A Preliminary Clinical Study Of Diagnostic Laparoscopy And Ultrasound-guided Percutaneous Microwave Ablation For Adenomyosis And Thermal Injury Experiment

Clinical Study of Microwave AblationObjectiveWith the development of ultrasound-guided percutaneous microwave ablation in the treatment of adenomyosis,its clinical efficacy has been recognized by doctors and patients.Since the patients with adenomyosis are often complicated with pelvic or abdominal adhesions and ultrasonic scanning has its limitations in identifying pelvic adhesions,it is easy to cause the injury of adhesive organ or tissue in the puncture path and can increase the potential risk of thermal injury for adhesive organ around the uterus during ablation.In order to reduce the risks above,the diagnostic laparoscopy was introduced in the surgery.This study is aimed to evaluate the safety and efficacy of diagnostic laparoscopy and ultrasound-guided percutaneous microwave ablation for symptomatic adenomyosis.MethodsFrom January 2017 to December 2019,a total of 76 patients with symptomatic adenomyosis in our hospital were recruited in this study.These patients were all diagnosed with adenomyosis by magnetic resonance imagingbefore treatment and had severe clinical symptoms and failed to respond to conservative treatments.Also,they had a strong desire to retain their uterus and volunteered to choose the therapy of microwave ablation,but they all had no fertility requirement.The lesion or uterine volume,hemoglobin,visual analog scale(VAS)score and adenomyosis symptom and health-related quality of life scores were recorded in detail before the treatment.The symptom and health-related quality of life scores were evaluated by reference to uterine fibroids symptoms and health-related quality of life questionnaire.All patients underwent contrast-enhanced ultrasonography before ablation and recorded the information.During the operation,the preset puncture path was located and marked under the guidance of ultrasound,and its safety was evaluated under laparoscopy.And the potential puncture and thermal injuries were all considered to be the risks of preset puncture path.During the ablation,pelvic adhesions,the bleeding of puncture points,the occurrence and treatments of complications,the amount of puncture needle,energy,ablation time and so on would be recorded.After ablation,fever,vaginal bleeding or discharge,pelvic infection and other complications would be recorded.Also,the lesion or uterine volume,hemoglobin,visual analog scale(VAS)score and the symptom and health-related quality of life scores were scheduled at 3,6,9 and 12 monthsafter ablation.Complications wereclassified as SIR A to SIR F according to the Society of Interventional Radiology(SIR)complication classification.SIR A and SIR B were considered to be minor complications and SIR C to SIR F were considered to be major complications.The total efficacy included ablation effect and clinical efficacy.The ablation effect was evaluated by ablation rate,which was calculated according tocontrast-enhanced ultrasonography before and after ablation.The clinical efficacy was evaluated by observing the changes of lesion or uterine volume,hemoglobin,VAS score and the symptom and health-related quality of life scores before and after ablation.ResultsBasic informationA total of 76 patients underwent the ablation treatment,with 47 patients for adenomyoma and 29 patients for diffuse adenomyosis.And 4 patients with adenomyosis were complicated with small myomas.The mean age,BMI,course of disease,lesion and uterine volume of the patients were 41.16±3.37 years,22.89±2.28kg/m2,6.79±6.16 years,117.42±6.89cm3 and 347.87±162.97cm3,respectively.In our study,36 patients showed main symptom of dysmenorrhea,16 patients had main symptom of hypermenorrhea,and 24 patients had hypermenorrhea complicated with dysmenorrhea.74 patients completed 12 months follow-up after operation,and 2 patients were lost to follow-up at 9-month after ablation.Safety evaluationDuring ablation:No severe adverse event was occurred during ablation,such as bowel injury,bladder injury and massive bleeding.Pelvic adhesion around the uterus or in other places was found in 19 patients among 76 cases under laparoscopic guidance and the occurrence rate was 25.00%.Among them,8 patients were complicated with ovarian endometrosis cysts and 2 patients were complicated with ovarian simple cysts.6 patients had a previous history of cesarean section and 3 patients had a previous history of appendectomy.The adhesions of preset puncture path were found in 16 cases under laparoscopy during operation,and the occurrence rate of preset puncture path adhesion was 21.05%(16/76).In these cases,adhesions were all separated before ablation.During the operation,puncture point bleeding was found in 4 cases under laparoscopy,and the incidence rate was 5.26%(4/76).Among them,2 patients had uterine puncture point bleeding and 2 patients had abdominal puncture point bleeding after retreating the needle,and the bleeding was stopped in time.After ablation:Most of the postoperative complications were mild(SIR A and SIR B),and extra treatments were not needed inmost of these adverse events.Among all patients,78.95%patitents(60/76)had mild lower abdominal pain,71.05%(54/76)patients had vaginal discharge,13.16%(10/76)patients had fever,9 patients of them had slight fever and one had moderate fever.Only two persons experienced abnormal uterine bleeding after ablation and were admitted in hospital for treatments again.Efficacy evaluationAblation effect:A total of 76 patients were enrolled in this study,with 29 patients for diffuse adenomyosis and 47 patients for adenomyoma.The mean ablation rate for adenomyosis patients was 72.78±20.59%,and the mean ablation rate for adenomyoma patients was 89.77±14.03%.The overall mean ablation rate was 81.98±19.02%.Clinical effect:Duringthe follow up,the uterine and lesion volume,hemoglobin level,VAS score,SSS and HRQL were all improved significantly compared with the condition before ablation,and the differences were statistically significant(p<0.05).The mean uterine volumes at 3,6,9,12 month after ablation were 208.01±88.54 cm3,171.60±80.85cm3,156.96±77.73cm3 and 141.38±77.09 cm3,respectively,and all decreased obviously compared with the condition before ablation,and the differences were statistically significant(p<0.05).The mean lesion volumes at 3,6,9,12 month after ablation were 50.97±45.33 cm3,34.06±26.74 cm3,27.49±23.40cm3 and 24.89±23.16cm3,respectively,and all decreased obviously compared with the condition before ablation,and the differences were statistically significant(p<0.05).The mean VAS scores at 3,6,9,12 month after ablation were 2.98± 1.71,2.79±1.942.62±2.08 and 2.62±2.07,respectively,and all decreased significantly compared with the condition before ablation,and the differences were statistically significant(p<0.05).The mean hemoglobin levels at 3,6,9,12 month after ablation were 112.08±17.93g/L,125.00±16.05g/L,127.80±10.55g/L and 128.40±5.56g/L,respectively,and allwere improved significantly compared with the condition before ablation,and the differences were statistically significant(p<0.05).The SSS at 3,6,9,12 month after ablation were 27.61±6.02,21.83±3.76,18.89±2.59 and 17.79±2.13,respectively,and all decreased significantly compared with the condition before ablation,and the differences were statistically significant(p<0.05).The HRQL at 3,6,9,12 month after ablation were 71.94±5.54,73.68±7.11,76.82±5.99 and 77.28±4.90,respectively,and all increased significantly compared with the condition before ablation,and the differences were statistically significant(p<0.05).Conclusions1.Since the patients with adenomyosis are often complicated with pelvic or abdominal adhesions,operation safety can be improved with laparoscopy since it may reduce the potential risks of injury in the puncture and ablation,and bleeding can be detected in time during operation.2.Diagnostic laparoscopy and ultrasound-guided percutaneous microwave ablation is a safe,effective and minimally invasive interventional technique for the treatment of adenomyosis and it shows a beneficial effect in improving clinical symptoms and the quality of lifeof patients,but the long term efficacy of microwave ablation for adenomyosis needs further study.Thermal Injury ExperimentObjectiveSince the ectopic endometrial lesions of adenomyosis are distributed diffusely in myometrium,the surrounding myometrium is damaged while ectopic lesions are destroyedin the microwave ablation,resulting in loss of myometrium function.In this experiment,we want to explore the tolerance difference to thermal injury ineutopic endometrium,ectopic endometriumand uterine smooth muscle,so as to find a potential ablation temperature to reserve the activity of uterine myometrium to the full extent while destroying the ectopic lesions.Methods10 samples were collected from patients who underwent hysterectomy for adenomyosis in our hospital from July 2019 to December 2019.During hysterectomy,the pieces of endometrium and myometrium tissues were cut from uterus in vitro immediately.Then they were made into frozen sections and underwent rewarming.After that,the sclies were heated in water bath with normal saline.Heating temperatures were 40?,45?,50?,55?,60?,65? and 70?,and heating times were lmin,2min,3min,4min,5min,6min,7min and 8min.All sections were stained with succinate dehydrogenase method and observed under the microscope.The cell activity after thermal injury was judged by SDH activity value.Theinactive tissue was defined as a score of 0-4 points,partial active tissue was defined as a score of 5-8 points and complete active tissue was defined as a score of 9-12 points.Results1.Under the condition of 40?/1min,45?/1min,50?/1min,55?/1min,60?/1min,65?/1min and 70?/1min,the SDH activity values of eutopic endometrium were 12.00±0.00,11.70±0.63,11.40±0.77,7.30±0.67,0.75±0.26,0 and 0,the SDH activity values of uterine muscle were 12.00±0.00,12.00±0.00,1 1.85±0.47,7.40±0.70,0.95±0.44,0 and 0,the SDH activity values of ectopic endometrium were 12.00±0.00,12.00±0.00,11.40±0.77,7.30±0.67,0.75±0.26,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).2.Under the condition of 40?/2min,45?/2min,50?/2min,55?/2min,60?/2min,65?/2min and 70?/2min,the SDH activity values of eutopic endometrium were 12.00±0.00,11.70±0.63,11.40±0.77,4.80±0.91,0.20±0.26,0 and 0,the SDH activity values of uterine muscle were 12.00±0.00,11.85±0.47,11.10±1.05,4.60±0.97,0.35±0.34,0 and 0,the SDH activity values of ectopic endometrium were 12.00±0.00,11.70±0.63,11.40±0.77,4.50±0.97,0.20±0.25,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).3.Under the condition of 40?/3min,45?/3min,50?/3min,55?/3min,60?/3min,65?/3min and 70?/3min,the SDH activity values of eutopic endometrium were 11.55±0.77,11.55±0.72,7.80±0.79,2.95±0.64,0,0 and 0,the SDH activity values of uterine muscle were 11.55±0.72,11.70±0.63,7.50±0.53,2.75±0.59,0,0 and 0,the SDH activity values of ectopic endometrium were 11.55 ±0.77,11.55±0.72,7.40±0.52,2.95±0.64,0,0and 0,respectively,and there was no statistical difference between three groups(p>0.05).4.Under the condition of 40?/4min,45?/4min,50?/4 min,55?/4 min,60?/4min,65?/4min and 70?/4min,the SDH activity values of eutopic endometrium were 11.57±0.77,11.25±0.79,4.70±1.06,1.75±0.63,0,0 and 0,the SDH activity values of uterine muscle were 11.40±0.77,11.40±0.77,4.80±1.03,1.65±0.67,0,0 and 0,the SDH activity values of ectopic endometrium were 11.25±0.79,11.25±0.79,4.70±1.06,1.75±0.63,0,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).5.Under the condition of 40?/5min,45?/5min,50?/5 min,55?/5min,60?/5min,65?/5min and 70?/5min,the SDH activity values of eutopic endometrium were 11.40±0.77,10.95±0.72,2.65±0.63,1.10±0.46,0,0 and 0,the SDH activity value of uterine muscle were 11.40±0.77,11.40±0.77,2.60±0.66,1.15±0.41,0,0 and0,the SDH activity values of ectopic endometrium were 11.25±0.79,10.95±0.72,2.65±0.63,1.10±0.46,0,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).6.Under the condition of 40?/6min,45?/6min,50?/6min,55?/6min,60?/6min,65?/6min and 70?/6min,the SDH activity values of eutopic endometrium were 11.40±0.77,10.05±0.72,1.55±0.50,0.95±0.28,0,0 and 0,the SDH activity values of uterine muscle were 11.25±0.79,10.05±0.72,1.35±0.47,1.00±0.24,0,0 and 0,the SDH activity values of ectopic endometrium were 11.10±0.77,10.95±0.72,1.55±0.50,0.95±0.28,0,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).7.Under the condition of 40?/7min,45?/7min,50?/7min,55?/7min,60?/7min,65?/7min and 70?/7min,the SDH activity values of eutopic endometrium were 11.40±0.77,7.70±0.48,1.15±0.41,0.45±0.37,0,0 and 0,the SDH activity values of uterine muscle were 11.10±0.77,7.60±0.52,1.15±0.41,0.45±0.37,0,0 and 0,the SDH activity values of ectopic endometrium were 10.80±0.63,7.50±0.53,1.15±0.41,0.45±0.37,0,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).8.Under the condition of 40?/8min,45?/8min,50?/8 min,55?/8min,60?/8min,65?/8min and 70?/8min,the SDH activity values of eutopic endometrium were 11.25±0.79,6.80±0.42,1.00±0.24,0.35±0.34,0,0 and 0,the SDH activity values of uterine muscle were 11.10±0.77,6.30±1.16,1.00±0.23,0.35±0.34,0,0 and 0,the SDH activity values of ectopic endometrium were 10.80±0.63,6.20±1.14,1.00±0.23,0.35±0.34,0,0 and 0,respectively,and there was no statistical difference between three groups(p>0.05).3.Conclusions1.At 40?,no obvious thermal injury was observed ineutopic endometrium,ectopic endometrium and uterine smooth muscle in 1-8 minutes.2.At 45?-55?,the activity of eutopic endometrium,ectopic endometrium and uterine smooth muscle decreased with the increase of heating temperature and time.3.At 60?-70?,eutopic endometrium,ectopic endometrium and uterine smooth muscle were instantly inactivated.4.The eutopic endometrium,ectopic endometrium and uterine smooth muscle had the same tolerance to heat injury.