tissue in the posterior uterine compartment. Prior interventions included a trial of combined hormonal contraceptive, leuprolide acetate, and tranexamic acid. She was interested in fertility-sparing adenomyomectomy to address symptoms and fertility potential and chose to proceed with the Osada procedure. She was optimized medically with oral and parenteral iron therapy to bring her hemoglobin from 55–111 g/L preoperatively. Institutional review board approval and informed consent from the patient were obtained.

Intervention(s)

The Osada procedure was performed using the following 8 surgical steps:

1.

Laparoscopic lysis of adhesions and excision of comorbid endometriosis.

2.

Pfannenstiel incision and exteriorization of the uterus.

3.

Establishment of prophylactic medical and surgical measures for hemostasis.

3A.

Vascular clamps on utero-ovarian ligaments.

3B.

Tourniquet around uterine isthmus.

3C.

Myometrial vasopressin injection.

4.

Bisection of the uterus, identification of endometrial cavity, marking of 1 cm margins.

5.

Excision of adenomyosis.

6.

Reconstruction of the uterus using the triple-flap method.

7.

Reperfusion of the uterus.

8.

Abdominal closure.

Systemic administration of tranexamic acid was also administered intraoperatively.

Main Outcome Measure(s)

Perioperative blood loss, anatomic normalization, symptom remediation, and maintenance of fertility potential.

Results

Perioperative blood loss was minimal, 469 g of adenomyotic tissue was extracted, and discharge was on postoperative day 2 without any complications. Three months later, cyclic pain and bleeding had improved markedly, ultrasound confirmed Doppler flow throughout the uterus, hysterosalpingogram demonstrated a nonobliterated endometrial cavity and tubal patency, and magnetic resonance imaging confirmed normalized uterine dimensions measuring 11 × 7 cm from 19 × 10 cm. Most literature supports waiting at least 6–12 months and until demonstration of normalized uterine blood flow in the operated area before attempting conception.

Conclusion

Fertility-sparing excision of diffuse adenomyosis can be achieved safely using the Osada procedure, following the 8 discrete steps demonstrated in this video. Reproductive surgeons can reference this video to teach and maintain this important procedure.

中文翻译：

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弥漫性子宫腺肌症的保留生育能力手术：Osada 手术的逐步方法

客观的

为生殖外科医生提供 Osada 手术方法和关键的预防性止血措施，以优化围手术期结果。

设计

带有叙述视频片段的 Osada 程序的逐步演示。

环境

症状性子宫腺肌病的最终治疗需要子宫切除术。然而，腺肌瘤切除术可以改善症状并恢复解剖结构，同时保持生育能力。微创子宫腺肌瘤切除术的围手术期结果有限但可比较，并且大多数涉及切除局灶性而非弥漫性子宫腺肌病。在涉及使用微创方法切除弥漫性子宫腺肌病的文献中，报道的切除组织体积相对较小，并且没有包括产科结果。大多数已发表的关于弥漫性子宫腺肌病切除术的报道都涉及剖腹手术，这可能是因为这种方法减少了特定的术中挑战。作为回应，日本生殖外科医生 Hisao Osada 博士于 2011 年开发了腹腔镜辅助剖腹手术方法。该手术涉及使用预防性止血技术积极切除子宫腺肌组织，随后使用三瓣法重建子宫壁。与弥漫性子宫腺肌瘤切除术的其他切除方法相比，Osada 手术报告的产科结果最好。

病人）

一名 37 岁的未生育女性因盆腔疼痛、肿块症状、异常子宫出血和不孕症就诊。体格检查显示一个 20 周大的子宫，双手活动受限。由于明显的解剖变形，她的子宫内膜腔无法进入。磁共振成像显示她的子宫内膜轮廓明显异常，因为子宫后腔有一个 15 厘米的腺肌瘤和弥漫性腺肌瘤组织。之前的干预措施包括联合激素避孕药、醋酸亮丙瑞林和氨甲环酸的试验。她对保留生育能力的子宫腺肌瘤切除术感兴趣，以解决症状和生育潜力，并选择继续进行 Osada 手术。她通过口服和肠胃外铁剂疗法在医学上进行了优化，使她的血红蛋白在术前从 55-111 克/升。

干预措施

使用以下 8 个手术步骤执行 Osada 手术：

1.

腹腔镜粘连松解术和共病子宫内膜异位症切除术。

2.

子宫的 Pfannenstiel 切开术和外切术。

3.

建立止血的预防性医疗和手术措施。

3A.

子宫-卵巢韧带上的血管夹。

3B。

子宫峡部止血带。

3C。

子宫肌层加压素注射。

4.

子宫一分为二，识别子宫内膜腔，标记 1 cm 边缘。

5.

子宫腺肌病切除术。

6.

使用三瓣法重建子宫。

7.

子宫再灌注。

8.

收腹。

术中也进行了全身性氨甲环酸给药。

主要观察指标）

围手术期失血、解剖正常化、症状修复和生育潜能维持。

结果

围手术期失血量极少，取出 469 g 腺肌组织，术后第 2 天出院，无任何并发症。三个月后，周期性疼痛和出血明显改善，超声证实多普勒血流遍及整个子宫，子宫输卵管造影显示子宫内膜腔未闭塞，输卵管通畅，磁共振成像证实子宫尺寸正常，从 19 × 10 厘米变为 11 × 7 厘米。大多数文献支持至少等待 6-12 个月，直到在尝试受孕之前证明手术区域的子宫血流正常。

结论

按照本视频中演示的 8 个独立步骤，使用 Osada 程序可以安全地实现弥漫性子宫腺肌病的保留生育力切除术。生殖外科医生可以参考此视频来教授和维护这一重要程序。