Long-term follow-up after conservative surgery for rectovaginal endometriosis

Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility

OBJECTIVE

We report the first randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis focusing on perioperative complications, improvement in symptoms, quality of life, and fertility.

SUMMARY OF BACKGROUND DATA

Bowel endometriosis is one of the most severe forms of endometriosis. Although laparoscopically assisted surgery is a validated technique for colorectal cancer, there are serious concerns about its appropriateness for endometriosis in young women wishing to conceive because it is almost invariably a traumatic procedure.

METHODS

We conducted a noninferiority trial and randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. The primary end point was improvement in dyschesia.

RESULTS

Overall, a significant improvement in digestive symptoms (dyschesia P < 0.0001, diarrhea P < 0.01, and bowel pain and cramping P < 0.0001), gynecologic symptoms (dysmenorrhea P < 0.0001 and dyspareunia P < 0.0001), and general symptoms (back pain P = 0.001 and asthenia P = 0.0001) was observed. No difference in the symptom delta values and quality of life was noted between the groups. Median blood loss was lower in the laparoscopic group (P < 0.05). Total number of complications was higher in the open surgery group (P = 0.04), especially grade 3 (P = 0.03). Pregnancy rate was higher in the laparoscopic group (P = 0.006), and the cumulative pregnancy rate was 60%.

CONCLUSION

Our findings support that laparoscopy is a safe option for women requiring colorectal resection for endometriosis. Moreover, laparoscopy offers a higher pregnancy rate than open surgery with similar improvements in symptoms and in quality of life.

Colorectal endometriosis: benefits of long-term follow-up in patients who underwent laparoscopic surgery

In this retrospective cohort study, three groups of patients were included: 60 women who underwent endometriosis surgery with colorectal segmental resection, 40 women with surgical evidence of bowel endometriosis who underwent endometriosis removal without bowel resection, and 55 women affected by moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The results of a long-term ambulatory follow-up showed that if colorectal endometriosis was present, postoperative pain regression was more frequent, and among patients with bowel endometriosis the rate of recurrence was lower if segmental resection was performed.

Fertility and clinical outcome after bowel resection in infertile women with endometriosis

Bowel resection for endometriosis improves pain symptoms and quality of life in symptomatic women. However, little is known about fertility after surgery, particularly after such treatment in women suffering from infertility. The aim of the present study was to evaluate post-operative fertility and long-term clinical outcome after laparoscopic colorectal resection for endometriosis in infertile women. This study reports clinical outcomes in 62 infertile women who underwent laparoscopic excision of endometriosis with segmental bowel resection performed for severe intestinal symptoms. Among women younger than 30 years trying to conceive spontaneously, the cumulative pregnancy rate was 58% and the cumulative pregnancy rate was 45% in those aged 30-34 years. The total pain recurrence was 9.7% (six cases) and endometriosis recurrence was diagnosed by ultrasound in 14.5% (nine cases) during the follow-up period. Four of these patients needed further surgery because of severe symptoms. The surgical treatment of bowel endometriosis seems to improve pain symptoms and patients' satisfaction rates, and it could also be indicated in infertile women.

Endometriosis and mechanisms of pelvic pain

Endometriosis remains an enigmatic disorder in that the cause, the natural history, and the precise mechanisms by which it causes pain are not completely understood. The pain symptoms most commonly attributed to endometriosis are dysmenorrhea, dyspareunia, and chronic pelvic pain. Pain may be due to nociceptive, inflammatory, or neuropathic mechanisms, and there is evidence that all 3 of these mechanisms are relevant to endometriosis-associated pelvic pain. It is proposed that the clinically observed inconsistencies of the relationships of endometriosis severity and the presence or severity of pain are likely due to variable roles of different pain mechanisms in endometriosis. A better understanding of the roles of nociceptive, inflammatory, and neuropathic pain in endometriosis is likely to improve the treatment of women with endometriosis-associated pelvic pain.

Endometriosis: current therapies and new pharmacological developments

Endometriosis is a chronic inflammatory condition that is responsive to management with steroids. The establishment of a steady hormonal environment and inhibition of ovulation can temporarily suppress ectopic implants and reduce inflammation as well as associated pain symptoms. In terms of pharmacological management, the currently available agents are not curative, and treatment often needs to be continued for years or until pregnancy is desired. Similar efficacy has been observed from the various therapies that have been investigated for endometriosis. Accordingly, combined oral contraceptives and progestins, based on their favourable safety profile, tolerability and cost, should be considered as first-line options, as an alternative to surgery and for post-operative adjuvant use. In situations where progestins and oral contraceptives prove ineffective, are poorly tolerated or are contraindicated, gonadotrophin-releasing hormone analogues, danazol or gestrinone may be used. Future therapeutic options for managing endometriosis must compare favourably against existing agents before they can be considered for inclusion into current practice. Finally, as reproductive prognosis is not ameliorated by medical treatment, it is not indicated for women seeking conception.

Transvaginal-laparoscopic anterior rectum resection in a hysterectomized woman with deep-infiltrating endometriosis: Description of a gynecologic natural orifice transendoluminal surgery approach

Deep-infiltrating endometriosis may affect the vagina, the rectum, and the cervicoisthmic part of the uterus, resulting in severe pain, particularly dyschezia, dysmenorrhea, dyspareunia, and diminished quality of life. Advanced surgical techniques, such as laparoscopic-assisted anterior rectum resection, are recognized as safe and effective therapeutic approaches. In some cases, a laparotomy or minilaparotomy has to be performed for technical reasons. This can be avoided in some cases by transvaginal-laparoscopic low anterior rectum resection. The technique is a 4-step procedure, which can be described as follows: step 1 (vaginal) - rectovaginal examination, preparation of the rectovaginal septum, opening of the pouch of Douglas, mobilization of the endometriotic nodule and the rectum, temporary vaginal closure; step 2 (laparoscopic) - removal of additional endometriotic lesions, adhesiolysis, final mobilization of the rectum, mobilization of the rectosigmoid, endoscopic resection using an endoscopic stapler step 3 (vaginal) - transvaginal resection of the lesion, preparation of the oral anvil, closure of the vagina; and step 4 (laparoscopic) - endoscopic transanal stapler anastomosis and underwater rectoscopy, prophylaxis of adhesions, drainage. We used this procedure to treat a 46-year-old woman (gravida 2, para 2) who was admitted to our hospital for severe lower abdominal pain, constipation, dyspareunia, dyschezia, and cyclic rectal bleedings. The symptoms were caused by an endometriotic nodule accompanied by a palpable rectum stenosis. In addition, she reported a past abdominal hysterectomy with complications caused by symptomatic myomatous uterus. As a gynecologic natural orifice surgery approach, the transvaginal-laparoscopic anterior rectum resection may be an additional useful surgical technique that could be offered by surgical gynecologists to some women with deep-infiltrating endometriosis.

Chinese herbal medicine for endometriosis

BACKGROUND

Endometriosis is characterized by the presence of tissue that is morphologically and biologically similar to normal endometrium in locations outside the uterus. Surgical and hormonal treatment of endometriosis have unpleasant side effects and high rates of relapse. In China, treatment of endometriosis using Chinese herbal medicine (CHM) is routine and considerable research into the role of CHM in alleviating pain, promoting fertility, and preventing relapse has taken place.

OBJECTIVES

To review the effectiveness and safety of CHM in alleviating endometriosis-related pain and infertility.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) and the following English language electronic databases (from their inception to the present): MEDLINE, EMBASE, AMED, CINAHL, NLH on the 30/04/09.We also searched Chinese language electronic databases: Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Sci & Tech Journals (VIP), Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), and Chinese Medical Current Contents (CMCC).

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving CHM versus placebo, biomedical treatment, another CHM intervention, or CHM plus biomedical treatment versus biomedical treatment were selected. Only trials with confirmed randomisation procedures and laparoscopic diagnosis of endometriosis were included.

DATA COLLECTION AND ANALYSIS

Risk of bias assessment, and data extraction and analysis were performed independently by three review authors. Data were combined for meta-analysis using relative risk (RR) for dichotomous data. A fixed-effect statistical model was used, where appropriate. Data not suitable for meta-analysis are presented as descriptive data.

MAIN RESULTS

Two Chinese RCTs involving 158 women were included in this review. Both these trials described adequate methodology. Neither trial compared CHM with placebo treatment.There was no evidence of a significant difference in rates of symptomatic relief between CHM and gestrinone administered subsequent to laparoscopic surgery (95.65% versus 93.87%; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.93 to 1.12, one RCT). The intention-to-treat analysis also showed no significant difference between the groups (RR 1.04, 95% CI 0.91 to 1.18). There was no significant difference between the CHM and gestrinone groups with regard to the total pregnancy rate (69.6% versus 59.1%; RR 1.18, 95% CI 0.87 to 1.59, one RCT).CHM administered orally and then in conjunction with a herbal enema resulted in a greater proportion of women obtaining symptomatic relief than with danazol (RR 5.06, 95% CI 1.28 to 20.05; RR 5.63, 95% CI 1.47 to 21.54, respectively).Overall, 100% of women in all the groups showed some improvement in their symptoms.Oral plus enema administration of CHM showed a greater reduction in average dysmenorrhoea pain scores than did danazol (mean difference (MD) -2.90, 95% CI -4.55 to -1.25; P < 0.01).Combined oral and enema administration of CHM showed a greater improvement, measured as the disappearance or shrinkage of adnexal masses, than with danazol (RR 1.70, 95% CI 1.04 to 2.78). For lumbosacral pain, rectal discomfort, or vaginal nodules tenderness, there was no significant difference either between CHM and danazol.

AUTHORS' CONCLUSIONS

Post-surgical administration of CHM may have comparable benefits to gestrinone but with fewer side effects. Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhea and shrinking adnexal masses when used in conjunction with a CHM enema. However, more rigorous research is required to accurately assess the potential role of CHM in treating endometriosis.

Medical treatment for rectovaginal endometriosis: what is the evidence?

BACKGROUND

Rectovaginal endometriosis usually causes distressing pain. Surgical treatment may be effective but is associated with a high risk of morbidity and major complications. Information on the effect of medical alternatives for pain relief in this condition is scarce.

METHODS

A comprehensive literature search was conducted to identify all the English language published observational and randomized studies evaluating the efficacy of medical treatments on pain associated with rectovaginal endometriosis. A combination of keywords was used to identify relevant citations in PubMed, MEDLINE and EMBASE.

RESULTS

A total of 217 cases of medically treated rectovaginal endometriosis were found; 68 in five observational, non-comparative studies, 59 in one patient preference cohort study, and 90 in a randomized controlled trial. An aromatase inhibitor was used in two of the non-comparative studies, vaginal danazol in one, a GnRH agonist in one, and an intrauterine progestin in one. Two estrogen-progestin combinations used transvaginally or transdermally were evaluated in the patient preference study, whereas an oral progestin and an estrogen-progestin combination were compared in the randomized controlled trial. With the exception of an aromatase inhibitor used alone, the antalgic effect of the considered medical therapies was high for the entire treatment period (from 6 to 12 months), with 60-90% of patients reporting considerable reduction or complete relief from pain symptoms.

CONCLUSIONS

Despite problems in interpretation of data, the effect of medical treatment in terms of pain relief in women with rectovaginal endometriosis appear substantial.

Outcome after multidisciplinary CO2 laser laparoscopic excision of deep infiltrating colorectal endometriosis

The aim of this retrospective cohort study was to evaluate clinical outcome after multidisciplinary laparoscopic excision of deep endometriosis. Patients (n = 56) were asked to complete questionnaires regarding quality of life (QOL), pain, fertility and sexuality to compare their status before and after surgery, and their medical files were analysed. Statistical analysis was performed with life table analysis, paired Wilcoxon and McNemar tests. Gynaecological pain, QOL and sexual activity improved significantly (P < 0.001; P < 0.0001 to P = 0.008 and P < 0.0001 to P = 0.0003 respectively) during a median follow-up 29 months after surgery. Post operative complications occurred in 11% but were directly related to surgery in only 5%. The cumulative recurrence rate of endometriosis was 2 and 7% at 1 and 4 years after surgery respectively. Cumulative pregnancy rate was 31 and 70% at 1 and 4 years after surgery respectively. In conclusion, multidisciplinary CO(2) laser laparoscopic excision of deep endometriosis with colorectal extension improves pain, QOL and sexuality with high fertility and low complication and recurrence rates.

Laparoscopic treatment of bowel endometriosis in infertile women

BACKGROUND

The purpose of the study was to determine the influence of bowel endometriosis on fertility, and to study whether its removal improves fecundity in women with endometriosis-associated infertility.

METHODS

Three groups of infertile patients were included in the study. Group A (60 women) consisted of patients who underwent surgery for endometriosis with colorectal segmental resection. In group B, 40 patients with evidence of bowel endometriosis underwent endometriosis removal without bowel resection. Group C consisted of 55 women who underwent surgery for moderate or severe endometriosis with at least one endometrioma and deep infiltrating endometriosis but without bowel involvement. The women were clinically evaluated before laparoscopy and then at 1 month, at 6 months and at each year up to 4 years after surgery. Main outcome measures were surgical complications as well as post-operative pregnancy rate, time to conception and monthly fecundity rate.

RESULTS

The monthly fecundity rates (MFR) in groups A, B and C were 2.3, 0.84 and 3.95%, respectively. The difference in the MFR between groups was significant (P < 0.05).

CONCLUSIONS

The presence of bowel infiltration by endometriosis seems to negatively influence the reproductive outcome in women with endometriosis-associated infertility. The complete removal of endometriosis with bowel segmental resection seems to offer better results in terms of post-operative fertility.

Avaliação da concordância entre a ultrassonografia transvaginal e a ressonância magnética da pelve na endometriose profunda, com ênfase para o comprometimento intestinal

OBJETIVO: Comparar achados ultrassonográficos e de ressonância magnética na endometriose profunda, com ênfase para o comprometimento intestinal. MATERIAIS E MÉTODOS: Dezoito pacientes entre 23 e 49 anos de idade, com suspeita clínica e exame ginecológico sugestivo de endometriose profunda, foram submetidas a ultrassonografia e ressonância magnética para correlação dos achados. RESULTADOS: A ultrassonografia detectou 40 lesões e a ressonância magnética detectou 53 lesões na pelve. O estudo comparativo entre ultrassonografia e ressonância magnética na detecção das lesões não mostrou diferença estatística significativa (p > 0,19 e p > 0,14, respectivamente). Considerando-se a junção retossigmoide, a ressonância magnética detectou uma lesão (5,6%) e a ultrassonografia apontou quatro lesões (22,2%). Nas lesões retais, a ultrassonografia apontou oito lesões (44,4%) e a ressonância magnética, sete lesões (38,9%). CONCLUSÃO: A concordância entre a ressonância magnética e a ultrassonografia não foi boa na junção retossigmoide e no reto, sendo que a ultrassonografia detectou um número maior de lesões nessas localizações, mas identificou número menor de lesões na pelve. Na análise comparativa global entre os dois métodos na detecção das lesões não houve diferença estatística significativa. O baixo custo, a boa tolerabilidade e o fácil acesso tornam a ultrassonografia instrumento diagnóstico valioso na endometriose profunda.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

Rectovaginal endometriosis-characteristics of operative treatment and factors predicting bowel resection

STUDY OBJECTIVE

The purpose of this study was to characterize operative treatment of patients with rectovaginal endometriosis (RVE), with special emphasis on factors predicting bowel resection.

DESIGN

A total of 153 symptomatic cases undergoing radical resection of RVE at our institution between January 2000 and May 2004 were reviewed. Univariable and multivariable association models were used in connection with various factors associated with bowel resection.

SETTING

Tertiary referral center.

MEASUREMENTS AND MAIN RESULTS

In all, 57 (37%) patients were treated laparoscopically, and 96 (63%) patients via laparotomy. Gastrointestinal and/or urologic surgeon was present in 30% of cases. A total of 54 (35%) patients underwent bowel resection. The median (range) operating times were 145 (75-315) minutes and 100 (20-300) minutes for patients with and without bowel resection, respectively (p <.0001). Four (2.6%) major complications occurred. In the univariable association model, the risk of bowel resection was increased among patients with previous surgery for endometriosis (OR 2.74, 95% CI 1.35-5.54), intestinal symptoms (OR 2.55, 95% CI 1.29-5.02), and revised American Fertility Society score IV (OR 4.71, 95% CI 2.06-10.78). Preoperative use of combined oral contraceptives was associated with a lower risk of bowel resection (OR 0.32, 95% CI 0.15-0.66).

CONCLUSION

Operative treatment of RVE is demanding; a multidisciplinary approach is often needed. Patients with intestinal symptoms and those with a history of endometriosis surgery are at increased risk of bowel resection.

Laparoscopic treatment of deep pelvic endometriosis with rectal involvement

PURPOSE

Our study aimed to evaluate the feasibility and outcome of laparoscopic excision of deep pelvic endometriosis with extensive rectal involvement causing severe symptoms.

METHODS

Ten patients, mean age 32 years (range, 27-43), with deep pelvic endometriosis and rectal wall involvement, requiring surgical resection, were studied since January 2004. Prior to surgery and 6 months postsurgery, patients completed a 100-point rank questionnaire on intensity of intestinal and extraintestinal symptoms. A laparoscopic approach was performed by a team of a gynecologist and colorectal surgeons.

RESULTS

At surgery, complete excision of infiltrating endometriosis was achieved, with 7 low rectal resections, 2 rectosigmoid resections, and 1 proctectomy with coloanal anastomosis. Additional procedures were: ureter resections (n = 2) with one reimplantation in the bladder, left ovariectomies (n = 2), ovarian endometrioma resections (n = 4), and laser ablation of superficial peritoneal lesions (n = 4). In four cases, a laparotomic conversion was needed. Mean follow-up was 27.6 months (range, 18-37). Neither intraoperative nor postoperative serious complications were observed. All the patients experienced significant improvement of intestinal and extraintestinal symptoms.

CONCLUSIONS

Laparoscopic resection of deep pelvic endometriosis with rectal involvement can be successful in improving digestive and gynecologic symptoms; however, this approach is challenging with a high rate of laparotomic conversion.

[Relevance of quality of life questionnaires in women with endometriosis]

High recurrence rates have been reported in women treated for endometriosis despite advances in medical and surgical treatments improving both fertility and symptoms. It should therefore be considered a chronic disorder. In this particular setting, the main objectives for practitioners are to limit disease progression, recurrence and to improve quality of life (QOL). Previous studies have demonstrated a relation between an increase in pain intensity and a decrease in QOL. However, visual analogue scales to measure general well-being are insufficient to quantify the impact of endometriosis on QOL. Several generic questionnaires, mainly the SF-36, are available in various languages but are not specific of women with endometriosis. Some specific questionnaires are available but have been validated in English population for the most part rending comparison between countries difficult. Despite these limits, QOL should be systematically monitored over time by a validated questionnaire for this chronic disorder and could be a criterion for therapeutic strategy.

The effect of surgery for symptomatic endometriosis: the other side of the story

BACKGROUND

Surgery is often considered the best treatment option in women with symptomatic endometriosis. However, extent and duration of the therapeutic benefit are still poorly defined.

METHODS

The best available evidence on surgery for endometriosis-associated pain has been reviewed to estimate the effect size of interventions in the most frequently encountered clinical conditions.

RESULTS

Methodological drawbacks limit considerably the validity of observational, non-comparative studies on the effect of laparoscopy for stage I-IV disease. As indicated by the results of three RCTs, the absolute benefit increase of destruction of lesions compared with diagnostic only operation in terms of proportion of women reporting pain relief was between 30% and 40% after short follow-up periods. The effect size tended to decrease with time and the re-operation rate, based on long-term follow-up studies, was as high as 50%. In most case series on excisional surgery for rectovaginal endometriosis, substantial short-term pain relief was experienced by approximately 70-80% of the subjects who continued the study. However, at 1 year follow-up, approximately 50% of the women needed analgesics or hormonal treatments. Major complications were observed in 3-10% of the patients. Medium-term recurrence of lesions was observed in approximately 20% of the cases, and around 25% of the women underwent repetitive surgery.

CONCLUSIONS

Pain recurrence and re-operation rates after conservative surgery for symptomatic endometriosis are high and probably underestimated. Clinicians and patients should be aware that the expected benefit is operator-dependent.

[Surgical and functional results of rectosigmoidal resection for severe endometriosis]

OBJECTIVES

Indications of colorectal resection for endometriosis are controversial because of the risk of major complications. This study aims to evaluate the value of different diagnostic tests in decision-making, and to evaluate the surgical results and complications, as well as long-term functional results after surgery.

PATIENTS AND METHODS

In the set of a retrospective case series, 50 patients who have been admitted for a colorectal resection because of deep endometriosis were included. Most of them have had an MRI and an endorectal ultrasonography. Specific questionnaires have been proposed in order to evaluate symptoms, sexuality (BISF-W) and quality of life (EHP-30).

RESULTS

For the diagnosis of rectal involvement, the sensitivity of MRI and endorectal ultrasonography were 55 and 100%, respectively. Forty-one colorectal amputations and nine partial colorectal resections have been done by 24 laparotomies, two laparoscopies and 24 laparoconversions. Major complications included six (12.5%) digestive fistulas, three (6%) anastomotic strictures, one ureterovaginal fistula and one ureteral stricture. Risk factors associated with digestive fistulas were the association of a vaginal opening (p=0.002) and an additional ileocaecal resection (p=0.007). The mean follow-up period was of 42 months. A significant improvement of dysmenorrhea (p<10(-4)), dyschesia (p<10(-4)), chronic pelvic pain (p<10(-4)), and of some digestive symptoms such as catamenial epreintes (p=0.002) and catamenial diarrheas (p=0.006), was noted. We noted postoperative 14 dysurias, six constipations and 12 rectal polykynesias. Four patients have had deep recurrent lesions. Twenty patients had a desire of pregnancy after the operation, 17 pregnancies were obtained (eight spontaneous and nine by ART) giving birth to 14 living children. Sexuality evaluation was below normal range. The quality of life was improved for most of the items. The global satisfaction was good (91%).

DISCUSSION AND CONCLUSION

Colorectal resection for deep endometriosis improve significantly most of the pain symptoms, but the women should have detailed counselling about the risks of major complications and recurrence.

Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate?

OBJECTIVE

To assess the effect of surgeon's increasing experience in conservative laparoscopic surgery of women with rectovaginal endometriosis on the surgical outcome of these patients recurrence rate.

DESIGN

Prospective cohort study.

SETTING

University teaching hospital.

PATIENT(S)

The first 60 consecutive patients undergoing laparoscopic conservative surgery for symptomatic rectovaginal endometriosis at our institution during a 4- year period.

INTERVENTION(S)

Cases were classified into two groups according to the date of the patient's operation: the first 30 cases were defined as the early cases and the subsequent 30 cases as the late cases.

MAIN OUTCOME MEASURE(S)

Operating time, perioperative complications, and surgical outcome. Univariate and multivariate analyses for risk factors with recurrence of disease.

RESULT(S)

The two groups were similar in patient characteristics. There was a reduction in the rate of laparoconversion, operating time, estimated amount of blood loss, cases with incomplete removal, and recurrence rate with increasing surgeon's experience. Surgical completeness was significantly associated with recurrence of disease.

CONCLUSION(S)

A learning curve is demonstrated in the conservative laparoscopic management of patients with rectovaginal endometriosis. After gaining experience in performing 30 cases, the recurrence rate is significantly reduced.

Uterine rupture in a primigravida with adenomyosis recently subjected to laparoscopic resection of rectovaginal endometriosis: case report

A case of intrapartum, complete, low-posterior wall, transverse uterine rupture, complicated by uterine atony and treated by emergency hysterectomy in a primigravida with uterine adenomyosis who delivered vaginally at 37 weeks plus 5 days of gestation, 9 months after undergoing laparoscopic resection of rectovaginal septum endometriosis.

Histopathology-based combined surgical approach to rectovaginal endometriosis

OBJECTIVE

To describe a new surgical approach to rectovaginal endometriosis. Rectovaginal endometriosis can be infiltrative or superficial involving the bowel. Only infiltrative disease should be treated by intestinal resection. However, infiltration of endometriosis cannot be confirmed by preoperative imaging techniques.

METHODS

A total of 48 women with infiltrative rectovaginal endometriosis were included in this prospective study. Surgery was performed using a newly developed technique. All bowel resections were indicated according to operative findings and not on the basis of preoperative imaging technique results.

RESULTS

The decision for rectosigmoidal resection was based on the results of the intraoperative dissection of the rectovaginal septum. Histologically, infiltration of the ventral bowel wall was confirmed in all cases.

CONCLUSION

This new surgical technique for the treatment of rectovaginal endometriosis allows precise diagnosis and treatment with low morbidity. A resection of the mesorectum is not necessary because the endometriotic nodules are always located on the antimesenteric surface of the bowel.

Is There a Role for Acupuncture in Endometriosis Pain, Or ‘endometrialgia’?

Endometriosis is a common cause of pelvic pain in women, many of whom suffer a progression of symptoms over their menstrual life. Symptoms may include combinations of abnormal visceral sensations and emotional distress. Endometriosis pain, or ‘endometrialgia’ often has a negative influence on the ability to work, on family relationships and sense of worth.

Endometrialgia is often considered to be a homogeneous sensory entity, mediated by a specialised high threshold sensory system, which extends from the periphery through the spinal cord, brain stem and thalamus to the cerebral cortex. However, multiple mechanisms have been detected in the nervous system responsible for the pain including peripheral sensitisation, phenotypic switches, central sensitisation, ectopic excitability, structural reorganisation, decreased inhibition and increased facilitation, all of which may contribute to the pain.

Although the causes of endometrialgia can differ (eg inflammatory, neuropathic and functional), they share some characteristics. Endometrialgia may be evoked by a low intensity, normally innocuous stimulus (allodynia), or it may be an exaggerated and prolonged response to a noxious stimulus (hyperalgesia). The pain may also be spontaneous in the absence of any apparent peripheral stimulus.

Oestrogens and prostaglandins probably play key modulatory roles in endometriosis and endometrialgia. Consequently many of the current medical treatments for the condition include oral drugs, like non-steroid anti-inflammatory drugs, contraceptives, progestogens, androgenic agents, gonadotrophin releasing hormone analogues, as well as laparoscopic surgical excision of the endometriosis lesions. However, management of pain in women with endometriosis is currently inadequate for many. Possibly acupuncture and cognitive therapy may be used as an adjunct.

Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line

BACKGROUND

Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required.

STUDY DESIGN

Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally.

RESULTS

The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management.

CONCLUSIONS

In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.

Use of the SF-36 questionnaire to predict quality-of-life improvement after laparoscopic colorectal resection for endometriosis

BACKGROUND

Laparoscopic colorectal resection for endometriosis can improve quality of life (QOL), but the results vary widely from one woman to another. The aim of this study was to determine whether the preoperative results on the Physical Component Summary (PCS) and Mental Component Summary (MCS) subscales of the SF-36 questionnaire could predict the improvement in QOL after surgery.

METHODS

The predictive value of the subscales was first evaluated on a training set of 57 patients. A mathematical model, quantified with respect to discrimination and calibration was then applied to the validation set of 36 patients.

RESULTS

Women with preoperative PCS and MCS scores below 37.5 and 44.5, respectively, had 80.7% and 84.2% probabilities of seeing their scores improve after surgery, whereas women with preoperative scores above 46.5 and 47.5, respectively, had probabilities of 0% and 10.7% to improve their scores.

CONCLUSIONS

With our mathematical model, the postoperative improvement in QOL can be reliably predicted. This model should help to identify those women who are most likely to benefit from this major surgery.

Predicting the presence of rectovaginal endometriosis from the clinical history: a retrospective observational study

Rectovaginal endometriosis is a severe variant of endometriosis. Common presenting symptoms for endometriosis include dysmenorrhoea, pelvic pain and dyspareunia. It is now recognised that there are other less traditional symptoms of endometriosis that are also relatively common. The aim of this study is to assess the relative strength of each of the potential symptoms of rectovaginal endometriosis and compare these with the laparoscopic and histological findings. In this retrospective, observational study the overall prevalence of rectovaginal endometriosis in the group was 31.4%. The presence of dyschesia gave a likelihood ratio of 1.27 (95% CI: 0.56 - 2.89) with a predictive prevalence of rectovaginal endometriosis of 37%. Apareunia and nausea or abdominal bloating were particularly strong markers for rectovaginal disease with a predictive prevalence of 87% and 89%, respectively. The classical symptoms often attributed to irritable bowel syndrome are also common in women with rectovaginal disease.

Outcome of laparoscopic colorectal resection for endometriosis

PURPOSE OF REVIEW

Endometriosis is a frequent gynaecological disorder in young women. Colorectal endometriosis accounts for about 90% of all intestinal locations. The effectiveness of medical therapies is poor, and surgery, including colorectal resection, is therefore often required. Since the first description of laparoscopic colorectal resection by Redwine and Sharp, the feasibility of this approach has been confirmed by several teams but remains a matter of debate.

RECENT FINDINGS

A review of the literature showed that conversion to laparotomy was necessary in 7.8% of cases. Segmental colorectal resection appears to be the best option, owing to the risk of incomplete resection in the case of full-thickness disc or superficial-thickness excision. However, complications are more frequent with segmental resection than with other procedures, and include de-novo urinary disorders. Laparoscopic colorectal resection for endometriosis is associated with symptom relief and a significant improvement in quality of life. In addition, 44.6% of women wishing to conceive were able to do so.

SUMMARY

Laparoscopic colorectal resection for endometriosis appears to be an adequate alternative to laparotomy. Further studies are required to identify objective criteria with which to select women most likely to benefit from this surgery, which must be performed in special units.

Urological and colorectal complications following surgery for rectovaginal endometriosis

OBJECTIVES

To report the short- and medium-term complications of laparoscopic laser excisional surgery for rectovaginal endometriosis.

DESIGN

Retrospective cohort study.

SETTING

University teaching hospital, UK.

POPULATION

A total of 128 women with histologically confirmed rectovaginal endometriosis who underwent laparoscopic laser surgery between May 1999 and September 2006.

METHODS

Women were identified from operative database, and a case note review was performed. Data for surgical outcome and surgical complications were collected.

MAIN OUTCOME MEASURES

Rates of urinary tract and colorectal complications.

RESULTS

A total of 128 women underwent surgery. Of these, 32 required intraoperative closure of a rectal wall defect, including 3 segmental rectosigmoid resections. There were three rectovaginal fistulae and one ureterovaginal fistula. Ureteric damage occurred in two women, and five women suffered postoperative urinary retention. The risk of intraoperative bowel intervention was increased in women who complained of cyclical rectal bleeding.

CONCLUSION

Laparoscopic laser excision of rectovaginal endometriosis is a safe procedure with similar, if not lower, complication rates to other published surgical series.

Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity

STUDY OBJECTIVE

Adequate surgical treatment of severe deep endometriosis requires complete excision of all implants, but the modality of bowel resection is still debated. We describe the results of our experience as a tertiary care endometriosis referral center in complete laparoscopic management of deep pelvic endometriosis with bowel involvement.

DESIGN

A prospective single-center study (Canadian Task Force classification II-1).

SETTING

In Sacro Cuore General Hospital of Negrar, Italy.

PATIENTS

One hundred ninety-two women treated with laparoscopic excision of deep endometriosis and segmental colorectal resections were evaluated.

INTERVENTION

From January 2003 through December 2005 we registered all consecutive patients laparoscopically treated for deep endometriosis who also were having segmental bowel resection.

MEASUREMENTS AND MAIN RESULTS

Data analysis included age, weight, body mass index, history of endometriosis, preoperative symptoms, parity, infertility, operative procedures, operating time, conversion, intraoperative and postoperative morbidity, recovery of bladder and bowel function, and discharge from hospital. We report our results in terms of feasibility and short-term morbidity. Radicality was achieved in 91.5% of patients. Laparoconversion occurred in 5 cases (2.6%). Major complications that required repeat operation occurred in 20 cases (10.4%): Nine anastomosis leakages (4.7%), 3 uroperitoneum (1.6%), 4 hemoperitoneum (2.1%), 1 pelvic abscess (0.5%), 1 bowel perforation, 1 intestinal obstruction, and 1 sepsis. Minor complications occurred in 50 patients (26%).

CONCLUSION

Laparoscopic segmental colorectal resection for endometriosis is feasible and, in hospitals with necessary experience, can be proposed to selected patients who are informed of the risk of complications.

Combined vaginal-laparoscopic-abdominal approach for the surgical treatment of rectovaginal endometriosis with bowel resection: a comparison of this new technique with various established approaches by laparoscopy and laparotomy

BACKGROUND

A new combined vaginal-laparoscopic-abdominal approach for rectovaginal endometriosis allows intraoperative digital bowel palpation to assess bowel infiltration and prevents unnecessary bowel resections. This technique was compared to various established approaches where bowel resection was indicated by clinical symptoms and imaging results only.

METHODS

Patients operated for rectovaginal endometriosis with endometriotic bowel involvement between March 2002 and April 2006 at the gynecological department Charité, Berlin, Germany were included. Bowel involvement was suspected by clinical symptoms, clinical examination, and/or results of imaging techniques. The study group (SG) was operated by the combined vaginal-laparoscopic-abdominal approach (n = 30) and the control group (CG) (n = 18) by laparoscopy (n = 4), laparotomy (n = 3), laparoscopy followed by laparotomy for bowel resection (n = 8) or laparoscopy followed by vaginal bowel resection (n = 3). In all cases histopathology was performed.

RESULTS

The study group and the control group were comparable regarding age, body mass index, symptoms, American Society for Reproductive Medicine (ASRM) classification, colorectal operative procedures, operating times, length of the resected bowel specimen, and concomitant surgical procedures. However, only in the CG were protective stomas required (p = 0.047). There were significantly less complications in the SG (p = 0.027). No patient experienced leakage of anastomosis. Bowel involvement by endometriosis was confirmed by histopathology in the SG in all cases whereas in the CG only in 16/18 (88.9%) cases. Hospitalization time was significantly shorter in the SG. Rehospitalizations were necessary only in the CG to repair one rectovaginal fistula and to reverse three stomas.

CONCLUSIONS

With the presented technique of a combined vaginal-laparoscopic-abdominal surgical procedure for rectovaginal endometriosis, we showed that the complication rate, rehospitalization rate, and hospitalization time were significantly lower than in the patients of the CG. Furthermore, the combined vaginal-laparoscopic-abdominal technique allowed better evaluation of the invasiveness of the endometriotic lesion and avoided unnecessary bowel surgery.

Bowel endometriosis: presentation, diagnosis, and treatment

Bowel endometriosis opens a new frontier for the gynecologist, as it forces the understanding of a new anatomy, a new physiology, and a new pathology. Although some women with bowel endometriosis may be asymptomatic, the majority of them develop a variety of gastrointestinal complains. No clear guideline exists for the evaluation of patients with suspected bowel endometriosis. Given the fact that, besides rectal nodules, bowel endometriosis can not be diagnosed by physical examination, imaging techniques should be used. Several techniques have been proposed for the diagnosis of bowel endometriosis including double-contrast barium enema, transvaginal ultrasonography, rectal endoscopic ultrasonography, magnetic resonance imaging, and multislice computed tomography enteroclysis. Medical management of bowel endometriosis is currently speculative; expectant management should be carefully balanced with the severity of symptoms and the feasibility of prolonged follow-up. Several studies demonstrated an improvement in quality of life after extensive surgical excision of the disease. Bowel endometriotic nodules can be removed by various techniques: mucosal skinning, nodulectomy, full thickness disc resection, and segmental resection. Although the indications for colorectal resection are controversial, recent data suggest that aggressive surgery improves symptoms and quality of life.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the varied appearance of bowel endometriosis, recall that it is difficult to diagnose preoperatively, and explain that surgical treatment offers the best treatment in symptomatic patients through a variety of surgical techniques which is best accomplished with a team approach.

RECTAL ENDOMETRIOSIS: RESULTS OF RADICAL EXCISION AND REVIEW OF PUBLISHED WORK

BACKGROUND

The aim of this paper is to review the results of surgical excision of rectal endometriosis and review the published work on this challenging condition.

METHODS

All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed.

RESULTS

Between 1995 and 2005, 213 rectal procedures were carried out on 203 patients together with an endogynaecologist. Eighteen cases involved dissection of endometriosis off the rectal wall, 58 involved full-thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were carried out. A loop ileostomy was required in 7 (5%) of the segmental resections. Seventy-five per cent of the cases were either laparoscopic or laparoscopically assisted. Infertility was significantly more common in the group requiring a segmental resection (P=0.026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P=0.031). There were no other significant differences between the different types of rectal surgery. The morbidity for all rectal procedures was 7% and there was one anastomotic leak in the segmental resection group. The actuarial rectal recurrence rate of endometriosis was 22.2% 95% confidence interval (CI) (2.5, 42.0) for dissection off the rectal wall and this was significantly different from the recurrence of 5.17% 95%CI (0.0, 10.9) for anterior rectal wall excision and 2.19% 95%CI (0.0, 4.6) for segmental rectal resection (P=0.007). The overall rectal recurrence for all cases was 4.69% 95%CI (1.8, 7.5).

CONCLUSION

Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.

Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis

The aim of this study was to assess the long-term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 +/- 162 ml (range 180-600), and average hospital stay was 8 days (range 6-19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis (P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions (P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.

Prise en charge chirurgicale de l'endométriose

Both laparoscopic techniques (excision and ablation) for the treatment of superficial peritoneal endometriosis are equally effective (EL2). For the treatment of ovarian endometriomas larger than 3 cm, laparoscopic cystectomy is superior to drainage and coagulation (EL1). Excision of deep rectovaginal endometriosis with or without rectal invasion significantly reduces endometriosis-associated pain (EL4). Laparoscopic partial bladder cystectomy is easier for dome endometriosis than vesical base lesions (EL4). Hysterectomy with ovarian conservation is associated with a high risk of pain recurrence (EL4). Despite bilateral oophorectomy, pain recurrence can occur with hormonal treatment (EL2). Rates of major (ureteral, vesical, intestinal or vascular) complications of endometriosis surgery range from 0.1 to 15% of patients. Higher rates are more common with deep endometriosis surgery (EL2). Patients should be aware of these specific major complications. It is advisable to explain that pain improves, either partially or completely, in about 80% of patients.

Prise en charge d'une endométriose douloureuse

OBJECTIVES

To establish guidelines for the medical and surgical management of painful endometriosis.

MATERIAL AND METHODS

An exhaustive review on Medline and Cochrane Database between 1980 and 2006 was performed.

RESULTS

GnRH agonists, progestins, continuous monophasic oral contraceptives and danazol have a suppressive effect on dysmenorrhoea, nonmenstrual pain and dyspareunia (grade A). Surgical treatment is effective in painful endometriosis (grade B). Complete surgical excision of deep endometriotic lesions with conservation of uterus and ovaries has a limited term efficacy on pain relief (grade C). A multidisciplinary approach is recommended (grade C). The use of the psychotherapy improves the management of chronic pain (grade A). There is a lack of information concerning the therapeutic strategy able to prevent recurrences. Whether endometriosis recurrences occur, medical treatment should be the first line approach (expert opinion). A hysterectomy with salpingo-oophorectomy and complete excision of the lesions is efficient in women with pain recurrence who no longer desire pregnancy (grade C).

CONCLUSION

Medical and surgical treatments have a limited term efficacy on painful endometriosis (grade A). The benefit/risk relationship, depending on secondary effect therapy, should be assessed on a case to case basis.

Laparoscopic segmental colorectal resection for endometriosis: limits and complications

BACKGROUND

Deep pelvic endometriosis with colorectal involvement is a complex disorder often requiring segmental bowel resection. This study investigated the limits and complications of laparoscopic segmental colorectal resection.

METHODS

Laparoscopic segmental colorectal resection was performed for 71 women with bowel endometriosis. Intra- and postoperative complications were evaluated, together with symptom outcomes, by means of questionnaires completed before and after surgery. Surgical procedures and complications were compared between the first part of the study (40 cases, previously published) and the second part (31 cases).

RESULTS

Of the 71 women, 64 (90%) underwent laparoscopic segmental colorectal resection, with 7 requiring laparoconversion. Major complications occurred in nine cases (12.6%), six with rectovaginal fistulae and three with pelvic abscesses. The mean operating time decreased significantly during the study (p < 0.05). The mean follow-up period after colorectal resection was 24.4 +/- 2.2 months. No differences in the rates of laparoconversion or complications were observed between the two periods, whereas major associated surgical procedures were more frequent during the second period. Dysmenorrhea (p < 0.0001), dyspareunia (p = 0.0001), pain at defecation (p = 0.0004), bowel movement pain or cramping (p < 0.0001), lower back pain (p < 0.0001), and asthenia (p < 0.0001) were improved after the operation, with no difference between the study periods.

CONCLUSION

This large series confirms the feasibility and efficacy of laparoscopic segmental colorectal resection. However, women must be informed of the risk for potentially severe complications.

Outcome after rectum or sigmoid resection: a review for gynecologists

It remains unclear when to perform a discoid or segmental bowel resection for large endometriotic nodules with intestinal invasion. Moreover, endometriosis series are rather small to fully evaluate functional consequences of bowel resection. We therefore reviewed the incidence of leakage and functional problems after anterior and sigmoid resection as reported in the surgical literature albeit for other indications. Endoscopic resection clearly is feasible but requires an experienced surgeon. The incidence of leakage is not different after hand-sewn or stapled anastomosis, but is higher after a low rectum resection than after a sigmoid resection. Similarly, functional bowel problems are higher after a low rectum resection than after sigmoid resection. Low rectum resection in addition can be associated with functional bladder problems and sexual disturbances as anorgasmia. In conclusion, short- and long-term complications are much higher after a low rectum than after a sigmoid resection. This seems to be important in making the decision to perform a discoid or a segmental bowel resection for severe endometriosis.

Accuracy of magnetic resonance imaging and rectal endoscopic sonography for the prediction of location of deep pelvic endometriosis

BACKGROUND

We compared the accuracy of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) for the diagnosis of deep pelvic endometriosis (DPE), with respect to surgical and histological findings.

METHODS

Longitudinal study of 88 consecutive patients referred for surgical management of DPE, who underwent both MRI and RES pre operatively. The diagnostic criteria were identical for MRI and RES and were based on visualization of hypointense/hypoechoic areas in specific locations. DPE was diagnosed when at least one site was involved. We calculated the sensitivity, specificity, predictive values, accuracy and 95% confidence interval of MRI and RES for DPE.

RESULTS

DPE and endometriomas were present in 97.7 and 39.7% of women, respectively. The sensitivity, specificity and positive and negative predictive values of MRI and RES, respectively, were 84.8 and 45.6%, 88.8 and 40%, 98.5 and 87.8% and 40 and 8.5% for uterosacral endometriosis; 77.7 and 7.4%, 70% and 100, 85.3 and 100% and 89.7 and 70.9% for vaginal endometriosis and 88.3 and 90%, 92.8 and 89.3%, 96.4 and 94.7% and 78.8 and 80.6% for colorectal endometriosis.

CONCLUSIONS

MRI is more accurate than RES for the diagnosis of uterosacral and vaginal endometriosis, whereas the two methods are similarly accurate for colorectal endometriosis.

Traitement de l'endométriose sévère par la grossesse: un pari risqué

We report the case of a young woman presenting with painful deep and rectal endometriosis. This condition had started long ago while the diagnosis had been delayed. Brutal colon occlusion followed the discontinuation of oral contraception. Left colectomy with terminal colostomy was carried out in emergency. The conservative surgical management of deep endometriosis was performed three months later. In women presenting deep endometriosis, the discontinuation of hormonal treatment in order to attempt a spontaneous pregnancy should not be recommended before undertaking a thorough endometriosis and fertility status investigation.

Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile?

OBJECTIVE

This study was undertaken to ascertain whether the incidence of pregnancy is increased and time-to-conception is reduced in infertile women with rectovaginal endometriosis undergoing conservative surgery compared with those on expectant management.

STUDY DESIGN

A total of 105 infertile women under the age of 40 years with rectovaginal endometriosis and no other associated major infertility factor underwent first-line conservative surgery at laparotomy or expectant management according to a shared decision-making approach.

RESULTS

Among the 44 women who had resection of rectovaginal endometriosis, 15 became pregnant, compared with 22 of the 61 women who choose expectant management (24-month cumulative probabilities, 44.9% and 46.8%, respectively; log-rank test, chi2(1) = 0.75; P = .38). One major and 9 minor postoperative complications occurred. Significant differences in pain-free survival time in favor of the surgery group were observed for dysmenorrhea, dyspareunia, and dyschezia.

CONCLUSION

Conservative surgery for rectovaginal endometriosis in infertile women does not modify the reproductive prognosis although it does increase pain-free survival time.