About the Editors-in-Chief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI
CHAPTER 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CHAPTER 2
Overview of Diffuse Uterine Pathologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1 Diffuse Adenomyosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.1 Etiology and Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1.2 Clinical Classification and Imaging Examination . . . . . . . . . . . 10
2.1.3 Clinical Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1.4 Key Points for AD Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.1.5 Principles for AD Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.1.6 Impairment of Reproductive Function and Preservation of Fertility . . . . . . 19
2.2 Diffuse Uterine Leiomyomatosis (DUL) . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.1 Etiology and Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.2 Clinical Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.3 Clinical Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.2.4 Diagnostic Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.2.5 Principles of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
CHAPTER 3
Innovations of PUSH Approach for Diffuse Lesions on Uterus . . . . . . . . . . . . 33
3.1 Innovations in Surgery and Evaluations . . . . . . . . . . . . . . . . . . . . . . . 33
3.1.1 IDEAL Framework for Novel Surgery Evaluation . . . . . . . . . . . 34
3.1.2 Renovation of Surgical Concepts for Diffuse Uterine Pathologies . . . . . .. . . . . . . . . . . . 35
3.2 Indications and Contraindications for Surgery . . . . . . . . . . . . . . . . . . . 37
3.2.1 The Indications for PUSH Approach . . . . . . . . . . . . . . . . . . . . 37
3.2.2 Contraindications for PUSH Approach . . . . . . . . . . . . . . . . . . . 38
3.3 The Innovations and Advantages of PUSH Approach . . . . . . . . . . . . . . 38
3.3.1 Techniques for PUSH Approach to Reshape the Uterus . . . . . . 39
3.3.2 Skills for Excising Lesions in the Functional Anatomies of the Uterus .. . . 40
3.3.3 The Advantages of PUSH Approach for the Treatment of Diffuse Adenomyosis . . .. . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
CHAPTER 4
PUSH Approach for Diffuse Adenomyosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1 The Procedures and Techniques of the PUSH Approach for Diffuse Adenomyosis . . . .. . . . 47
4.1.1 The Essential Steps of the PUSH Approach . . . . . . . . . . . . . . . 47
4.1.2 Technical Requirements for PUSH Approach . . . . . . . . . . . . . . 57
4.2 Protecting Functional Uterine Anatomy with the PUSH Approach . . . 58
4.2.1 Protection of the Cervical Canal Mucosa . . . . . . . . . . . . . . . . . 59
4.2.2 Protect the Anatomy of the Interstitial Region of the Fallopian Tubes . . . . . .. . . . . 61
4.2.3 Protect the Endometrium from Damage . . . . . . . . . . . . . . . . . . 63
4.2.4 Maintain the Integrity of the Musculature from the Fundus to the Uterine Horn. . . . 66
4.2.5 Ensure the Reconstructed Myometrium has Sufficient Thickness for Pressure Tolerance . . .. . . 66
4.3 Challenges and Solutions of the PUSH Approach for Diffuse Adenomyosis . . .. . 72
4.3.1 Incision Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.3.2 Resection of Lesions that Invade the Functional Uterine Anatomies (FUA) . .. . . . 72
4.3.3 The Procedures for the PUSH Approach for a Typical DAD . . 83
4.4 Perioperative Management, Postoperative Follow-Up, and Birth Management of DAD Patients. . . 94
4.4.1 Preoperative Evaluation and Perioperative Monitoring . . . . . . . 94
4.4.2 Postoperative Management and Long-Term Follow-Ups . . . . . . 95
4.4.3 Management of Fertility and Childbirth . . . . . . . . . . . . . . . . . . 95
4.5 Evaluation of PUSH Approach for DAD . . . . . . . . . . . . . . . . . . . . . . . 96
4.5.1 Method for Evaluating Surgical Efficacy . . . . . . . . . . . . . . . . . . 96
4.5.2 The Short- and Long-Term Efficacy of the PUSH Approach . . . 97
4.6 The Potential Complications and Preventive Measures . . . . . . . . . . . . 97
4.6.1 Uterine Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.6.2 Postoperative Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.6.3 Uterine Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.6.4 Postoperative Intrauterine Adhesions . . . . . . . . . . . . . . . . . . . . 99
4.6.5 Uterine Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.6.6 Regular Follow-Ups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
CHAPTER 5
PUSH Approach for Diffuse Uterine Leiomyomatosis . . . . . . . . . . . . . . . . . . 103
5.1 Procedures and Techniques of the PUSH Approach for Diffuse Uterine Leiomyomatosis . . . . 106
5.1.1 The Initial Operational Steps . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.1.2 Resection of Myomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.1.3 Reconstruction of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . 120
5.1.4 Anti-Adhesion Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
5.2 Special Types of Diffuse Uterine Leiomyomatosis. . . . . . . . . . . . . . . . . 122
5.2.1 Millimeter Myomas Clustered in the Submucous Myometrium and Spread Throughout the Entire Endometrium. . . . . . . . . . . 122
5.2.2 Myomas not Invading the Endometrium. . . . . . . . . . . . . . . . . . 123
5.2.3 Diffuse Uterine Leiomyomatosis with a Large Myoma at the Isthmus or Cervix . . . 124
5.2.4 On a Uterus that was Severely Damaged by Multiple Previous Operations . . . . . . . 125
5.3 Preserving Important Functional Uterine Anatomies Through the PUSH Approach in Cases of Diffuse Uterine Leiomyomatosis . . . . . . . 126
5.4 Perioperative Management and Postoperative Follow-Up for Patients Undergoing the PUSH Approach for Diffuse Uterine Leiomyomatosis . 126
5.4.1 Preoperative Evaluation and Perioperative Monitoring . . . . . . . 126
5.4.2 Postoperative Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
CHAPTER 6
Questions and Answers (Q/A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6.1 Q/A On the PUSH Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6.2 Q/A On the Option of the PUSH Approach . . . . . . . . . . . . . . . . . . . . 130
6.3 Q/A On Common Concerns After the PUSH Approach . . . . . . . . . . . 132
6.4 Q/A On the Procedures of the PUSH Approach . . . . . . . . . . . . . . . . . 133
6.5 Q/A Regarding Perioperative Management and Fertility Issues After the PUSH Approach . .. . . . . . 135
CHAPTER 7
Case Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
7.1 Case 1. Spontaneous Labor Lasted for 2 h, Showing a Good Tolerance to Uterine Contractions of the Uterine Wall Reconstructed with the PUSH Approach . . . . .. . . . . 137
7.2 Case 2. Live Birth Following a Cervical Cerclage During the PUSH Approach for DAD Invasion Resulted in Cervical Insufficiency . . . . . . 140
7.3 Case 3. Two Full-Term Cesarean Sections Following Three Natural Pregnancies After the PUSH Approach for Diffuse Adenomyosis . . . . . 145
7.4 Case 4. Uterine Arteriovenous Fistula Following the PUSH Approach Resulting in Hysterectomy . . . . . . . . . . . . . . . . 147
7.5 Case 5. Satisfactory Outcome Achieved by Reperforming the PUSH Approach for Recurrence. . . . . . . . . . . . . . . . . . . . 150
7.6 Case 6. Treatment of Diffuse Uterine Leiomyomatosis with the PUSH Approach, in Which the Uterus Was Filled with Sub-Endometrial Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . 154
7.7 Case 7. Diffuse Uterine Leiomyomatosis Complicated by Fumarate Hydratase Deficiency (FHD) . . . . .. . . . . . . . 157
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
