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yeah if you have other things to do you could do that okay see you later see you see you you hi hi hello hello how you doing today good afternoon i'm fine thank you i hope you're so fine yes yes i am yeah and great it's enhanced that um expecting hands yes i think he is going to be a bit late uh he he will just join for uh his presentation and uh because he is currently traveling i think yeah said so okay maybe we'll start then so yeah hopefully before is there is talk then we'll have it so [Music] so good morning good afternoon good evening wherever whatever part of the world you are thanks for joining us on this webinar that is jointly organized by the society of gynecology and obsessions of nigeria and the european endometriosis leak and on this pressure we've been talking about adenomyosis this is probably a canonic called any other place where there has been a well-being on adenomyosis either in nigeria west africa that i can recall and that's one of the reasons why we're doing this because we've seen that it's probably one of the most misdiagnosed conditions in the female service and this we think is something that is worthy to be spoken about majority of the people also or let me say some of the people that we diagnosed with you tried fibroids and we know how common fibroids are in this environment also i not have an adenomyosis or they actually have adenomas that has been understandable so today we have a very rich panel to discuss this both local and [Music] international and um we expect the president of the society of gynecology and obstetrics to us to join and then also we have dr kinsley agola who will be introducing better on later on and then we have a and steaming bag and then we have hara kentel and professor al ali from shanghai so why kentel and their hands are from germany of course dr argola is from nigeria like myself so we'll be we hope to have a cross-fertilization of ideas and see how we can uh improve the knowledge and the diagnosis of this condition in this environment so um i think without much i do we will not since the president or someone is still being expected i think we better just keep things set things rolling so i'm going to introduce dr algolon and then so that i can uh take the floor and start with because one of the things is that we need to make a diagnosis before we can even talk about looking between adenomyosis and that's where it comes in we know the ultrasound is something that is quite portable and almost freely available everywhere and therefore we think it's something that will help us in the diagnosis of adenomyosis so doctor christiano is a consultant obstetrician and gynecologist he's a sonologist and endoscopic surgeon he's a fellow of the west african colleague of surgeons and fellow of the national medical he has offered many articles in both local and international journals but what fascinates me fascinates me about him is his interest in ultrasound and since like i said ultrasound is really very freely available i think is a low-hanging fruit for a low resource economy like us to be able to make more diagnosis of adenomyosis so a doctor i got up it's so great to have you please you can share your screen now and there you have the microphone thank you thank you so much for inviting me it's an excitement for me to be here um to be part of this uh process um so i thank you your organizers for inviting me to come and discuss the ultrasound diagnosis of these enigmatic disease adenomyosis with a focus on the nigerian experience i have no disclosures to make so my pocket is empty all right adenomyosis yes anonymous has always been considered the classic condition of multiparous women aged over over 40 years age 40 years and over these women usually have chronic pelvic pain and abnormal uterine and or abnormal uterine bleeding with the condition believed to be diagnosed possibly only from histological examination of hysterectomy specimen of those women that are treated surgically suddenly evidence in andrea indicates that we have not moved from these long-haired beliefs despite the fact that the epidemiology diplomatic scenario has changed completely with with advances in the imaging techniques first with mri in this paper by togashi in 1988 and later with waterstone in this to work by legally federally in 1992 these advances in imaging techniques have shown that adenomyosis that have shown improvement and i don't know basic diagnosis with identification of sonographic features with features of adenomyosis in young women of reproductive age as far back as 1986 renegade and my teacher professor eugene opera showed that we in nigeria were actually at par with the rest of the world in recognizing that there were challenges recognizing that were challenges with the difficulties the diagnosis of adenomyosis and to work towards the prevention or elimination of these frequent measles diagnosis acetylene fibroids at surgery but by 1991 while the rest of the world was moving forward with ultrasound and mri our diagnosis in manchester was the mostly post-operative and we still believed that adenomyosis was common as a multiparous women in the fifth decade of life by 2019 we had gone full cycle back to 1986 with adenomyosis believed to be commoner in the fourth decade of life and retrospective histology after hysterectomy still diagnostic too for the disease in nigeria and just last day here in 2020 right in the heart of middle clovid a side of four and others walking in the navy examined adenomyosis and uterine fibroids and reach the conclusion that histological examination is the only two the only two to differentiate adenomyosis from uterine fibroids again the highest number of cases that they saw were women in their fifth decade of life is the global narrative different yes i mentioned that earlier and provided the evidence as well that transvaginal ultrasound and magnetic resonance imaging have improved the diagnosis and led to the identification of adenomyosis in young nulliparous women of fetal age not just multiparous women in their fifth decade of life let's talk about ultrasound that's why we are here and so we find that with ultrasound the disease is actually indeed common in younger women with identification of endometrial lines my mutual cease and their association to adolescents and young women in this work by the seven gods group insertee and katrina zakuti's group showed us how young these women can truly be with a demonstration or documentation of sonography features that diffuse adenomyosis a young 18 year old and or 30 year old women who have never been pregnant their efforts showed us that adenomyosis actually develops earlier in reproductive life than we previously thought in fact zanoni at all showed us again that the disease can be found in adolescence and that the prevalence of adenomyosis in young women that whole population of young women presenting with perennial pain amounted to about 46 percent all of these ultrasound so we need to up the stakes in pre-surgical diagnosis of adenomyosis in nigeria we really need to ask questions whether histology is still the goal standard for the diagnosis of adenomas because the evidence in nigeria that histology is the gold standard for the diagnosis of adenomyosis and that the disease is common or most common in older women older multiparous women means that the condition will be likely under diagnosed i mean you're not going to take a young non-parous woman 28 year old woman with chronic perfect pain and abnormal just because you want to relax if she has adenomyosis so there will be diagnostic delays and with it are the attendant problems of application of the wrong treatment or misapplication of treatment by clinician so clearly there's a need for pre-surgical diagnosis using non-invasive diagnostic methods like mri or transfer nascar indeed when the results of trans vagina scan and mri were compared with histological findings the outcome showed that these um these um imaging techniques correlated very well with histological diagnosis official atomic specimen in simple terms translation has scan mri and histology all compare together in the diagnosis of adenomyosis known as superiority order this evidence let the authors of these meta analysis in systematic review to recommend transfer channel scan as the first line diagnostic imaging technique of course avatar scan is widely available of course therefore more accessible better tolerated by patients and cheaper than mri leaving mri as a second line treatment only if transgender scam is inconclusive and transgenders can be inconclusive i mean we can remove the income it will be very few or none at all if traumatized can is performed by dedicated photographers who can identify distinct ultrasound pattern of requiring the diagnosis of adenomas and so truly uh professor heisen's honor and his team of activity specialists demonstrated the sonographic features of adenomyosis in the population of young infertile women in nigeria this is the only evidence documenting ultrasound finding of adenomyosis in the nigerian population however but they did not actually state the exact sonographic features of adenomyosis that they identified nonetheless they identified these features in only two percent of the population recall from the evidence i provided here today that the estimated prevalence from histological diagnosis in nigeria is about 10 percent so why do we have these variants these variants may be explained by inconclusive ultrasound reports like the one presented to us by this 28 year old lady she came to us seeking resolution of infertility having been trying to get pregnant for the past two years she also complained of severe dysmenorrhea and deep disparity she came with two water sunscreen reports the first one this one here was done on the 10th of august and the photographer used first the trans abdominal probe and then he described the lever the gallbladder the kidney the pancreas spring bowels and then you use the translational probe to image the uterus and describe the uterus as normal in size antiverted and long gravity now what is normal in size the exact measurement ought to have inputted in this report so we are sure that the operator's subjective judgment is not in doubt because of course uh sakel and alfred abu muhammad showed us that globular uterine enlightenment that is generally up to 12 cm in uterine length that is not explained by the presence of fiber it's a characteristic finding of adenomyosis so we lose that information because the measurement is not there and he described again the myometrium as a measures identified a tiny fibroid mass notable uterine wall and measures that so conclusion was that features in keeping with tiny uterine fibroids but infertility persisted this manure are persistent and deep disparity not persistent so as is common in nigeria patients drive their own treatment and so she presented estuar for another ultrasound scar so she had a second ultrasound scan on the 27th of august about 17 days apart and in the report we noticed that the uterine length now measures approximately 11 centimeters and that uterus is suddenly bulky importantly the sonographer notes that there are e-defined echogenic areas involving the posterior and fundamental regions these are temps used for the description of adenomyosis the sonographer acknowledges the association of these terms with adenomyosis in his final report where he knows query background analysis and the patient is advised to seek confirmation of his findings using a transfer channel so she presented to us when i scanned her i saw using the timeline i put of course i saw a bulky neutrals measuring 12.4 by 8.5 by 7.7 centimeter therefore our findings are in keeping with that of sacrament that measurement greater than two twelve centimeter naughty uh where uterine fibroids are not seen may be associated with that pneumonia so we decided to look at it again what else did we see we saw global thunder enlargement and then we saw small myomitra seas and then we saw shadows and so shadows and then we saw indistinct endometrial myometrial junction and then we saw echogenic islands all of these are terms that are used to describe adenomyosis now why did we have those inconclusive or misleading reports initially in afghanistan why should we have inconclusive reports at all we found answers in these unpublished data where we sampled fertility specialists in order to better understand barriers to utilization of gynecological ultrasound and what did we find we found that the major reason why we have inconclusive or misleading reports concerning adenomyosis this lack of ultrasounds can scale manakaya and i in this paper identified the apparent lack of ultrasound scans give to be due to the absence of formal training programs with many images sonographers technologies being often self-taught unlike in high-income countries where gynecological ultrasound is a core it's like it's a it's a part of the curriculum or specialty training so in training sonographers will learn how to identify the sonographic features of adenomyosis in order to avoid misdiagnosis language really matters and so this consensual statement from the musa group present has presented us with both a language to describe the sonographic features of adenomyosis and a system of how to identify it i invite you to read the paper because again it also provides guidance on how to distinguish uterine fibroids clearly from adenomyosis so for our refinement of definition by the moisture group has led to the recognition of the sonographic features of adenomyosis as primary features or secondary features the primary features usually uh they are more they signify the presence of ectopic indubition and they are seen on ultrasound they are also called direct direct feeds direct signs that are seen on ultrasound as myometrial seized hyperechogenic islands or or some of them dimitrial instant balls while the secondary features also called indirect features you know these are indicators indicators secondary to the presence of atopic endometrium so you may see them on ultrasound as asymmetrical thickening of the myometrial wall because of the distribution localized distribution of the adenomyotic tissues here in this place they are distributed more to the posterior wall so you see posterior wall thickening and where there is a uniform distribution of the adenomatic lesion you see global uniform enlargement of the myometrium you may also see fan shape shadowing transitional vascularity and then the of my mutual junction may be interrupted or it may be irregular now recall that in the first scan from the clinical case uh presentation that clicker case scenario represented the sonographer used both the trans-abdominal probe and the transfer channel pro the second sonographer used the trans vagina pro but adenomyosis is best visualized using the trans fat and approach why but it's not possible to get a good image resolution with a trans abdominal scan to enable a reliable distinction between adenomas and eternal fibroids so what is recommended it is recommended that a transvaginal probe transverse scan should be the primary tool in all clinical cases of suspected adenomyosis however within nigeria there are still some reservations about the acceptability of the transvaginal probe or transgender scam as a diagnostic too however these most recent publications showed us uh the concluded that the translational transgenography is universally acceptable to women in nigeria and recommend that ultrasounds scan providers should acquire this key for transfer channel scan and then aim to use it routinely in all gynecological evaluation and when eventually this field is acquired what will these ultrasound providers see look at this image then we see that the fondus of the uterus is analyzed regularly then we also notice asymmetry in the anterior and posterior myometrial wall but like we said these are secondary signs of indirect sine secondary features so you look deeper you ask yourself why do i see these things when you look deeper you see loss of endometrial myometria junction and then you see shadows see shadows more in the transverse image you see shadows and then you see myometriasis myometriasis and then you see echogenic islands so when you put your probe and you scan the patient the first thing you see are indirect signs so you ask yourself why do i see these signs let me show you some video examples now bloom and majidohum actually showed that we learned from them that sonographic features of adenomyosis are best demonstrated using video clips so i'll show you my own videos these are my own videos so in this video in this video you see that the uterus is globally enlarged they gave more reformed us and then as you scan you see a fibroid no do and you shout to the car the fibroid nodule must be releasing for the environment and you decide to measure it and what do you find you have a 0.8 by 1.2 1.12 percent no no that's the cannot be that's like a seed of grammar that cannot be reason for the enlightenment zero point eight by one point two so you scan further and then you see asymmetry of the anterior and posterior myometrial wall and then you see that the anterior myometrial wall appears wider than the posterior biomaterial and then you notice that the myometrium mesotheliogenes hyperechoic areas hyperechoic errors in the anterior wall so what you do you you scan further you scan further to look at this region of interest the anterior myometrial work that has high parachogenic lesions right there so you zoom your image zoom in your image you zoom in your image and then you see the hyperechogenic errors what do you see myometriasis myometriasis synthesis with the echogenic cream cc with the echogenic ring system echogenic cream so and then you you switch on your doppler just to see what type of version it is switch on your doppler yes switch on the docker ccd is coming soon my material sees the place coming soon sit on the doppler yes she's on the doppler and then we see translational muscularity the verses go through the lesion as if there is no lesion okay now let us look at our fibroid nodule and see the type of vascularity the fibroid has look is verified by this you see circular flow see circular flow this thing from this translational vascularity of gadolo myosis we got it this is tecla flow here thus telling you where the fiber is this thing that so the fibroid lesion is well defined the adenomyosis assistant is a defined that's the difference now let us look at the junctional zone again look at the junction as well in this image look at how the anterior myometrial junction is where demonstrated very clearly demonstrated and you still got the posterior zone not well demonstrated see that so see we're demonstrated here again look at this image this um little battery uterus you see global thunder enlargement yes but what strikes you first are the shadows look at the shadows fan shapes shadows fine shape shadows got the shadows fan shape shadows and then you see why do we have these shadows you zoom in again and then you see you see the my matrix is echogenic cream biometricized epigenetically my matrices nicogenic cream so you see that you see that these are the features of adenomas again if you switch on your doppler you see translational flow you see translucent okay so how did this cease really appear look at it this sister and nikoi structures surrounded by echogenic cream look at this is here they are the single most reliable um sign for the diagnosis of adenomyosis so you see ccr ccr echogenic islands all over then you see shadows you see shadows that's the in the direction of the ultrasound beam ultrasound is generated by by by the waveforms you see that so when you see shadows there must be a reason why the shadows exist and here it is quite simple so i put this image this video so we can understand how the shadows arise so we have here exists um quite in like and just below the seas you see um acoustic enhancement you see that acoustic enhancement and on either side you see edge shadowing so we see a large seas we see acoustic enhancement retro across the enhancement and then we see shadows on either side now if it was a smaller seas you just see linear high pi coil stripe alternating with inner hypo echo extract you know so like this one yeah a good example of shadows you see that hyper echoic shadows i bike with lines stripes alternating ribbon if you move up you see the cheese you've got the system in your soil ceased to see so it's actually um shadows alternating with a retro aquatic enhancement shadows retro acoustic enhancement shadows retracement in a grossly enlarged uterus and if with further ski development and better machines will be able to see sub and meter lines and boards and then you look at it you see the saw and the mutual lines and boards syllabus this must be distinguished from echogenic psychogenic uh spots which are actually progenitors of echogenic islands and so here you also see the sorbendometer lines and boards just below the endometrium infiltration of the endometer myometrial junction and if you have 3d you can reconstruct the uterus and then you'll be able to see the actual infiltration of the endometrial myometrial junction like this look at how beautiful this area is and then you see the infiltration in the corner point here again the lateral uh left side wall here you see the infiltration there are usually perpendicular lines perpendicular lines between the myometrial walls hello hello and then we need to say hey was that hello hello and you are you out for some time yeah you're back so go on um yeah that is the broadband the the broadband so um we might pause for a few minutes to allow dr agulla to come back yeah i must say that dr aguilar is not in lagos is in a part of my jackal worry and so sometimes this happens hello yeah you're back am i back now yeah yeah you are okay oh my skin can i still come back can i scream come back please yeah yeah one minute you have to share your screen again okay you have to try your screen again yes yes share it again church thank you so much thank you am i back yeah yeah yeah you're good okay good so i i i was saying i was saying that i hope we all followed the aspect um can i work what can i go about yeah yes i i talked about the possibility of 3d reconstruction of the uterus and then us being able to of course see joshua's own imputation that's where we were before i got cut off okay so now we see that it is possible to diagnose adenomyosis using ultrasound so it is quite sad that despite the availability of this knowledge adenomas is continues to be misdiagnosed in nigeria and that surgeons continue to be surprised by what they find at surgery and patients continue to be surprised to learn of surgical findings when they are awake many times going back home with the problems that brought them to the hospital in the first session problems of abdominal uterine bleeding pain dismantling and dysparina soft fertility and challenges with you know of a poor strategic outcome this needs to stop manakaya and i preferred solutions along three needs one provision of good attractions can be seen with of course assets for servicing repairs and and maintenance but we talked about training training and reaching individuals and of course we talked about the need for accurate reporting of ultrasound scan images using technological tools like discom or even prepared available uh templates for ganache ultrasound scan reporting like um uh uh forms that are available uh sorry about this yes you could use um one monaco or viewpoint those are systems that are valuable that can be used in our setting so let me summarize all of this for you yes ultrasound scan diagnosis of adenomyosis is um affordable in nigeria but what we know is that affordable evidence indicates that we are still lagging behind the global community in the appropriate use of transvaginal ultrasound as the first tool for the diagnosis of adenomas as a result misdiagnosis of adenomyosis an application of inappropriate treatment continues in nigeria researchers have identified lack of training as a major challenge therefore there is a need to provide training opportunities if you have to improve accuracy in ultrasound diagnosis of adenomas especially as treatment options including high food surgery available now thank you thank you so very much thank you so very much dr agola you put it so clearly um the the need for us to [Music] be able to diagnose adenomyosis pre-surgery because that's whether for surgery or five-year that is when the patient can benefit not after so and you have highlighted the importance of training so thank you so very much um i have the pleasure of inviting the next speaker uh to now that we've made been able to make the diagnosis of adenomyosis surgery for adenomyosis and their hands turning back we'll be talking about this so hand standing back is not a stranger to many of us in all these endometriosis things that we organize we know there is a pioneer president of the european endometric endometriosis league he has altered so many publications and he's on a very limited time schedule today because that's a family thing to do but thank you so much hans for creating time to talk to us about surgery for adenomyosis so i hand over to you hans thank you yomi it's it's a great pleasure for me to be with you and i hope that we might be able to to extend this in the future to come and as you said we have spoken about endometriosis related topics before and i hope we will do in the future now i am very grateful to the previous speaker dr akolor because he had stated something that i think might change the entire attitude to endometriosis including adenomyosis and it's only because of that that i also took one ultrasound picture this is a 3d pick and you can see the disc proportion all the other signs that dr akolor had shown and i would like to to add one aspect and i will come back to this at the end of my talk we have the privilege of doing the ultrasound or the diagnosis and the treatment in one hand so it should be that also the surgeon should learn to read these these ultrasound findings because ultrasound is not only easier available but it is also a dynamic investigation and therefore we can have an excellent approach to this type of disease this is an mri finding and i had this because um the advice that i have heard most by gynecologists is okay sorry we now know that you have uh are suffering from adenomyosis and we recommend hysterectomy this is no option for women that have still not completed their family planning and if they want to have a child by themselves then they need their uterus full stop there's there's no discussion about this and this is why um i am propagating not to further entertain the idea of hysterectomy but to look at other options and i'm very grateful to to dr yomi abbayi that he has also alternatives to certain ways and of course what we can do is cite reduction we can try a complete excision we have non-surgical interventions and we also in some options might have medical therapy up to date medical therapy for particularly extensive adenomyosis mainly diffuse adenomyosis was the only way especially in case of infertility that was recommended and i'm sure that dr abbayi know knows all the stimulation protocols including long-term gnah analog downstaging what i would very much like to talk about is complete excision which is sort of conflicting with site reduction now perhaps some of you know a surgical technique that has been propagated by osada from japan the the technique that i am practicing is slightly different from this because my former teacher had um propagated a technique similar to this but in a in a slightly different way but this this picture is fine i think to explain what it works like so what we do is we place a tonic a around the ascending branches of the uterine artery we also have a tonic a around the ovarian vessels so that the ovaries will still be perfused we do not set a clamp here but we set a clamp here and the tubes will recover so there is a tornicate here on both sides and the tornicate at the esmocervical level then we split the uterus in two parts uh probably this is not very obvious because we split that we also open uh the uterine cavity then um and i'm doing this with the mini labrotomy i i take sorry i take the uterus out in front of the abdominal wall and then excise with a bipolar scissor i excise all the affected tissue by having one finger in the uterine cavity and with the bipolar dissecting scissor i excise the tissue leaving part of the junctional zone intact as well as part of the subserious normal myemetrum there's always normal myometrium sometimes only a very thin layer in this area and there's this is also some healthy tissue so if you like this is um the maximum way of site reductive way of going about here you can see there is uh the the finger is um in the the the uterine cavity this is the bipolar scissor by erba called bisect and i dissect this this tissue and remove it on in four areas where there's the the main diffuse adenomyosis at the posterior anterior wall and the same at the posterior wall left and right sided so there are four areas where where to dissect here you can see this is also going close to the uterine cavity here you can see that there's little normal tissue left so as we also try to remove even small eyelets of this tissue and here is a short video that shows you all the tissue of the all the adenomyotic tissue has been removed and now we suture the the edges of the uterine cavity with micro uh micro three zero sometimes two zero depending on how thick the the tissue is and this these are sutures without any forceful uh knotting so this is just for approximation we do not want that there are uh um rough edges inside the uterine cavity the uterine cavity because of the endometrium has a high capacity of reforming the layer of of the uterine cavity and this is what we can trust to [Music] to depend on and you can see there's very little oozing uh that's because of the the tony cake and some people have asked for how long can we leave the tourniquet the tony k i think can be left up to six hours or even more the uterus is extremely resistant to ischemia but we do not need to have this so and now we will do additional incisions in order to have flaps that are overlying because what we want to do is we want to reconstruct the uterus and that's why i'm doing an additional incision in order to have an overlapping of the tissue to strengthen the uterine wall basically this is the the most creative work and this is why it is always a new challenge because what we have to aim for is we have to reform the uterus in a way that there are hardly any pockets left behind because we do not want that there are seromas developing or that there are hematomas in these these layers and you can see what we do is we we fold the tissue in a way that we have overlapping also filling the possible gaps with a healthy tissue and this is now no longer vicro this is pds because pds takes much longer to lose its its strength it takes about three months in order to have half the pulling strength and now as you can see this has been the first or the second layer and this is now the third layer which is also used in order to cover up the entire tissue and we pull it together sorry this is a head camera so um if someone is looking for something by the way uh the the cameraman is my dear and respected co-worker dr allen constantine who is also doing this type of work in a very very nice manner and you can see we are covering it reconstructing the uterus so that in the end the shape looks similar to what it should have looked under normal conditions as you can see so this is now the uterus we remove the tourniquet and this is how the uterus looks now and in order to reduce the chance of developing uh seromas in there what we also do is we place we place you suture in order to as you can see there's a straight needle and it goes front to back through the uterus it is an in suture a u suture and this u is in order to compress from outside it also goes through the uterine cavity to compress the all these layers so that there is less chance of developing a seroma or even a hematoma okay in order to avoid adhesion formation we will perform thorough rinsing and sometimes we even apply an uh anti-atis adhesion uh device in order to prevent uh disum so this is what it this is a different case but this is i would my the the tubes have because now is being removed even introduced a also we also propagate to use the there is f a which stands for adenoma for endometriosis and this classification used pre-surgical so that the patient less my disease in imaging how long will the surgery take and that you have other aspects that might not have been seen the uh the frankfurt way of the osasa one contribution to having not only more to showing up ways of how to deal with and for all of that we need more awareness today would be passed through frankfurt or being there and let's discuss things together if you like yeah thank you so very much hans yes um definitely just wait for kovi to go by and then i'm sure some of your listeners will take up the knocking on your door in frankfurt anyway uh thank you so much uh we'll just um i think we take all the questions together so oh but you need to to run can we just take a few questions do you want are you can we just take a few questions yeah but oh and i got the sign the internet connection is a little in so let's let's try it if if not i see that um active if i cannot answer this thing doing so but please let's try okay um all right and i i have a first question to start with have you tried to look um stereoscopically at the you try that you have done this reconstruction before i do look try to look at it what what did you find if you have done that yes we have looked at it he looked at it we did not see an intra be afraid of and we did not see and electroscopic related topics i think [Music] an excellent speaker to show this but most important involved in infertility treatment these [Music] were highly fertile even though they they had with ivf xc and what have you so it really helped them having a baby i think what we just do is we get you to answer the questions i think the internet is not our best friend here now we just get you to answer the questions and then we we can read the questions is that okay great okay i think what we just do can we um the questions or you have a lot of questions so maybe um can you understand everything oh yeah then we would we can even send some of them to you to answer no problem it's unstable so yeah i know i know we we just let you go stance you be are that i'm going to bombard you with the questions [Music] um yummy you know if you don't mind perhaps um if people are really interested in this you can can send me there or alternatively um i see that alright is talking next after you now so internet connection is better so that he might answer this question okay thank you so much so hara do you have them i'm sorry if i'm holding you no problem no problem hands you you attend to what you've got to do okay thank you for being part of this and always very helpful and also you have them you have an extra headache added on to you now as we come to you happily answer the questions yes so let me just introduce the next speaker yeah but i can say from all the comments that people are really having a good time with all this adenomyosis is a topic we cannot uh uh be tired of talking about so my the next speaker is a harap krentel is a specialist of course gynecologist and obstetrician and then the certified gynecological oncologist and the specialist in minimally invasive surgery especially specialized in the steroscopic and laparoscopic procedures in adenomyosis including adenomyomectomy and psycho-reductive procedures in infertility kentucky is a very important and very active member of the eel and there so you'll be sharing the experience with us clinton and dr prenter is really my um pleasure to have you here today and now that you also have you have been inherited part of uh has the questions there we tend we're going to have a lovely time talking to you today so all right i just let you do your thing okay then okay perfect yeah first of all thank you so much for your very kind introduction and uh the invitation i'm very happy and it's it's a big pleasure for me to be with you today i think it's an excellent idea to have a webinar just on adenomyosis as it is a very very important area of of patients with endometriosis we shouldn't all we should always think in all our patients with endometriosis also in adenomyosis and i would like to congratulate uh the previous speakers for the excellent lectures especially ultrasound is the most important tool in the detection of adenomyosis as it is available for most of us in our daily practice and as hans said we also do um the ultrasound and the surgery and if it's needed we have radiologists to do an mri but the most important point is that we think in adenomyosis and that we try to diagnose it uh that's the condition for the treatment and it's the condition for a complete counseling of our patients with endometriosis and and in this point it's not important whether they have symptoms like bleeding disorders or dysmenorrhea or infertility in all aspects it's important and as dr golor mentioned also it's important to distinguish adenomyosis from from fibroids now my topic today is hysteroscopy in patients with adenomyosis and i think it's um an interesting um surgical field in adenomyosis um first before i start with hysteroscopy i just would like to show you the new um hashtag ancient classification of endometriosis which has been published in february this year hans already showed it to us i think it's a very important um classification as it is a comprehensive uh description system for endometriosis including all aspects of the disease and i'm talking about peritoneal lesions but also deep endo and also adenomyosis when we have a look at the classification it's important to know that you can assess it by ultrasound and that means that you just put a u and that means the autosonographer is able to have a pre-surgical classification of the disease the same can be achieved by mri and then you can have the surgical classification of the disease and the best way is to merge your ultrasound mri and surgery and then have a clear view of the special and individual classification of each patient uh when we talk about adenomyosis it's the f a which determines adenomyosis in this classification and as you can see it would be helpful to have an additional unique adenomyosis classification which still does not exist so why is um adenomyosis of such a great importance it has a very high incidence and we do not know exactly how high as we heard before in previous years it was just diagnosed by hysterectomy speciemen and now we just start to see and to care for adenomyosis so we do not have exact dates on prevalence and incidents in age depending way so we do not know if a 25 year old infertile patient has got adenomyosis or not just when we are very good in ultrasound or we have good radiologists who are able to interpret mri then maybe we can detect it but still we are not sure how often adenomyosis plays a role the uterus is the central reproductive organ and when you think in the older times we talk about endometrial uh about peritoneal endometriosis about the ovaries and about a lot of details but we did not care about adenomyosis and the uterus most of the patients with adenomyosis have symptoms another important factor and adenomyosis and i think this has been shown clearly so far has a negative impact on fertility uh it can cause reduced pregnancy rates reduced birth rates and higher abortion rates and there is also a link to obstetrical complications like premature birth pprm uterine rupture and pph so this is what we have in our daily practice and adenomyosis plays an important role which are the treatment options medical treatment surgical treatment and of course reproductive treatment and there are many options and many things to discuss i will focus on surgical treatment and on hysteroscopy the treatment factors for your decision taking are symptoms family planning additional deep endo and patient age so when we talk about the surgical options uh there are many and as hans showed the open surgical resection the cyto-reductive surgery you can also use laparoscopic resection you can use radio frequency ablation you can use hifu which we will listen to later and now we focus on hysteroscopy when we uh resect adenomyosis it has the effect that the pain is reduced the bleeding disorders can be reduced and this is also measurable in terms of ch125 there are some examples and um i i just would like to show you these uh videos because uh it is important to understand uh that adenomyosis in some cases is is clearly visible but in many many cases you just find some endometrial microcysts like in these very young patients these are typical findings and here you can see how it looks like when you cut off the specimen out of such a uterus and this is a three millimeter chocolate bubble and this is a sub endometrial adenomyosis finding which can cause symptoms and the problems we just heard so the idea now is what can i do with hysteroscopy is it is it possible to to see these lesions or to reject these lesions we will see this is a larger diffuse adenomyosis and of course here in this case it's it's easier to detect and this is nothing you can treat by hysteroscopy and what we usually see in hysteroscopy is that the endometrium is irregular with tiny openings on the endometrial surface we have a hypervascularization we have the so-called strawberry pattern we may have fibrous cystic appearance of introducing lesions and we may have hemorrhagic cystic lesions this is a review from 2017 and of course the hysteroscopy is always good for the inspection of the uterine cavity as you just mentioned so what we do we do hysteroscopy in all our patients with endometriosis this is our standard procedure we use the trophy scope by carl schwartz which is a three millimeter diagnostic hysteroscope we do not use any dilatation we do not use any um any medical pre-treatment and this this is just the typical standard way to to do hysteroscopy in all patients with endometriosis and this is just part of our fertility checkup and sometimes you have some findings like for example here adhesions or a septum that you can treat but of course in most of the cases there is no finding at all and you just see a normal uterine cavity and you just can tell your patient okay everything's perfect inside and i can tell you that in many patients that have adenomyosis the endometrial layer is completely normal in some cases it looks like this this is not not the video is not running well however these are typical findings like these brownish cystic lesions these spots in the endometrium um and sometimes you have these findings in hysteroscopy but in many many cases of adenomyosis you just have a healthy normal endometrial layer this is an example for a small opening the tiny opening of the endometrium it's not the tube it's it's an opening to a cystic adenomyosis this is how it histologically looks like this is resection of cystic adenomyosis with the bipolar loop and this is a small adenomyosis lesion within the myometrium and as you can see we are just like dwelling in in the depth of the uterus and then you have an endometrial like tissue again which is very interesting when you see it and of course it's even more interesting when you have the chocolate coming out the problem is that when we try to do hysteroscopic resection the the uh the frequency that we really find our lesions is not 100 percent of course because sometimes the lesions are big enough and it's easy to detect them but sometimes they are very small and then it's really difficult so if you want a histological proof and you want to have a small biopsy by hysteroscopy then it might be difficult to find the lesion so for example in the actual german and austrian and swiss guideline on endometriosis there is no recommendation for obtaining a biopsy in patients with adenomyosis by hysteroscopy however i think it might be important and if you combine ultrasound and hysteroscopic biopsy you have a more or less high specificity like in this publication about 90 percent we have some data too and we were able to find the his uh the the proof the histological proof of adenomyosis in more or less 50 percent of those patients with a suspicion of adenomyosis so you can see that it's not so easy and of course it depends on the size of the lesion the problem is that you have a lot of false negative results why could a histological proof by hysteroscopy be important because it it might have consequences on the on on the on the plan it might have consequences on reproductive treatment on surgical treatment and it might be an explanation for the ongoing problems of the patient and it might also be a factor for the coverage by hal hal's insurances so we believe that if you see adenomyosis you should try to get get it resected here is another example this is a cystic lesion this is the proof by doppler that it's not a vessel and this is um the result as you can see of course this is not a hysteroscopic resection and here you can see how we uh do um the biopsy in patients with adenomyosis in this case you can see that there's a certain strawberry pattern there this these small lesions in the endometrial layer this is a mini hysterosectoscope it's a five millimeter rezectoscope bipolar which is really good for fertility patients because you do not have to do a dilatation to eight or nine millimeters then you obtain the first layer which is the layer of endometrium and junctional zone and maybe a small layer of myometrium and then in the same tunnel you take the next layer which is a deeper one with the myometrium and then the pathologists have the chance to detect if there is adenomyosis or not but just to repeat this of course in some cases you need ultrasound in the or you need a good description of the localization of the lesion here it's easier because it's bigger and you can just resect it and then you see the opening in the uterine wall and this is a case of a much larger cystic adenomyosis which we treated by hysteroscopy so one thing is hysteroscopy as a diagnostic tool and the other thing is hysteroscopy for biopsies and the third thing is hysteroscopy in use for adenomyosis resection this patient did not wish to conceive in the future which means that we can just evacuate the cystic lesion and coagulate it inside like an ablation um but of course if this patient would have an ongoing family planning it would have been much better to do the surgery by laparoscopy in order to suture the uterus or even by open surgery in order to have a good suture on the uterus because this is a large defect of the posterior uterine wall and you can see that now when the brownish liquid comes out it's a cystic lesion filled with endometrial tissue and what we do next is um the obligation of this area [Music] and this is a minimally invasive treatment uh instead of hysterectomy and the treatment was successful and she left the hospital without pain so it would be recommendable to take a small biopsy a small resectant resection chip in order to have a histological result and then you can do the ablation with mono or bipolar loop i recommend that i recommend that you use bipolar because these procedures might take some time so this is another case that is also adenomyosis it's cystic but as you can see it's it's on the uh it's on the other it's it's on the sorry it's not reachable by um [Music] by his microscopy this is a 17 year old patient and here's the uterus and there's the lesion but it's too large and it's too far away that's why we we decided to do this one by laparoscopy and it's just opening it um and then the recession of the adenomyotic tissue and this was the hysteroscopy in the same patient so it was completely normal any finding very young patient 17 as i told you with severe dysmenorrhea no bleeding disorders but dysmenorrhea and absolutely normal uterine cavity and with a very beautiful endometrial layer completely healthy so um if you do resection of cystic lesions or adenomyosis of course it's a save the uterus technique it's hormone-free it's uh it has a high impact on bleeding disorders and it causes less pain but of course there's a uterine wall defect you have no suture when you do it by hysteroscopy and it might be less safe regarding malignant transformation when we talk about pre or peri menopausal women so the conclusions are uh hysteroscopy uh from my point of view should be performed in all patients with endometriosis and ongoing family planning his euroscopic biopsy is not really evaluated so far but might be a good tool in some patients you have the visualization during tissue sampling and it's easy and minimally invasive of course there are difficulties in deep or diffuse adenomyosis you have false negative results and you have to train your pathologist too and just one issue if you do resection and then you want to do a chromoperturbation when you continue with the laparoscopy it might be a bit difficult as uh the blue dye just enters the uterine wall and is not leaving the fallopian tubes so you have to have this in mind and i would like to take the chance to invite you if you like endometriosis case discussions to our eel activity which runs from time to time next time uh 28th of september 7 to 8 pm uh central european time it's just one hour of case discussion with your keck stein harass ramon and mohammad brooke and our young team and of course you are all invited to come to bordeaux france in june next year to our european endometriosis congress we have a very good program i think and it would be an honor and pleasure for us to welcome you to bordeaux and i just can say as han said if you wish to visit our department in germany in duisburg you're always welcome thank you so much yes thank you thank you so much i have uh very very lovely presentation and one thing again that i really want to emphasize especially for the our colleagues in nigeria which is one of the things i've been discussing with you is to see how we also not only train the gynecologist but also the pathologist and that's one of the things i saw from your presentation because sometimes you bring that face and they can't make a diagnosis because they've not been trained to see face so wonderful thank you so very much with we have a lot of questions from what i can see and then we heritate some also so i i think uh fine because said so many people thinking and i'm sure will benefit greatly from this presentation so i just go on to talk about um i don't know my house i'm and infertility so we made a diagnosis we see that we can use the stereoscope but we know that a lot of these are patients also having fertility so how do we treat them so that's what uh i'm going to be talking about in the next 20 minutes or so perfect so thank you so much and uh um yes adenomas is an infertility uh organized by saugon mendomitosis european endometriosis league and endometriosis support group nigeria now this we uh hopefully we translate into other things in our activities to train the emphasis is actually how we can train ourselves to be able to from doctor i got lost point of view be able to make more diagnosis of endometriosis adenomyosis with a scan from clinton's point of view uh how we can use this telescope which unfortunately we're using a lot now more in nigeria from hunts point of view we can use the laparoscope and even uh the mini lab to treat this condition so i i'll try to start by defining what adenomyosis is if we are not tired of hearing it and denially trying this is characterized by the presence of entrepreneur endometrial glands and stroma surrounded by hypertrophied and hyper plastic smooth muscles deep within the myometrium so it can be described as endometriosis of the uterus so we see that most of the time a lot of times a lot of doctors are mistake this for fibroids because there is bulky uterus the symptoms are almost the same and therefore it's not unusual to [Music] misdiagnosis as fibroids the incidence like we've had so far is unknown because we lack standardized definition and diagnostic criteria even the new classification is foreign for endometriosis not for adenomyosis and therefore prevalence is difficult to estimate is between 5 to 70 percent unlikely um dr angola pointed out in his own paper which unfortunately is what still exists in nigeria we still diagnosed a lot only by astrology and one of the things we want to take away from this series of activities is to increase our pre-surgical diagnosis of adrenal analysis and we saw there was a paper that was done just recently that they saw up to about 35 percent of patients who had hysterectomy for fibroids but about 35 percent of them actually had adenomyosis with the fibroids so it's something that is very common here the risk factors for adrenal meiosis of course is endometriosis and that's why we're saying it in younger people now 40 to 50 percent of people who have endometriosis we also have adrenal analysis smoking is also a risk factor and of course trauma when you have done cesarean section but we've done a recharge in the past it might be risk factors for you to have adenosine like we said from where you heard all day the narrative seems to be changing from because of the use of high resolution ultrasound imaging from the typical story of the multiparous woman in our forties and fifties now we're seeing a lot of adenomyosis 9 fertility clinics especially now that child bearing is being believed people say in their developed countries but i think it's all over the world well 30 to 35 of our of patients with that pneumonia might not be diagnosed uh symptomatic so we need to pay more attention in making diagnosis especially during our fertility evaluation because sometimes this is the only time that this patient is actually see the gynecologist you know maybe they've been seeing other doctors before now and we know of course again the time interval usually between the diagnosis the onset of symptoms in endometriosis and diagnosis we made and especially in our environment where the the chance to see the gynecologists might be very reduced except when they have infectivity well from what we've heard from dr krentel with several studies point to the negative influence of adding analysis on natural reproduction and there are several uncontrolled studies because of limited data that suggests that when you treat this adenomyosis also reproduction of fertility tends to improve so that is one of the things why even being able to treat adenomyosis with the stereoscope might be very very important to us that if you can also debug the adenomyosis at least this might improve fertility now how do we link is any linkage between infertility and analysis the answer is yes there is definitely a linkage and one of the papers i like is this one by uh there are so to have i hope i but she's a base in that sketch italy working with some sweets and some of the things that they described in the paper title treatment options and reproductive outcome for adenomyosis associated with fertility some of the reasons they deduce an anatomical distortions you try and dispel starches which affects sperm transport and implantation and even a gentleman called me herself was able to see the different ultrastructures smooth muscles in adenomyosis different from the ones in the myometrial and the loss of nerve fibers between the endometrial myometrium interface in patients who have adenosine and they also saw the altered vascularization in the secretory phase of the endometrium which actually alters the implantation when patients try to get pregnant not to talk of the molecular markers like vascular egf and other cytokines that need to oxidant gene that has deranged in patients who have administration but is there a causal relationship between adenomyosis and infertility and the answer is no there is no causal relationship so the fact that you have adenomyosis does not mean you have infectivity okay and this was pointed out in this paper in 2019 by the group from the milan uh follow western and so what do we do when we have a patient who has infectivity and hazard analysis so the first thing is that we must have a comprehensive activity assessment we like we said the fact that you have adenomas does not mean you have infertility but if you have then the first thing to do is to do a proper fertility assessment for the man and for the woman and then we have three options available to us and this is where actually we need to the robot meets the root uh we have three options either with considering surgery we're considering the drugs or we're considering alt now it depends on who are we talking about that's why it's important to individualize by doing your fertility assessment so you look at what are the factors responsible what is the age of the patient is this somebody who should be trying natural conception or who can try natural conception for example if all you found was just a a a focal adenomas with adenomyosis yeah can such a patient try natural conception for if you are trying natural concept from two options either [Music] you can try surgery you can try medications and you can combine the two together and if you're trying to do ivf two options are so available to you you can try drugs you can try ivf and you can combine the two of them sorry you can do ivf you know and you can combine drugs and ivf together so for someone who is trying to naturally conceive and fight like we said you find a low focal lesion especially and she probably has the current she's presented with his current miscarriages it might be important for you to try to do some of the things that both dr prentel and fans have spoken about um i saw in kansas presentation a this monster will be busy who is from tesla america in greece we did a systemic review and describe three main categories of new transparent surgical treatment which can be complete excision by the myomectomy it can be partial excision through or psycho reductive surgery and then you can have the non-exceptional techniques which a professor ali is going to be talking to us about haifu and of course the other one is that you can be talking about utilitarian embolization now when we talk about surgery for complete excisation or partial excision it can be by laparotomy it can be laparoscopy and like rental described it can be vice versa now the problem most of the time is to achieve the balance between like when hans describe the surgical techniques that's why i asked for the stereoscopic finding so most of the time your problem is to find the balance between completely removable aphrodisiac and preservation of uterine control you know and there's also the risk of you trying rupturing pregnancy and some even reports have uh shown that there is some pph that is not responsive to conservative treatment which leads to peripheral misdirection and so i saw a question also electives there section after you so this seems to be the best option for the movie so all these things are making there to be a push for the non-exceptional techniques even for patients who want to do ivf and that's why professor ali's talk is very very very important how we can do some non-exceptional things either we're doing we're considering haifu and we're thinking of detrimentary and mobilization of course and then the two of them sound different the the indications that are alike but at the same time a little bit different but of course we also spoke about the drugs there are two groups of drugs that we can consider if we're talking about adenomyosis and infectivity the generic agonist this of course reduces the free radicals in the globular endothelium by suppressing the expression of nitric oxide synthesis and of course they also decrease the 450 aromatics expression which enhances uterine receptivity and the second group of drugs are the aromatics inhibitors and there was a study done in egypt which was a prospective randomized control study and found that there was no difference in volume and symptoms of patients who have adequate houses at 12 weeks but one interesting thing he also found that that the group that were using their rheumatism because two of them got pregnant and none of the people who are using generation goodness got pregnant well there was nothing too significant to suggest about that but it was just something that was noticed so what about ivf in adenomyosis related infertility we've looked at surgery we looked at meditations now let's look at about idea when it comes to ivf the data is still conflicting although many studies suggest deleterious effect on ivf outcome that's what also hara told us the same way that adenomyosis affects natural reproduction it's also affect the outcome of ibm and one of the things good ones that uh earlier meta-analysis is one done by the group in milan a day and they had a meta-analysis of night published data which involved 1865 women 306 of which had adenomyosis they concluded from this study that women with adenomyosis have a 20 reduction in clinical pregnancy rate due to reduced implantation and increased miscarriage rate grace yields from the from canada also went on to do one recently um another meta analysis trying to start from where the milan group stopped they did nice studies she went ahead and looked at 15 studies 11 of which were observational studies and four respective studies and this study involved two thousand and fifty four women 519 with adenomyosis she obtained also a similar result but also showed that there was a 41 reduction in live birth rates in women who had adenomyosis this is also another review article which showed a another uh s

2021-10-13 05:41

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