Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis

Comparison of perioperative outcomes between robotic surgery and traditional laparoscopy for colorectal endometriosis: a systematic review and meta-analysis

Robotic-assisted surgery (RAS) offers a broader surgical field, enhanced visualization, and greater instrument maneuverability, suggesting potential advantages over traditional laparoscopic surgery (LPS), which is currently the gold standard for treating colorectal endometriosis. To address this gap, we conducted a comprehensive review of existing studies to compare the perioperative outcomes of RAS and LPS in the management of colorectal endometriosis. A comprehensive search was conducted in the databases of PubMed, Web of Science, the Cochrane Library, and SpringerLink to identify any studies that prior to February 2nd, 2025. To compare RAS to LPS for colorectal endometriosis, we looked at things like operation duration, expected blood loss, length of stay, conversion to laparotomy, all complications, and bowel endometriosis resection. The operative time for RAS in colorectal endometriosis resection was significantly longer than that for LPS (data aggregated from six studies; WMD 21.51 min, 95% CI 4.58-38.43, p < 0.05). However, there were no significant differences between the two groups in intraoperative blood loss (four studies; WMD 1.2 ml, 95% CI - 34.01-36.41, p = 0.95), length of hospital stay (four studies; WMD 0.2 days, 95% CI - 1.09-1.49, p = 0.76), or the number of cases requiring conversion to laparotomy (four studies; OR 2.27, 95% CI 0.52-9.95, p = 0.28) (Fig. 2). LPS demonstrated a significantly higher utilization of segmental resection (six studies; OR 0.71, 95% CI 0.54-0.93, p < 0.05), while no significant differences were observed in the rates of shaving (six studies; OR 1.06, 95% CI 0.77-1.47, p = 0.71) or double discoid excision (six studies; OR 1.3, 95% CI 0.95-1.78, p = 0.1) (Fig. 3). Additionally, the included studies reported no significant differences in overall complication rates (five studies; OR 0.9, 95% CI 0.64-1.28, p = 0.57) (Fig. 3) or the incidence of Clavien-Dindo classification complications classified as Grade I(five studies; OR 0.85, 95% CI 0.44-1.65, p = 0.64), II(five studies; OR 0.59, 95% CI 0.35-1.0, p = 0.5), III(five studies; OR 1.12, 95% CI 0.63-2.0, p = 0.7), or IV(five studies; OR 0.8, 95% CI 0.14-4.59, p = 0.81). Our study found that, apart from a significantly longer operative time for RAS compared to LPS, RAS demonstrated comparable outcomes in intraoperative blood loss, length of hospital stay, conversion to open surgery, bowel endometriosis resection, and postoperative complication rates. These findings suggest that RAS has the potential to become a viable alternative to LPS in the future. However, this conclusion still requires validation through large-scale, prospective, randomized controlled trials.

[Colorectal endometriosis surgery: Technical and technological innovations in service of a complex surgery]

INTRODUCTION

Digestive endometriosis represents the most common form of deep endometriosis, significantly impacting patients' quality of life. The optimization of its surgical management has been marked by major technological advances. This review explores the evolution of colorectal endometriosis surgery, highlighting the progress in laparoscopy, the contribution of robotics, the shift towards organ preservation, and the optimization of postoperative care.

METHODS

A systematic literature search was conducted in the PubMed and Embase databases, focusing on clinical studies, meta-analyses, and international guidelines published between 1980 and 2025. Articles were selected based on their relevance to technical advancements and clinical outcomes.

RESULTS

Laparoscopy has replaced laparotomy, leading to a reduction in complications and an improvement in postoperative quality of life. Robotics, while not a groundbreaking revolution, provides advantages in precision and surgeon comfort. Conservative procedures have emerged as safe alternatives to systematic extensive segmental resection. Indication criteria have evolved to favor strategies tailored to the depth and extent of lesions while minimizing complication risks and preserving digestive function and quality of life. The standardization of procedures, the abandonment of systematic protective ileostomy, and enhanced recovery protocols have contributed to reducing surgical morbidity and improving patients' quality of life.

CONCLUSION

Technical and technological advancements have transformed colorectal endometriosis surgery. Surgical strategies are shifting towards personalized approaches, integrating minimally invasive surgery and optimized multidisciplinary management. The future lies in the continuous improvement of techniques and the better standardization of surgical indications.

Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more

PURPOSE

To compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH-SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection.

METHODS

Retrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis.

RESULTS

100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively).

CONCLUSION

No statistically significant differences were found in the rate of digestive complications in case of total hysterectomy and concomitant segmental resection when performing or not preventing stoma.

Bowel endometriosis: Surgical customization is demanding

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Does surgery for colorectal endometriosis prior to IVF±ICSI have an impact on cumulative live birth rates?

RESEARCH QUESTION

Does colorectal endometriosis surgery prior to IVF ± intracytoplasmic sperm injection (ICSI) impact cumulative live birth rates?

DESIGN

This retrospective, monocentric study (Lille University Hospital) was conducted between 1 January 2007 and 31 December 2018. Two groups of patients from the JFIV database were included: a group undergoing IVF±ICSI alone (120 patients, 215 oocyte retrievals), and a group undergoing surgery and then IVF±ICSI (69 patients, 109 oocyte retrievals). The mode of management was decided after a multidisciplinary team meeting. Different criteria such as age (cut-off 35 years), anti-Müllerian hormone concentration (cut off 2 ng/ml), imaging results and the patient's symptomatology were considered: the most symptomatic patients underwent surgery prior to IVF±ICSI. The cumulative clinical pregnancy and live birth rates obtained after four IVF attempts were estimated and compared between the two groups using competing risk survival methods.

RESULTS

The cumulative live birth rates after four IVF attempts in the two groups were not statistically significantly different (50.8% in the IVF±ICSI group versus 52.2% in the surgery followed by IVF±ICSI group, P = 0.43). The results for the cumulative clinical pregnancy rates were the same (56.7% in the IVF±ICSI group versus 58% in the surgery followed by IVF±ICSI group, P = 0.47).

CONCLUSION

The study shows that cumulative live birth and pregnancy rates were similar in infertile patients with colorectal endometriosis who underwent IVF±ICSI either with or without prior colorectal endometriosis surgery.

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81 min vs 240 ± 79 min, p = 0.010, and 216 ± 78 min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4 days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.

Discoid excision for colorectal endometriosis associated infertility: A balance between fertility outcomes and complication rates

OBJECTIVE

The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes.

METHODS

49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed.

RESULTS

Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16).

CONCLUSION

Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.

Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial

BACKGROUND

The conventional laparoscopic approach for the surgical management of deep endometriosis (DE) infiltrating the rectum appears to ensure improved digestive functional outcomes. The natural orifice specimen extraction (NOSE) technique for the treatment of colorectal DE can significantly accelerate postoperative recovery; however, data on gastrointestinal function following conventional laparoscopic segmental bowel resection (CLR) compared with NOSE colectomy (NC) for DE are sparse.

MATERIALS AND METHODS

Between 30 September 2019 and 31 December 2020, a randomized, open-label, two-arm, parallel-group controlled trial with women aged 18-45 years was conducted at University Hospital.Ninety-nine patients were randomized to CLR or NC, with DE infiltrating at least the muscular layer, at least 50% of the circumference of the bowel, up to 15 cm from the anal verge, exhibiting pain and bowel symptoms and/or infertility. The primary endpoint was bowel function, represented by low anterior resection syndrome (LARS). Secondary parameters included the Endometriosis Health Profile 30 (EHP30), Gastrointestinal Quality of Life Index (GIQLI), Visual Analog Scale (VAS) scores preoperatively and at set times (1 and 6 months, 1 year) following surgery.

RESULTS

No significant differences were observed in the postoperative LARS scores, VAS, EHP30, and GIQLI between the NC and CLR groups. LARS scores did not reveal significant differences 12 months postoperatively compared to the preoperative values in both groups (CLR group P =0.93 versus NC group, P =0.87). GIQLI scores were significantly improved 12 months after the operation compared with baseline values in the CLR group ( P =0.002) and NC group ( P =0.001). Pain symptoms and quality of life scores significantly improved 12 months postoperatively in both groups.

CONCLUSIONS

NC is a feasible surgical approach for treating patients with rectal DE. Our study did not show a statistically significant difference between CLR and NC techniques in mid-term digestive and pain outcomes.

Diagnostic Accuracy of Transvaginal Sonography for Deeply Infiltrating Endometriosis and Pouch of Douglas Obliteration in the Presence or Absence of Ovarian Endometrioma

Background: Endometriosis is one of the most common gynecological diseases worldwide. Significant attention has been drawn to this multiorgan and often painful disorder. Objectives: This study aimed to examine the accuracy of transvaginal sonography (TVS) in the diagnosis of deeply infiltrating endometriosis (DIE) with respect to the presence or absence of ovarian endometrioma (OE). Patients and Methods: This cross-sectional study was performed on all patients undergoing TVS before gynecological laparoscopy. With pathological confirmation as the standard reference, the diagnostic accuracy of TVS for DIE and pouch of Douglas (POD) obliteration was compared with that of laparoscopy in the anterior and posterior pelvic compartments with respect to the presence or absence of OE. Agreement between TVS and laparoscopy was evaluated for each case, and Cohen’s kappa statistic was measured for each site of involvement. Moreover, sensitivity, specificity, negative and positive predictive values, and likelihood ratios of TVS were calculated, with laparoscopy as the reference test. Results: A total of 110 patients, with a mean age of 37.20 ± 7.16 years, were recruited in this study. The accuracy, sensitivity, and negative predictive value of TVS for the diagnosis of DIE and POD obliteration were estimated at 89.5%, 58.3%, and 88.9% in the anterior pelvic compartment and 93.3%, 92%, and 70.6% in the posterior pelvic compartment, respectively. Nevertheless, TVS showed lower sensitivity for detecting pelvic adhesions and peritoneal cysts compared to laparoscopy. The presence of OE did not significantly increase the accuracy of TVS for the diagnosis of DIE or POD obliteration (P > 0.05). Conclusion: The present study showed that TVS is an adequately accurate and non-invasive diagnostic tool for the detection and mapping of DIE and POD obliteration, regardless of the presence of OE. TVS may waive the need for exploratory laparoscopy in DIE or at least facilitate precise pre-procedural DIE mapping.

Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review

INTRODUCTION

The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis.

MATERIAL AND METHODS

Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed.

PROSPERO ID

CRD42021250974.

RESULTS

A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR.

CONCLUSIONS

Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

Surgical and functional impact of nerve-sparing radical hysterectomy for parametrial deep endometriosis: a single centre experience

Background: Deep endometriosis (DE) usually creates a distortion of the retroperitoneal anatomy and may infiltrate the parametria with an oncomimetic pathway similar to cervical cancer. The condition represents a severe manifestation of endometriosis that may result in a functional impairment of the inferior hypogastric plexus. An extensive surgical resection may be required with an associated risk of increased neurogenic postoperative pelvic organ dysfunction. Objectives: To evaluate the post-operative function and complications following hysterectomy with posterolateral parametrial resection for DE. Materials and Methods: In total, 23 patients underwent radical hysterectomy for DE with the parametria involved. The severity of pain was assessed by the Visual Analogue Scale (VAS) score. The KESS, GQLI, BFLUTS and FSFI were used to examine the gastrointestinal, urinary and sexual functions respectively. Intra and post-operative complications were recorded. Main outcome measures: The main outcomes were gastrointestinal, urinary and sexual function and intra and post-operative complications. Results: Dyschezia, dyspareunia and chronic pelvic pain were significantly reduced following hysterectomy. Furthermore, an improvement of gastrointestinal function was observed, while sexual functions, examined by FSFI and urinary symptoms, examined by BFLUTS, was not shown to be significant. Conclusion: The modified nerve-sparing radical hysterectomy for DE results in an improvement of symptoms. Nevertheless, despite the nerve-sparing approach, this procedure may be associated with a not-negligible risk of post-operative bladder voiding deficit. What is new? This is the first study that focuses on parametrial endometriosis using validated questionnaires to assess functional outcomes following radical hysterectomy for DE.

Surgery vs. hormone-based treatment for pain control in deep infiltrating endometriosis: a retrospective cohort study

OBJECTIVE

To evaluate the outcome of surgical or hormone-based pharmacological treatment for deep infiltrating endometriosis (DIE) in patients with pain symptoms.

STUDY DESIGN

A retrospective cohort study of 122 women with DIE of the bowel was conducted: 61 women underwent surgical treatment due to poor pain control and 61 received hormone-based treatment alone for at least six months. Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia and dysuria were evaluated by a visual analog scale (VAS) to measure pain on a scale from 0 to 10. Dyspareunia was further evaluated using the Deep Dyspareunia Scale (scores of 0-3).

RESULTS

Surgery (n = 61 women) was performed at a mean of 3.3 ± 1.6 years previously, while hormone-based treatment alone (n = 61 women) was used for a mean of 3.0 ± 1.41 years. After surgery, women without a desire to procreate received hormone-based treatment. Before treatment, the most intense endometriosis-related pain in the surgical treatment group and hormone-based treatment group alone were chronic pelvic pain (VAS = 9.48 ± 1.49; 8.57 ± 2.22), dysmenorrhea (VAS = 9.61 ± 1.45; 9.02 ± 1.35) and deep dyspareunia (VAS = 8.04 ± 2.82; 7.47 ± 3.21, respectively), all with mean pain scores of around 8 (0-10) in both groups. Both treatments were effective at reducing all symptoms (p < .001). The surgical treatment proved to be more effective and more enduring at improving chronic pelvic pain (p < .001), dyschezia (p = .003) and deep dyspareunia (p < .001). Regarding deep dyspareunia, using the deep dyspareunia scale, ∼70% of surgically treated women scored 0 or 1 (absent or mild deep dyspareunia) after treatment, compared to scores 2 or 3 (intense dyspareunia) in about 70% of the group using hormone-based treatment (p < .001).

CONCLUSION

Both types of treatment, surgical and pharmacological, effectively improved pain symptoms associated with DIE. However, improvement in chronic pelvic pain, dyschezia and deep dyspareunia was greater and longer-lasting after surgery.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.

Live surgery of colorectal endometriosis broadcasted from a surgeon's routine operating theater is not associated with higher complications rate

INTRODUCTION

Although live surgeries are routinely included in surgical congress programs, they are the subject of an ongoing debate in terms of patient safety and teaching value. The goal of our study was to assess the risk of postoperative complications related to live surgery broadcast from the surgeon's routine theater, in patients managed for deep endometriosis infiltrating the digestive tract.

MATERIAL AND METHODS

We report a retrospective comparative study, enrolling women managed for colorectal endometriosis by a gynecologic surgeon, from September 2013 to March 2020 in two referral centers. We compared the rate of postoperative bowel fistula in women managed during live surgery in the routine operating theater, with that observed in women for whom surgery was not broadcast.

RESULTS

Among 813 women, 33 (4.1% of cases) underwent surgical procedures transmitted live to various conference rooms located outside the hospital and were compared with 780 patients who underwent non-broadcast surgery. Women's age, body mass index, past surgical and obstetrical history, and major preoperative complaints were comparable. Cases presented with impaired constipation score, more frequent sciatic pain, and infiltration of the vagina, whereas overall revised American Fertility Society classification scores were more severe in controls. The rate of rectal nodules over 3 cm in size was comparable between the two groups (72.7% in cases vs. 72.1% in controls). Operative time was also comparable (153 ± 52 minutes vs. 148 ± 79 minutes). Cases were more frequently managed by disk excision of rectal nodules (63.7% vs. 30.3%), and more frequently involved the sacral plexus (18.2% vs. 7.3%). Postoperative complications were comparable between the two groups, in terms of bowel fistula (3% in the live surgery group vs. 4.1% in controls), pelvic abscess requiring secondary laparoscopy (3% vs. 4.9%), or bladder dysfunction requiring self-catheterization after discharge (6.1% vs. 5.3%).

CONCLUSIONS

Performing laparoscopic management of colorectal endometriosis with live transmission of surgery from a surgeon's routine operating theater, is not related to a higher risk of major postoperative complications.

Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study

STUDY OBJECTIVE

To assess the risk of low anterior resection syndrome (LARS) between women managed by either disk excision or rectal resection for low rectal endometriosis.

DESIGN

Retrospective study of a prospective database.

SETTING

University hospital.

PATIENTS

One hundred seventy-two patients managed by disk excision or rectal resection for deep endometriosis infiltrating the rectum <7 cm from the anal verge.

INTERVENTIONS

Rectal disk excision and/or segmental resection using transanal staplers.

MEASUREMENTS AND MAIN RESULTS

One hundred eight patients (62.8%) were treated by disk excision (group D) and 64 (37.2%) by rectal resection (group R). All patients answered the LARS score questionnaire. Follow-up was 33.3 ± 22 months for group D (range 12-108 months) and 37.3 ± 22.1 months (range 12-96 months) for group R (p = .25). The rates of rectovaginal fistula and pelvis abscess requiring radiologic drainage and surgery in the D and R groups were, respectively, 7.4% and 8.3% vs 7.8% and 9.3%. The rate of women with normal bowel movements postoperatively was higher in group D (61.1% vs 42.8%, p = .05). Women enrolled in group R reported higher frequency of stools (p <.001), clustering of stools (p = .02), and fecal urgency (p = .05). Regression logistic model revealed 2 independent risk factors for minor/major LARS: performing low rectal resection (adjusted odds ratio 2.28; 95% confidence interval, 1.1-4.7) and presenting with bladder atony requiring self-catheterization beyond postoperative day 7 (adjusted odds ratio 2.52; 95% confidence interval, 1.1-5.8).

CONCLUSION

The probability of normal bowel movements is higher after disk excision than after low rectal resection in women with deep endometriosis infiltrating the low rectum.

Rates of anastomotic leak and fistula following surgical management of bowel endometriosis: a comparison of shaving, discoid excision, and segmental resection

Endometriosis is a complex chronic inflammatory condition that can create a multitude of bothersome painful symptoms for women. Bowel endometriosis is often misdiagnosed or overlooked leading to years of suffering for many women. The surgical management of bowel endometriosis varies based on extent of disease as well as surgeon experience. Surgical treatment for bowel endometriosis is complex and a variety of intraoperative and postoperative complications must be considered. Two significant postoperative complications for bowel endometriosis include anastomotic leak and fistula formation. There is continued debate regarding the appropriate surgical treatment for bowel endometriosis. Aggressive surgery with segmental bowel resection is being utilized more cautiously, with an increase in less aggressive shaving or disc excision techniques. Historic beliefs regarding the limitations of shaving and disc excision are being challenged, and with a reduction in morbidity these less aggressive techniques are winning favor among gynecologic surgeons. Shaving, discoid excision, and segmental bowel resection are all feasible surgical management options for bowel endometriosis. Segmental resection is associated with the highest rates of both anastomotic leak and fistula formation, while shaving is associated with the lowest.

Crude complication rate is not an accurate marker of a surgeon's skill: A single surgeon retrospective series of 1060 procedures for colorectal endometriosis

OBJECTIVE

To assess the relationship between the rate of postoperative bowel fistula and surgeon experience.

DESIGN

Retrospective study.

SETTING

Two referral centers.

PATIENTS

1060 women managed for colorectal deep endometriosis by one gynecologist surgeon from January 2005 to March 2020.

INTERVENTIONS

Shaving, disc excision and segmental colorectal resection.

MAIN OUTCOME MEASURES

Rate of bowel fistula stratified according to 4 time periods: P1 from 2005 to 2009, P2 from 2010 to 2014, P3 from 2015 to June 2018 and P4 from September 2018 to March 2020.

RESULTS

68 patients (6.4%) were managed during P1, 299 patients (28.2%) during P2, 422 patients (39.8%) during P3 and 271 patients (25.6%) during P4. Both diameter of rectal infiltration and rate of complex surgical procedures progressively increased from P1 to P4. Bowel fistula rate was comparable between all 4 time periods, respectively 2.9, 3.3, 4 and 4.4%. Logistic regression model revealed that risk of fistula decreased when shaving was performed when compared to segmental resection (adj OR 0.1, 95% CI 0-0.5) and increased when deep endometriosis nodules also involved sacral roots (adjOR 4.9, 95%CI 1.8-13.3) and infiltration of the vagina (adj OR 3, 95%CI 1.3-7). No statistically significant relationship was found between surgery time period and risk of fistula.

CONCLUSION

Crude rates of bowel fistula following surgical management of deep endometriosis infiltrating the colon and the rectum are not an accurate marker of surgeon expertise and should be considered in conjunction with expected higher risks related to challenging procedures performed by experienced surgeons.

Value of sonography in assessing parametrial endometriotic involvement: Preliminary results

Objectives:

The aims of the study were to evaluate ultrasound (US) in the diagnosis of parametrial endometriosis compared with surgical-pathological findings, and to define an optimal cut-off of lesion size for correlation between torus/uterosacral ligaments (USL) or rectosigmoid and parametrial involvement by deep endometriosis.

Methods:

Longitudinal study of 60 patients referred for surgical management of pelvic endometriosis, who underwent sonography performed by an experienced sonographer. The presence of parametrial endometriosis shown by US was compared with surgical and histologic findings. The presence of endometrial cysts, deep endometriotic locations, and their potential association with parametrial endometriosis was assessed by US. The sensitivity, specificity, predictive values (PV), accuracy, and positive and negative likelihood ratios (LR) of US for predicting parametrial endometriosis and other pelvic endometriotic locations were assessed. Descriptive analysis, optimal cut-off analysis, categorical (Fisher’s exact test) and non-categorical variables (Mann—Whitney) were calculated.

Results:

Parametrial, ovarian, and deep endometriosis were found by surgery in respectively 30 (50%), 21 (35%), and 59 (98.63%) of the 60 patients. The sensitivity, specificity, PPV, NPV, accuracy, PLR, and NLR of US for the sonographic diagnosis of parametrial endometriosis were 40%, 96.7%, 92.3%, 61.7%, 68.3%, 12, and 0.62 respectively. In patients with parametrial involvement, a relation with rectosigmoid ( p = 0.005) and USL ( p = 0.0074) endometriosis was noted. For isolated torus/USL and rectosigmoid endometriosis, optimal cut-offs suggesting parametrial involvement by DE were 11 mm and 30 mm, respectively.

Conclusions:

US has low sensitivity but high specificity to diagnose parametrial endometriosis and could be used to rule in diagnosis before surgery.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes.

DATA SOURCES

We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications").

METHODS OF STUDY SELECTION

Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.

TABULATION, INTEGRATION, AND RESULTS

Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I² = 71%).

CONCLUSION

Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.

DATA SOURCES

We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.

METHODS OF STUDY SELECTION

Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.

TABULATION, INTEGRATION AND RESULTS

Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I² = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I² = 63%; p = .28).

CONCLUSION

Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.

Bowel resection for intestinal endometriosis

Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.

Post-operative management and follow-up of surgical treatment in the case of rectovaginal and retrocervical endometriosis

Introduction

Deep infiltrating endometriosis (DIE) affects between 3.8% and 37% of all endometriosis patients, mostly affecting rectovaginal septum or retrocervical space and characterized by the severe endometriosis-related complaints. Nowadays, generally managed with surgery. However, this is associated with a risk of postoperative complications. To better evaluate intra- and postoperative complications and outcomes for rectovaginal (RVE) and retrocervical endometriosis (RCE), the preoperative management should be accurately described and compared.

Methodology

This is a cohort retrospective study performed at the Endometriosis Centre of Charité-University Clinic, Berlin. 34 patients were investigated in their reproductive age, n = 19 with RVE and n = 15 RCE, operated between 2011 and 2015. The surgical approach was divergent in both groups. Single laparoscopy was performed in RCE patients (RCEP) and vaginal assisted laparoscopy in RVE patients (RVEP). Long-term postoperative outcome included complications, fertility rate and recurrence rate.

Results

The median follow-up time was three years (y). Symptom-free status was revealed in n = 12 RVEP and n = 9 RCEP. Postoperatively, endometriosis-related complaints were presented in n = 7 RVEP and n = 6 RCEP, but with significant pain relief. From n = 8 RVE patients seeking fertility, pregnancy occurred in n = 7 and from n = 9 RCEP pregnancy appeared in n = 5 patients in the meantime of 6 months. Postoperative complications were reported in n = 1 RVEP with early postoperative bleeding, after ureter leakage and n = 1 RCEP with postoperative anastomotic insufficiency. The postoperative recurrence rate was equivalent to zero.

Conclusion

The appropriate surgical approach for each group, preserving anatomy and functionality of the organs, seems to be very essential and efficient.

Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients

PURPOSE

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery.

METHODS

We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics.

RESULTS

164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005].

CONCLUSION

The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

Deep endometriosis: The place of laparoscopic shaving

Deep endometriosis (DE) is considered to be one of the most challenging conditions to manage, especially when it invades surrounding organs like the rectum. Surgical excision of deep rectovaginal endometriosis is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions, or if they evolve. Preoperative radiological examination should be extensive to determine the appropriate surgery: laparoscopic shaving, disc excision, or rectal resection. We demonstrated that in the hands of experienced surgeons, rectal shaving is possible for DE in more than 95% of cases, with low complication rates compared to rectal resection. Shaving and bowel resection are associated with comparable recurrence rates. As shaving is indicated whatever the size of deep lesions, surgeons should first consider rectal shaving to remove DE. Bowel resection should only be performed in case of major rectal stenosis (>80%), multiple and/or posterior rectal lesions and stenotic sigmoid colon lesions.

[Anatomic reports of vegetative nerves within para rectal fossa, to the rectal endometriosis surgery application]

OBJECTIVES

The objective of the study was to describe the inferior hypogastric plexus and nerves constituting the para-rectal fossa in order to study the importance of anatomical knowledge in rectal endometriosis surgery.

METHODS

In order to discover the complete anatomy of the study area, we carried out a review of the literature and relied on dissection of a female cadaver and operative dissections in patients treated for rectal endometriosis.

RESULTS

The inferior hypogastric plexus, the hypogastric nerve and the pelvic splanchnic nerves are the nervous elements component the para-rectal fossa. These nerves were important urinary, digestive and sexual functions. The dissection of the Okabayashi and the Latzko spaces within the para-rectal fossa and sparing nerve within this zone is more important for the prevention of traumatic nervous sequelae during rectal endometriosis surgery. The pelvic anatomy can be by attraction and sheathing nerve structures by endometriosis lesions which can complicate preservation techniques.

CONCLUSION

Lesions of pelvic vegetative nerves running through the para-rectal fossa can be responsible for urinary, digestive and sexual disorders that can affect patients quality of life. There is currently only one standardized "nerve sparing" technique in pelvic endometriosis surgery. Knowledge of the anatomy of the nerves making up the para-rectal fossa helps to orient the operative dissection and prevent postoperative nerve complications after surgery for rectal endometriosis.

Prevesical peritoneum interposition to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: Results of a pilot study

OBJECTIVE

To evaluate the risk of rectovaginal fistula after en bloc hysterectomy and colorectal resection (H-CR) for endometriosis using prevesical peritoneum interposition.

STUDY DESIGN

A retrospective study conducted at Tenon University Hospital, expert center in endometriosis, from June 2016 to June 2018. Patients undergoing H-CR with prevesical peritoneum interposition without protective defunctioning stoma were included.

RESULTS

Of the 160 patients who underwent surgery with colorectal resection for endometriosis during the study period, 27 had H-CR (15 with segmental and 12 with discoïd colorectal resection) and were included. The median age (range) was 45 years (41-47.5). Eight patients (13 %) were nulliparous. All procedures were performed by laparoscopy. Parametrial resection was performed in 14 cases (52 %). Associated bowel procedures were ileocecal resection (n = 5) and appendectomy (n = 2). Median follow-up (range) was 14.6 months (10.5-20.2). Nine (33.3 %) patients experienced intra- or postoperative complications including one grade I, four grade II, two grade IIIA and two grade IIIB complications (Clavien-Dindo classification). Seven patients (26 %) experienced postoperative voiding dysfunction. One suspicion of rectovaginal fistula associated with pelvic abscess was diagnosed 4 weeks after surgery but not confirmed during a second operation.

CONCLUSION

Despite the small sample size, the present pilot study supports the practice of prevesical peritoneum interposition to limit the risk of rectovaginal fistula in patients who undergo H-CR for deep endometriosis.

[Endometriosis: Assessment of the Ultrasound-Based Endometriosis Staging System score (UBESS) in predicting surgical difficulty]

OBJECTIVES

Surgical management of endometriosis may require different levels of surgical skill which influences the orientation of the patient. The Ultrasound-Based Endometriosis Staging System (UBESS) is a score developed in 2016 to predict the difficulty of surgery. To study the correlation between UBESS score and two main surgical classifications in the literature.

METHODS

Study performed at the center of Poissy, France, between July 2016 and December 2017. Patients who underwent prospective UBESS staging then operated of their endometriosis were included. The patients were classified according to the levels of surgical difficulty of the Royal College of Obstetricians and Gynecologists (RCOG) and the classification created by Chi et al. The criterion of judgment was the correlation between the UBESS stages and RCOG and CHI levels. In a second analysis, we determined the predictive value of the operative plan for items included in the systematic sonographic evaluation described by Menakaya et al. RESULTS: Thirty-three patients were included in the study. Correlation was found to be low between UBESS and RCOG (θ=0.22) and between UBESS and CHI (θ=0.30). The prediction of the operative plan was good for endometrioma, sites specific tenderness, sliding sign, vaginal and digestive tract involvement; but modest for the anterior compartment and uterosacrals ligaments.

CONCLUSION

In our study on a small number of patients, the UBESS score does not adequately predict the surgical difficulty. Taken separately, the items of systematic sonographic evaluation based on 5 domains successfully predict the operative plan.

Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial

STUDY QUESTION

Is there a difference in functional outcome between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 2 years postoperatively?

SUMMARY ANSWER

No evidence was found that functional outcomes differed when conservative surgery was compared to radical rectal surgery for deeply invasive endometriosis involving the bowel.

WHAT IS KNOWN ALREADY

Adopting a conservative approach to the surgical management of deep endometriosis infiltrating the rectum, by employing shaving or disc excision, appears to yield improved digestive functional outcomes. However, previous comparative studies were not randomized, introducing a possible bias regarding the presumed superiority of conservative techniques due to the inclusion of patients with more severe deep endometriosis who underwent colorectal resection.

STUDY DESIGN SIZE, DURATION

From March 2011 to August 2013, we performed a 2-arm randomized trial, enroling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth and up to 50% of rectal circumference. No women were lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients were enroled in three French university hospitals and had either conservative surgery, by shaving or disc excision, or radical rectal surgery, by segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of the results of randomization. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), defecation pain, anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were the values of the Visual Analog Scale (VAS), Knowles-Eccersley-Scott-Symptom Questionnaire (KESS), the Gastrointestinal Quality of Life Index (GIQLI), the Wexner scale, the Urinary Symptom Profile (USP) and the Short Form 36 Health Survey (SF36).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 60 patients were enroled. Among the 27 patients in the conservative surgery arm, two were converted to segmental resection (7.4%). In each group, 13 presented with at least one functional problem at 24 months after surgery (48.1 versus 39.4%, OR = 0.70, 95% CI 0.22-2.21). The intention-to-treat comparison of the overall scores on KESS, GIQLI, Wexner, USP and SF36 did not reveal significant differences between the two arms. Segmental resection was associated with a significant risk of bowel stenosis.

LIMITATIONS REASONS FOR CAUTION

The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <20 mm in length. The presumption of a 40% difference favourable to conservative surgery in terms of postoperative functional outcomes resulted in a lack of power to demonstrate a difference for the primary endpoint.

WIDER IMPLICATIONS OF THE FINDINGS

Conservative surgery is feasible in patients managed for large deep rectal endometriosis. The trial does not show a statistically significant superiority of conservative surgery for mid-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. There is a higher risk of rectal stenosis after segmental resection, requiring additional endoscopic or surgical procedures.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the clinical research programme for hospitals (PHRC) in France. The authors declare no competing interests related to this study.

TRIAL REGISTRATION NUMBER

This study is registered with ClinicalTrials.gov, number NCT 01291576.

TRIAL REGISTRATION DATE

31 January 2011.

DATE OF FIRST PATIENT’S ENROLMENT

7 March 2011.

Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis

OBJECTIVE(S)

To investigate Mesenteric vascular and nerve Sparing Surgery (MSS) as surgical laparoscopic technique to perform segmental intestinal resection for deep infiltrating endometriosis (DIE).

STUDY DESIGN

Prospective cohort study between January 2013 and December 2016. Consecutive patients with suspected intestinal DIE underwent clinical and imaging evaluation to confirm intestinal involvement. Indications for radical surgery and surgical technique (intestinal resection versus shaving) were consistent with Abrão algorithm. Surgeons aimed to perform MSS in all the consecutive patients that required intestinal resection. MSS consists in mesenteric artery, branching arteries, and surrounding nerve fibers preservation by dissecting mesentery adherent to the intestinal wall. Data about history, preoperative and post-operative evaluation, surgery and complications were recorded. Symptoms were evaluated before and 30-60 days after surgery with numeric rating scale for pain. Constipation was evaluated with the Constipation Assessment Scale (CAS). Patients with diagnosis of irritable bowel syndrome, inflammatory bowel diseases, diverticulitis, and previous segmental intestinal resection were excluded.

RESULTS

Sixty-two out of 75 (82.7%) consecutive women with intestinal endometriosis underwent laparoscopic segmental intestinal resection performed with MSS. Major complications that required repeated operation occurred in 4 cases (6.5%). Anastomotic leakage occurred in only 1 case (1.6%). Dysmenorrhea (p < .001; r = -0.86), dyspareunia (p < .001; r = -0.80), dyschezia (p < .001; r = -0.86) and dysuria (p < .001; r = -0.56) were significantly improved after surgery. After an average of 33.1 months from surgery, severe constipation was reported only by two patients (3.6%) (CAS: 13-16). The median time from surgery to intestinal function recovery (flatus or stool passage) was one day. Logistic regression analysis showed constipation related to the distance from anal verge and time since surgery.

CONCLUSION(S)

MSS in laparoscopic intestinal resection for DIE may be reproducible, safe and effective. MSS could be combined with pelvic nerve-sparing surgery as an effective approach to improve intestinal symptoms after radical surgery for DIE that requires segmental intestinal resection.

Functional outcomes of nerve-sparing laparoscopic eradication of deep infiltrating endometriosis: a prospective analysis using validated questionnaires

PURPOSE

Radical eradication of deep infiltrating endometriosis (DIE) is associated with a high risk of iatrogenic autonomic denervation and pelvic dysfunction. Our aim was to prospectively analyze peri-operative details and post-operative functional outcomes (in terms of pain relief and bladder, rectal, and sexual function) among women operated for DIE of the posterior compartment with nerve-sparing technique, using the visual analogue scale and validated questionnaires.

METHODS

All women undergoing laparoscopic nerve-sparing eradicative surgery for DIE nodules of the posterior compartment ≥ 4 cm ± bowel resection were included. Pain scores [using Visual Analogue Scale (VAS) scores] were collected before surgery and 6 and 12 months after surgery. Functional outcomes in terms of bladder, rectal, and sexual function, were evaluated using validated questionnaires (i.e., ICIQ-UISF, NBD score, and FSFI) administered pre-operatively and 6 months after surgery.

MAIN RESULTS

A total of 34 patients were included. Twenty-eight (82.4%) of them had already undergone a previous abdominal surgery for endometriosis. Bowel resection was performed in 16 (47.1%) patients. Median VAS score levels of pelvic pain were significantly decreased after surgery both at 6 (median 3, range 0-7 and 2, 0-7, respectively) and at 12 months (3, 0-8 and 2, 0-7), compared to pre-operative levels (9, 1-10 and 3, 0-7, respectively) (p < 0.0001). No differences were found in terms of urinary function between pre- and post-operative ICIQ-SF questionnaires. In no cases, bladder self-catheterization was needed at the 6-and 12-month follow-up. Median NBD score was 3.5 (0-21) pre-operatively and 2 (0-18) after 6 months (p = 0.72). The pre-operative total FSFI score was 19.1 (1.2-28.9) vs. 22.7 (12.2-31) post-operatively (p = 0.004).

CONCLUSIONS

The nerve-sparing approach is effective in eradicating DIE of the posterior compartment, with satisfactory pain control, significant improvement of sexual function, and preservation of bladder and rectal function.

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review

PURPOSE

"Endometriosis" is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis.

METHODS

We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: "rectal resection" AND "endometriosis" and "rectosigmoid resection" AND "endometriosis." The search revealed 380 papers of which 78 were fully analyzed.

RESULTS

Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28 ± 2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47 ± 66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88 ± 3.71 days.

CONCLUSIONS

Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

Rectovaginal fistula following surgery for deep infiltrating endometriosis: Does lesion size matter?

Objective This study was performed to identify risk factors for postoperative rectovaginal fistula (PRF) in patients with deep infiltrating endometriosis (DIE). Methods Data were retrospectively obtained from the medical records of 104 patients with DIE, and statistical analysis was used to detect risk factors for PRF. Results Five of 104 (4.8%) patients developed PRF from 5 to 16 days postoperatively. The operative procedures included 84 (80.8%) superficial excisions, 6 (5.8%) full-thickness disc excisions, and 14 (13.5%) bowel resections. Most lesions were located in the cul-de-sac, and the mean lesion size was 2.6 cm (range, 0.5-7.0 cm). The univariate analysis showed that lesion location, larger lesion size, and surgical technique were statistically significant risk factors for PRF. Conclusion Surgical procedures should be very carefully executed in patients with DIE lesions of ≥4 cm.

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.

Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?

Deep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.

Management of deep infiltrating endometriosis of the rectum: Is a systematic temporary stoma relevant?

STUDY OBJECTIVE

To assess the value of performing a protective stoma in patients operated for rectal endometriosis.

MATERIAL AND METHODS

From June 2009 to December 2011, 47 patients were operated for rectal endometriosis by segmental or discoid resection in 4 different centers. Two groups were formed: one with protective stoma (group S), n=33 and one without protective stoma (group NS), n=14. Data were collected from the CIRENDO database.

MEASUREMENTS AND MAIN RESULTS

Postoperative complication rate of group NS was 57% against 48% in group S (P=0.75). There was an increasing trend of the rate of anastomotic leakage in group S as compared to group NS: 21% against 3% (P=0.073). All 3 patients of group NS with an anastomotic leakage were reoperated and the group S patient had medical treatment. In a center, digestive operative time was not necessarily performed in association with a gastrointestinal surgeon. All patients in group S had a restoration of continuity in about 3 months. Two of them had dilation of anastomotic stricture and 3 others showed a transient postoperative ileus during this recovery. Quality of life was assessed by the MOS SF-36 and significantly improved in both groups thanks to the intervention.

CONCLUSION

Temporary digestive stoma in patients operated for rectal endometriosis has to be considered because in our study, it seems reducing complications such as anastomotic leakage. This must be confirmed with studies with larger numbers.

[Impact of osteopathic manipulative therapy in patient with deep with colorectal endometriosis: A classification based on symptoms and quality of life]

OBJECTIVES

A prospective study to evaluate the clinical impact of osteopathic manipulative therapy (OMT) on symptoms and quality of life (QOL) of patients with colorectal endometriosis.

METHODS

Forty-six patients with colorectal endometriosis completed the SF-36 QOL and symptoms questionnaire before and after OMT. A comparison and clustering analysis was performed to identify subgroups of patient's profile and symptom classification.

RESULTS

The mean age of the patients was 32±6.2 years. Prior surgery for endometriosis was recorded in 73.9 % of cases but none for deep infiltrating endometriosis. About three-quarters of the patients were nulliparous. The time between pre- and post-OMT completion of questionnaires was 28 days (15-63), A significant improvement in SF-36 QOL physical component summary (P<0.001) and mental component summary (P<0.001) was observed after OMT. Similarly, a significant improvement in gynecological, digestive and general symptoms values was observed. A clustering analysis allowed to identify four profiles of patients with colorectal endometriosis based on symptoms and a respective OMT gain of 30 %, 60 %, 64 % et 45 %.

CONCLUSIONS

Our results support that OMT improve QOL and endometriosis symptoms of patients with colorectal endometriosis. Moreover, this symptom classification based on OMT gain can serve to design future randomized trial.

Robotic-assisted laparoscopy in reproductive surgery: a contemporary review

Robotic surgery is a conceptual fusion of the conventional open surgery and the minimally invasive laparoscopic surgery. We reviewed the current role of robotic-assisted laparoscopy in the field of reproductive surgery by a literature search in PubMed database. We analyzed the reported advantages and limitations of the use of robotics in reproductive surgeries like myomectomy, tubal reanastomosis, endometriosis, ovarian tissue cryopreservation, and ovarian transposition. Overall, robotic assistance in reproductive surgery resulted in decreased blood loss, less post-operative pain, shorter hospital stay, and faster convalescence, whereas reproductive outcomes were similar to open/laparoscopic approaches. The main drawbacks of robotic surgery were higher cost and longer operating times. It is as safe and effective as the conventional laparoscopy and represents a reasonable alternate to abdominal approach. Procedures that are technically challenging with the conventional laparoscopy can be performed with robotic assistance. It has advantages of improved visualization and Endowrist™ movements allowing precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and may shorten the steep learning curve in minimal invasive surgery. Randomized controlled trials looking at both short- and long-term outcomes are warranted to strengthen the role of robotic surgery in the field of reproductive surgery.

Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis

BACKGROUND

Two surgical approaches usually are used in the surgical management of deep infiltrating endometriosis of the rectum: the radical approach that mainly is based on colorectal resection and the conservative or symptom-guided approach that prioritizes conservation of the rectum. There are no data available that compare long-term functional digestive outcomes of 1 approach to the other.

OBJECTIVE

The purpose of this study was to compare long-term digestive outcomes in women who were treated by either rectal shaving or colorectal resection for deep endometriosis infiltrating the rectum.

STUDY DESIGN

A retrospective comparative study was performed. All women who were treated with surgery for deep endometriosis infiltrating the rectum by either shaving or colorectal resection at the University Hospital of Rouen from January 2005 to January 2010 were enrolled. Follow-up evaluation was carried out for a minimum of 5 years. Postoperative evaluation of digestive symptoms was performed by 4 standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index, the Knowles-Eccersley-Scott-Symptom score for constipation, the Wexner score for anal continence, and the Bristol Stool Score. Symptoms that were related to endometriosis, fertility, and disease recurrence were obtained from a specific questionnaire.

RESULTS

A total of 77 women were included. Three women were lost to follow up (3.9%), and 3 were treated by disc excision (3.9%). The mean follow-up time was 80±19 months. Forty-six women underwent conservative rectal shaving, and 25 women underwent colorectal resection. Patient characteristics and the severity of the disease were comparable in both groups. Patients who were treated by rectal shaving had significantly better Gastrointestinal Quality of Life Index values, lower Knowles-Eccersley-Scott-Symptom scores for postoperative constipation, and better anal continence. No statistically significant differences were revealed for postoperative pelvic pain. Rectal recurrence occurred in 8.7% of patients who were treated by conservative surgery: 4.3% underwent secondary colorectal resection and 4.3% were treated secondarily by rectal shaving. Consequently, avoiding a recurrence for merely 1 patient would have required 11 patients to undergo colorectal resection instead of shaving.

CONCLUSION

Our data suggest that, in patients who are treated for rectal endometriosis, colorectal resection does not improve long-term postoperative functional outcomes when compared with rectal shaving.

Is pelvic MRI in women presenting with pelvic endometriosis suggestive of associated ileal, appendicular, or cecal involvement?

PURPOSE

To evaluate whether deep pelvic endometriosis or endometriomas diagnosed at pelvic MRI are associated with extrapelvic bowel endometriosis (EPBE) (ileal, appendicular, or cecal involvement) in order to suggest criteria for performing an additional imaging examination dedicated to the assessment of EPBE.

METHODS

Ninety-six patients operated on for deep pelvic endometriosis were retrospectively included. They were classified in two groups according to the presence of surgically and histologically proven EPBE. According to pelvic endometriotic lesions described on the preoperative pelvic MRI, a logistic regression analysis was performed to evaluate a possible association between EPBE and pelvic endometriosis.

RESULTS

Eleven patients had EPBE (5 appendicular, 2 cecal, and 4 ileocecal lesions) at surgery. In adjusted models, involvement of the right ureter, rectosigmoid, and sigmoid localizations were statistically associated with EPBE with adjusted OR of 9.13 (95% CI 1.98-42.19), 5.8 (95% CI 1.12-30.07), and 6.74 (95% CI 1.23-36.77), respectively.

CONCLUSIONS

Further imaging evaluation to assess ileal, appendicular, or cecal endometriosis should be proposed in case of sigmoid or rectosigmoid endometriosis diagnosed at pelvic MRI. A right ureteral lesion diagnosed preoperatively should be considered carefully as its association with EPBE is not described so far.