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

Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery

BACKGROUND

Various options exist for treating endometriosis, including ovarian suppression therapy, surgical treatment or a combination of these strategies. Surgical treatment of endometriosis sets out to remove visible areas of endometriosis and restore anatomy by division of adhesions. The aim of medical therapy is to inhibit growth of endometriotic implants by suppression of ovarian steroids and induction of a hypo-estrogenic state. Postoperative treatment with a hormone-releasing intrauterine system, using levonorgestrel (LNG-IUS), has been suggested.

OBJECTIVES

To determine if postoperative use of an LNG-IUS in women with endometriosis improves pain symptoms associated with menstruation and reduces recurrence compared with treatment with surgery only, placebo or systemic hormones.

SEARCH STRATEGY

The following databases were searched: (1) Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials; (2) Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1); (3) MEDLINE (1966 to January 2006) and EMBASE (1980 to January 2006); (4) National Research Register (NRR). (5) The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched.

SELECTION CRITERIA

Trials were included if they compared women undergoing any type of surgical treatment for endometriosis with uterine preservation then randomized to LNG-IUS insertion within two to three months versus no treatment, placebo (inert IUD) or systemic treatment. Diagnostic laparoscopy alone was excluded.

DATA COLLECTION AND ANALYSIS

Two review authors (AM Abou-Setta and HG Al-Inany) independently selected studies for inclusion and extracted data. Statistical analysis was performed in accordance with the statistical guidelines developed by the Cochrane Menstrual Disorders and Subfertility Group. Data extracted from the trials was analyzed on an intention-to-treat basis. For binary data, the overall common odds ratio (OR) (that is, the odds of having clinical symptoms) and the risk difference with 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effect method.

MAIN RESULTS

In one small randomized controlled trial (RCT) there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUS group compared with the control group receiving a gonadotrophin-releasing hormone (GnRH) agonist (OR 0.14, 95% CI = 0.02 to 0.75). The proportion of women who were satisfied with their treatment was higher in the LNG-IUS group than in the control group but this difference did not reach statistical difference (OR 3.00, 0.79 to 11.44).

AUTHORS' CONCLUSIONS

One small study has shown that postoperative use of the LNG-IUS reduces the recurrence of painful periods in women who have had surgery for endometriosis. There is a need for further well-designed RCTs of this approach.

Outcomes and treatment options in rectovaginal endometriosis

PURPOSE OF REVIEW

This review aims to explore the recent literature surrounding the role of colorectal surgery in rectovaginal endometriosis.

RECENT FINDINGS

Recent findings would suggest that excision of a portion of the rectum along with complete excision of surrounding endometriosis is beneficial in terms of improvement in quality of life and recurrence of disease. However, further randomized controlled trials are needed to clarify this finding.

SUMMARY

The optimal management of women with deeply infiltrating rectovaginal endometriosis remains a challenge to physicians involved in this disease process. The choice between medical and surgical treatments is not clearly defined, and neither is the role of adjunctive medical therapy prior to or following surgery. It is only when these questions have been asked in the context of well conducted clinical trials, with good outcome data, can the answers be given.

Is the endometriosis recurrence rate increased after ovarian hyperstimulation?

OBJECTIVE

To test the hypothesis that the cumulative endometriosis recurrence rate (CERR) after fertility surgery for endometriosis stage III or IV is increased in women exposed to very high E(2) levels during ovarian hyperstimulation (OH) for IVF when compared with women exposed to less high E(2) levels during OH for intrauterine insemination (IUI).

DESIGN

Retrospective cohort study including infertility patients with endometriosis stage III or IV.

SETTING

Leuven University Fertility Center, between 1990 and 2001.

PATIENT(S)

Patients (n = 67) with endometriosis stage III (n = 45) or IV (n = 22) who underwent pelvic reconstructive surgery and subsequently started fertility treatment with either IVF only (n = 39), both IVF and IUI in different cycles (n = 11), or IUI only (n = 17).

INTERVENTION(S)

Life table analysis was used to calculate the CERR.

MAIN OUTCOME MEASURE(S)

The CERR based on histologic or cytologic proof of disease recurrence.

RESULT(S)

At 21 months after the start of OH the overall CERR was 31% and was significantly lower in patients treated with IVF only (7%) or women treated with both IVF and IUI in different cycles (43 %) than in those treated with IUI only (70%). At 36 months after the start of OH, the overall CERR was 63%.

CONCLUSION(S)

In contrast to our hypothesis, the results from this study showed that the CERR is lower after ovarian hyperstimulation for IVF than after lower-dose ovarian stimulation for IUI, suggesting that temporary exposure to very high E(2) levels in women during OH for IVF is not a major risk factor for endometriosis recurrence in women treated with assisted reproductive technology.

Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up

BACKGROUND

The objective of the study is to evaluate the short- and long-term efficacy of complete laparoscopic excision of deep endometriosis, without rectum involvement, with the opening and partial excision of the posterior vaginal fornix.

METHODS

Thirty-one patients were included in the study with symptomatic extensive disease including involvement of the cul-de-sac, rectovaginal space and posterior vaginal fornix without rectum involvement. Endoscopic surgery was performed with complete separation of rectovaginal space and in-block resection of the diseased tissue, opening and partial excision of the posterior vaginal fornix and vaginal closure either by laparoscopic or by vaginal route. Patients filled in questionnaires on pain before and 12, 24, 36, 48 and 60 months after surgical treatment.

RESULTS

No intraoperative complications were observed; 65% were free of analgesic on post-operative day 2, 38% had total remission of chronic pain and 22% were improved; 38% had total remission of dysmenorrhoea and 22% were improved; 45% had total remission of dyspareunia and 25% were improved. Follow-up improvement of symptoms was statistically significant and was maintained for 5 years without recurrence of the disease or repeated surgery (P < 0.001).

CONCLUSION

Complete surgical resection of deep infiltrative endometriosis with excision of the adjacent tissue of the posterior vaginal fornix improves quality of life with persistence of results for long time in patients not responsive to medical treatment.

Quality of life after laparoscopic colorectal resection for endometriosis

BACKGROUND

Indications of colorectal resection for endometriosis remain controversial because of the risk of major complications. Therefore, the aims of the current study were to evaluate the efficacy of laparoscopic segmental colorectal resection for endometriosis on quality of life and gynaecologic and digestive symptoms, and its complications.

METHODS

After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 58 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires and the short-form (SF)-36 Health Status and the quality of life score were completed. Linear intensity scores for several gynaecologic and digestive symptoms and perioperative complications were also recorded.

RESULTS

Fifty-one women (88%) underwent laparoscopic segmental colorectal resection and seven required laparoconversion. Major complications occurred in nine cases (15.5%), including six rectovaginal fistulae (10.3%), and the three remaining complications corresponded to a haemoperitoneum, a uroperitoneum and a pelvic abscess. Median follow-up after colorectal resection was 22.5 months (2-55 months). A significant improvement in dysmenorrhoea (P < 0.0001), dysparaeunia (P < 0.0001), bowel movement pain or cramping (P < 0.0001), pain on defecation (P < 0.0001), diarrhoea (P < 0.016), lower back pain (P < 0.0001) and asthaenia (P < 0.0002) was observed. Tenesmus, rectorrhagia and constipation were not improved. All the items of the SF-36 Health Status and the quality of life score were improved after colorectal resection for endometriosis.

CONCLUSION

Laparoscopic segmental colorectal resection for endometriosis significantly improves quality of life and gynaecologic and digestive symptoms. However, women have to be informed on the risk of complications including rectovaginal fistula.

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

OBJECTIVE

To describe the long-term outcome of surgical conservative treatment of bladder endometriosis.

DESIGN

Descriptive study.

SETTING

Tertiary referral center for the treatment of endometriosis.

PATIENT(S)

Forty-seven patients with symptomatic bladder endometriosis.

INTERVENTION(S)

Partial cystectomy by laparoscopy or laparotomy.

MAIN OUTCOME MEASURE(S)

Rates of recurrence at a 36-month follow-up.

RESULT(S)

All 14 patients with isolated bladder dome lesions remained symptom-free. Among the 33 patients with lesions involving the vesical base and vesicouterine septum, cumulative recurrence rates at 36 months were 24.7% and 15.5% for recurrence of symptoms and of clinical-instrumental evidence of lesion, respectively. The only factor influencing rate of recurrence was the extent of surgical excision. When the resection included both the vesical lesion and a 0.5- to 1-cm deep portion of the adjacent myometrium, recurrence was significantly less frequent compared to the removal of the bladder lesion only (7% vs. 37% for symptom recurrence and 0% vs. 26% for clinical-instrumental recurrence, respectively).

CONCLUSION(S)

Conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality.

Radical resection of invasive endometriosis with bowel or bladder involvement—Long-term results

OBJECTIVE

With the present study we wanted to evaluate the effect of a radical resection of bowel and bladder endometriosis with respect to relief of pain symptoms and long-term effects.

STUDY DESIGN

Retrospectively we analyzed 23 patients undergoing bowel or bladder resection for infiltrating endometriosis between 1995 and 2004. Chart review was performed and data were analyzed with respect to pain symptoms, fertility, type of surgery, operative morbidity and mortality. At 1, 3 and 5 years of follow-up patients were asked to evaluate their symptoms based on a visual analogue pain scale (0: no pain, 10: most severe pain). Results were compared using the Student's t-test.

RESULTS

Leading symptoms were chronic pelvic pain (17/23, 73.9%), dysmenorrhea (11/23, 47.8%), dyspareunia (6/23, 26.1%), infertility (4/23, 17.4%) and dyschezia (4/23, 17.4%). Three patients (13%) had abdominal hysterectomy, 5 (21.7%) LSO (n = 2) or BSO (n = 3), 18 (78.3%) anterior rectal resection, 4 (17.4%) sigmoid resection, 2 (8.6%) segmental bladder resection and one patient (4.3%) cecal resection. Major complications requiring re-operation occurred in three patients (2x postoperative bleeding, 1x anastomosis break-down). During follow-up (mean 40.5 months) 21 of the 23 patients (91.3%) had a persistent improvement of symptoms, 8 of the 23 (34.8%) had recurrent symptoms with a mean symptom-free interval of 40.4 months after surgery (24-60 months). No patient developed dyspareunia or dyschezia during follow-up. Overall cure rate was 73.9%. Four patients became pregnant (23%). Average pain scores increased during follow-up period but still remained significantly below the initial score (p < 0.001).

CONCLUSION

Radical surgery for deep endometriosis with bowel or bladder involvement leads to a reliable and persistent relief of pain symptoms. Especially deep dyspareunia and dyschezia might be eliminated by this procedure.

Treatment of symptomatic rectovaginal endometriosis with an estrogen–progestogen combination versus low-dose norethindrone acetate

OBJECTIVE

To evaluate the efficacy, safety, and tolerability of an estrogen-progestogen combination versus low-dose norethindrone acetate in the treatment of persistent pain after surgery for symptomatic rectovaginal endometriosis.

DESIGN

Randomized controlled trial.

SETTING

Academic center.

PATIENT(S)

Ninety women with recurrent moderate or severe pelvic pain after unsuccessful conservative surgery for symptomatic rectovaginal endometriosis.

INTERVENTION(S)

Twelve-month, continuous treatment with oral ethinyl E2, 0.01 mg, plus cyproterone acetate, 3 mg/day, or norethindrone acetate, 2.5 mg/day.

MAIN OUTCOME MEASURE(S)

Degree of satisfaction with therapy.

RESULT(S)

Seven women in the ethinyl E2 plus cyproterone acetate arm and five in the norethindrone acetate arm withdrew because of side effects (n=5), treatment inefficacy (n=6), or loss to follow-up (n=1). At 12 months, dysmenorrhea, deep dyspareunia, nonmenstrual pelvic pain, and dyschezia scores were substantially reduced without major between-group differences. Both regimens induced minor unfavorable variations in the serum lipid profile. According to an intention-to-treat analysis, 28 (62%) out of 45 patients in the ethinyl E2 plus cyproterone acetate group and 33 (73%) out of 45 in the norethindrone acetate group were satisfied with the treatment received.

CONCLUSION(S)

Low-dose norethindrone acetate could be considered an effective, tolerable, and inexpensive first-choice medical alternative to repeat surgery for treating symptomatic rectovaginal endometriotic lesions in patients who do not seek conception.

Fertility after laparoscopic colorectal resection for endometriosis: preliminary results

OBJECTIVE

To examine fertility, reproductive outcomes, and determinants of fertility after laparoscopic segmental colorectal resection for endometriosis.

DESIGN

Retrospective longitudinal study.

SETTING

Tertiary university gynecology unit.

PATIENT(S)

The study population consisted of 34 women with colorectal endometriosis, of whom 22 wished to conceive. Demographic, surgical, and histological characteristics of 10 women who conceived were compared with those of 12 women who failed to conceive.

INTERVENTION(S)

Laparoscopic colorectal resection for endometriosis.

MAIN OUTCOME MEASURE(S)

Rates of pregnancy and live birth.

RESULT(S)

Mean follow-up after segmental colorectal resection was 24 months (range 6-42 months), and the pregnancy rate was 45.5%. The median time to conceive was 8 months (range 3-13 months). Twelve pregnancies occurred in 10 women, comprising nine spontaneous singleton pregnancies (7 vaginal deliveries, 1 cesarean section, and 1 ongoing pregnancy), and three pregnancies obtained by IVF (one miscarriage, one ongoing twin pregnancy, and one triplet pregnancy necessitating cesarean section at 29 weeks for premature rupture of the membranes, with two surviving infants). The live birth rate was 82%. The women who did and did not conceive did not differ in terms of mean follow-up, mean age, body mass index (BMI), parity, smoking, use and duration of oral contraception (OC), duration of infertility, or the length of the resected colorectal segment. Uterine adenomyosis was the main determinant of pregnancy after colorectal resection.

CONCLUSION(S)

These preliminary results suggest that extensive laparoscopic segmental colorectal resection for endometriosis can enhance fertility, with high rates of spontaneous pregnancy and live birth.

ESHRE guideline for the diagnosis and treatment of endometriosis

The objective was to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms. A working group was convened comprised of practising gynaecologists and experts in evidence-based medicine from Europe, as well as an endometriosis self-help group representative. After reviewing existing evidence-based guidelines and systematic reviews, the expert panel met on three occasions for a day during which the guideline was developed and refined. Recommendations based solely on the clinical experience of the panel were avoided as much as possible. The entire ESHRE Special Interest Group for Endometriosis and Endometrium was given the opportunity to comment on the draft guideline, after which it was available for comment on the ESHRE website for 3 months. The working group then ratified the guideline by unanimous or near-unanimous voting; finally, it was approved by the ESHRE Executive Committee. The guideline will be updated regularly, and will be made available at http://www.endometriosis.org/guidelines.html with hyperlinks to the supporting evidence, and the relevant references and abstracts. For women presenting with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of endometriosis requires visual inspection of the pelvis at laparoscopy as the 'gold standard' investigation. However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow. In women with laparoscopically confirmed disease, suppression of ovarian function for 6 months reduces endometriosis-associated pain; all hormonal drugs studied are equally effective although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary. In minimal-mild endometriosis, suppression of ovarian function to improve fertility is not effective, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate-severe endometriosis enhances pregnancy rates. IVF is appropriate treatment especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility. The management of severe/deeply infiltrating endometriosis is complex and referral to a centre with the necessary expertise is strongly recommended. Patient self-help groups can provide invaluable counselling, support and advice.