Video Transcript: The OSADA Procedure Preserving Fertility in Diffuse Adenomyosis
The University of Ottawa’s Division of Minimally Invasive Gynaecologic Surgery presents the OSADA procedure, preserving fertility in diffuse adenomyosis.
We have no disclosures to declare. Adenomyosis is a benign gynecological condition where endometrial glands and stroma are present within the uterine musculature.
Patients often present with heavy menstrual bleeding, dysmenorrhea, and possible chronic pelvic pain.
Adenomyosis is commonly found in patients with infertility. Although this association is controversial, meta-analytical studies looking at clinical pregnancy rates in IVF patients have found that women with adenomyosis had a 28% reduction in the likelihood of clinical pregnancy compared to those women without adenomyosis.
The definitive treatment of adenomyosis is total hysterectomy. However, for patients wishing to preserve fertility, treatment modalities range from medical treatment to interventional radiology and surgical resection.
The OSADA procedure involves the radical excision of adenomyosis followed by uterine wall reconstruction. This was pioneered by Dr. H. Osada. We aim to demonstrate the surgical approach to adenomyomectomy in a patient with diffuse adenomyosis using a modified version of the OSADA procedure.
We present the case of a 37-year-old woman, gravida three, abortus three, referred for any possible management of adenomyosis in the context of fertility planning.
She presented after a chemical pregnancy and one failed IVF cycle. She had a large bulky adenomyotic uterus elevating her ovaries out of the pelvis, further complicating egg retrieval.
Transvaginal ultrasound imaging revealed a large bulky uterus with typical findings suggestive of adenomyosis, including a poorly defined endomyometrial junction, thickened endometrium, and sub endometrial echogenic linear striations, as shown in this ultrasound image.
Pelvic MRI further supported the diagnosis of adenomyosis and provided superior imaging for surgical planning purposes. This image demonstrates a diffuse enlargement of the uterus, with a markedly thickened junctional zone reaching up to 46 mm.
After reviewing her treatment options, the patient opted for a laparotomy with abdominal adenomyomectomy via the modified OSADA procedure. The following video describes her surgery.
We entered the abdomen using a Pfannenstiel skin incision, with a perpendicular vertical fascial incision, for optimal visualization. A self-retaining Alexis retractor was used.
To decrease bleeding, we placed a cervical tourniquet using a quarter-inch Penrose drain. To facilitate this, we took down the bladder flap and created bilateral broad ligament windows.
The Penrose drain was firmly tied around the uterine walls, which secured our uterine artery blood supply. We attempted to lift the uterus through our incision atraumatically, as well as with the use of a tenacula. However, this was not successful due to the bulk of the uterus. We, therefore, utilized a handheld obstetrical vacuum cup, which provided the necessary traction.
The right utero-ovarian ligament was identified, and a temporary bulldog clamp was used to secure this vascular supply. The same procedure was repeated on the left. In doing so, we had secured all four major vessels to the uterus prior to beginning the adenomyomectomy.
Next, we injected a mixture of vasopressin, ten units diluted in 100 ccs of normal saline, into the uterine serosa, for prophylactic hemostasis along the planned incision line.
A longitudinal incision was carried down at the midline of the uterus, bisecting the uterus in two halves. A clear demarcation between the thick adenomyotic tissue and normal outer myometrium can be noted.
This incision was continued through the adenomyosis until the uterine cavity was reached. A sudden gush of blood can be seen as we enter the endometrial cavity. In this manner, the entire extent of the adenomyosis was made clearly visible, with the crucial landmarks of the endometrium, as demarcated by the blue line, and the serosal surface, as demarcated by the red arrow, always kept in view.
The endometrial cavity was sufficiently opened to permit the introduction of the index finger. This allows for protection and guidance during the excision of the adenomyotic tissues. The goal of the procedure consists of radical excision of adenomyosis, leaving a 1 cm margin of tissues above the endometrium and a 1 cm margin of tissues below the serosal surface.
In preparation for the resection of the adenomyosis, the margins between normal myometrium and adenomyotic tissues were demarcated using a marking pen. This was performed as described by Osada and colleagues, with subsequent sharp dissection of the abnormal tissues. With the aid of a tenaculum and Allis clamps for traction, we slowly resected the abnormal tissue using a scalpel.
We ensured we continuously left behind a 1 cm margin of normal tissue. This was done by both palpation and direct visualization.
Special attention was taken as our dissection approached the endometrial margin. This ensured we did not enter the endometrial cavity inadvertently nor disturb the anatomy of the tubal ostia.
We continued this dissection until we had resected all abnormal tissue. Again, palpation of the endometrium and serosal surfaces allowed us to maintain a 1 cm margin on both sides.
Here you can note the uterus once radical resection of the adenomyotic tissue was complete. In this picture, the endometrial and serosal margins are highlighted by the blue line and red arrow, respectively.
Despite radical resection, there are always residual amounts of adenomyotic tissue left behind, as there is no tissue plane nor capsule present in this type of diffuse adenomyosis. The endometrium was then reconstructed by bringing together the cut edges using 2-O Maxon sutures.
We continued this technique sequentially until the endometrium was fully reapproximated.
Using a stronger O-Maxon suture, the deeper layer of the myometrium was reapproximated using interrupted stitches in non-overlapping layers. The more superficial layer of the myometrium was reapproximated in a running fashion using the same O-Maxon suture.
Once all the layers of the uterine walls had been reapproximated, the serosa was closed using the standard baseball stitch with large bites. Here we can view the newly reconstructed uterus. Our modification to the original OSADA procedure can be clearly noted, as we did not use overlapping flaps.
Adenomyosis is a challenging condition to manage, with hysterectomy being the only definite treatment. However, for women wishing to preserve fertility, exploration of alternative treatment options is warranted.
Surgical management with radical adenomyomectomy via the OSADA procedure is a safe and feasible option.