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

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.

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.

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.

Hormone treatment as first line therapy is safe and relieves pelvic pain in women with bowel endometriosis

OBJECTIVE

To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy.

METHODS

Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016.

RESULTS

Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001).

CONCLUSION

Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.

Laparoscopic excision of deeply infiltrating endometriosis: a prospective observational study assessing perioperative complications in 244 patients

PURPOSE

To examine peri-operative complications in patients undergoing laparoscopic excision of deeply infiltrating endometriosis (DIE).

METHODS

This was a prospective study of a case series of women having laparoscopic excision of deeply infiltrating endometriosis from September 2013 through August 2016 in a tertiary referral center for endometriosis and minimally invasive gynaecological surgery in Iran. Data collected included demographics, baseline characteristics, intraoperative and postoperative data up to 1 month following surgery.

RESULTS

We analysed data from 244 consecutive patients, who underwent radical laparoscopic excision of all visible DIE. Major postoperative complications occurred in 3 (1.2%) and minor complications in 27 (11.1%) of patients. 80.3% of our patient group had Stage IV endometriosis. Segmental bowel resection was performed in 34 (13.9%), disc resection in 7 (2.9%), rectal shave in 53 (21.7%). Joint operating between a gynaecologist and colorectal and/or urological colleague was required in 29.6% of cases. The mean operating time was 223.8 min (± 80.7 standard deviation, range 60-440 min) and mean hospital stay was 2.9 days (± 1.5 standard deviation, range 1-11). The conversion to laparotomy rate was 1.6%.

CONCLUSIONS

A combination of different laparoscopic surgical techniques to completely excise all visible DIE, within the context of a tertiary referral center offering multi-disciplinary approach, produces safe outcomes with low complication rates.

Effect of Anterior Compartment Endometriosis Excision on Infertility

Background and Objectives:

Laparoscopic surgical excision of bladder nodules has been demonstrated to be effective in relieving associated painful symptoms; the data are lacking concerning the impact of anterior compartment endometriosis on infertility. We conducted this study to evaluate whether or not the surgical excision of deep endometriosis affecting the anterior compartment plays a role in restoring fertility.

Methods:

This multicentre, retrospective study included a group of 55 patients presenting with otherwise-unexplained infertility who had undergone laparoscopic excision of anterior compartment endometriosis with histological confirmation. Patient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term followup of fertility outcomes.

Results:

The pregnancy rate following surgical excision of endometriotic lesions was 44% (n = 11) among those with anterior compartment involvement alone and 50% (n = 15) in case of posterior lesions association without any significant difference. The symptoms related to bladder endometriosis resolved in the 84.2% of the cases with a recurrence rate of 1.8% at the 2-year followup not requiring further surgery.

Conclusion:

Laparoscopic excision of anterior compartment endometriosis is effective in restoring fertility in patients with otherwise-unexplained infertility and in treating endometriosis-related symptoms.

[Surgical management of deep endometriosis with colorectal involvement: CNGOF-HAS Endometriosis Guidelines]

Deep endometriosis with colorectal involvement is considered one of the most severe forms of the disease due to its impact on patients' quality of life and fertility but also by the difficulties encountered by the clinicians when proposing a therapeutic strategy. Although the literature is very rich, evidence based medicine remains poor explaining the great heterogeneity concerning the management of such patients. Surgery therefore remains a therapeutic option. It improves the intensity of gynecological, digestive and general symptoms and the quality of life. Concerning the surgical approach, it appears that laparoscopy should be the first option; the laparoscopic robot-assisted route can also be proposed. The techniques of rectal shaving, discoid resection and segmental resection are the three techniques used for surgical excision of colorectal endometriosis. The parameters taken into account for the use of either technique are: the surgeon's experience, the depth of infiltration of the lesion within the rectosigmoid wall, the lesion size and circumference, multifocality and the distance of the lesion from the anal margin. In the case of deep endometriosis with colorectal involvement, performing an incomplete surgery increases the rate of pain recurrence and decreases postoperative fertility. In case of surgery for colorectal endometriosis, pregnancy rates are similar to those obtained after ART in non-operated patients. Existing data are insufficient to formally recommend first line surgery or ART in infertile patients with colorectal endometriosis. The surgery for colorectal endometriosis exposes to a risk of postoperative complications and recurrence of which the patients should be informed preoperatively.

[Urinary tract involvement by endometriosis. Techniques and outcomes of surgical management: CNGOF-HAS Endometriosis Guidelines]

Urinary tract involvement by endometriosis is reported in 1% of endometriosis patients (NP3). Consequences range from pelvic pain for bladder localizations to silent kidney loss in case of chronic ureteral obstruction (NP3). The feasibility of laparoscopic management was widely proven (NP3) and may reduce hospital stay length (NP4). Radical surgery with partial cystectomy for bladder localizations was shown to significantly and durably reduce pain symptoms with low risk of a severe postoperative complications (NP3). Medical hormonal treatment also shows short-term reduction of pain symptoms (NP4). Transureteral resection of bladder endometriosis nodule is not recommended (grade C) because of a high postoperative recurrence rate (NP4). Given a high risk of silent kidney loss, it is recommended that patients with ureteral involvement by endometriosis are managed by a multidisciplinary team considering urinary and potential extra-urinary localizations of endometriosis (grade C). No recommendation can be made on which technique to prefer between conservative (ureterolysis) or radical surgical techniques or on benefit and length of ureteral stents in case of ureteral involvement. Surgical management of bladder and ureteral localizations of endometriosis do not seem to be associated with altered or improved postoperative fertility (NP4). Since late postoperative ureteral anastomosis stenosis were reported with silent kidney loss, repeated postoperative imaging monitoring is justified (expert opinion).

Urinary Tract Endometriosis

Endometriosis is a multifactorial polygenic genetic disorder that affects 10–20% of women. The urinary tract is affected in only 1–5% of cases and here most commonly the urinary bladder. Diagnosis of urinary tract endometriosis is made late due to its commonly asymptomatic course. The management of urinary tract endometriosis depends on the severity of the symptoms and signs, the extent of the disease, its location and the presence of renal damage because of ureteral obstruction. A conservative medical treatment is recommended for small areas of endometriosis in the bladder. For urinary tract endometriosis covering a large area, or where infiltration causes architectural damage, surgery is recommended. Partial cystectomy should be considered because of the transmural nature of bladder endometriosis. In cases of ureteral endometriosis, the surgical technique is determined by the location and extent of the lesion. For the distal ureter an ureterocystoneostomy using the Psoas hitch or Boari flap is recommended. For short, proximal ureteral involvement an end-to-end anastomosis or endoscopic incision may be used, and for extended areas, ileum interposition or kidney mobilization using nephropexy. A multidisciplinary approach is strongly recommended. Endometriosis with urological involvement more often needs surgical treatment, especially when ureteral obstruction leads to progressive kidney damage.

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.

From Endometriosis to Pregnancy: Which is the “Road-Map”?

In the last decade, pregnancy was considered as a therapeutic period for patients affected by endometriosis and painful symptoms. However, several studies have taken into consideration how endometriosis affects pregnancy achievement and pregnancy development, including obstetric complications. The adverse effects of endometriosis on the development of pregnancy include miscarriage, hypertensive disorders and pre-eclampsia, placenta previa, obstetric hemorrhages, preterm birth, small for gestational age, and adverse neonatal outcomes. The aim of this review is to analyze the current literature regarding the relationship between different forms of endometriosis (endometrioma, peritoneal endometriosis, deep endometriosis) and infertility, and the impact of endometriosis on pregnancy outcomes.

The role of the multidisciplinary team in the management of deep infiltrating endometriosis

The multidisciplinary team (MDT) is considered good practice in the management of chronic conditions and is now a well-established part of clinical care in the NHS. There has been a recent drive to have MDTs in the management of women with severe endometriosis requiring complex surgery as a result of recommendations from the European Society for Human Reproduction and Embryology (ESHRE) and British Society for Gynaecological Endoscopy (BSGE). The multidisciplinary approach to the management of patients with endometriosis leads to better results in patient outcomes; however, there are potentially a number of barriers to its implementation and maintenance. This paper aims to review the potential benefits, disadvantages and barriers of the multidisciplinary team in the management of severe endometriosis.

Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation

CONTEXT

The bladder is the most common site affected in urinary tract endometriosis. There is controversy regarding the pathogenesis, clinical management (diagnosis and treatment), impact on fertility, and risk of malignant transformation of bladder endometriosis (BE).

OBJECTIVE

To systematically evaluate evidence regarding the pathogenesis, diagnosis, medical and surgical treatment, impact on female fertility, and risk of malignant transformation of BE.

EVIDENCE ACQUISITION

A systematic review of PubMed/Medline from inception until October 2016 was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/prospero; CRD42016039281). Eighty-seven articles were selected for inclusion in this analysis.

EVIDENCE SYNTHESIS

BE is defined as the presence of endometrial glands and stroma in the detrusor muscle. Ultrasonography is the first-line technique for assessment of BE owing to its accuracy, safety, and cost. Clinical management can be conservative, using hormonal therapies, or surgical. When conservative treatment is preferred, estrogen-progestogen combinations and progestogens should be chosen because of their favorable profile that allows long-term therapy. Surgery should guarantee complete removal of the bladder nodule to minimize recurrence, so transurethral surgery alone should be avoided in favor of segmental bladder resection. There is not a strong rationale for hypothesizing a detrimental impact of BE per se on fertility. Furthermore, current evidence does not support the removal of bladder endometriotic lesions because of the potential risk of malignant transformation since this phenomenon is exceedingly rare.

CONCLUSIONS

BE is a challenging condition, and the common coexistence of other types of endometriosis means that clinical management of BE should involve collaboration between gynecologists and urologists.

PATIENT SUMMARY

In this article we review available knowledge on bladder endometriosis. The review provides a useful tool to guide physicians in the management of this complex condition.

Laparoscopic Surgery for Rectovaginal Endometriosis: A Retrospective Descriptive Study from a Single Centre

Introduction

Rectovaginal endometriosis is a form of deep infiltrating endometriosis and accounts for 5%-10% of cases. It is a very difficult to treat and can be associated with severe complications.

Objectives

The aim was to document the outcomes of patients undergoing laparoscopic surgery for rectovaginal endometriosis.

Methods

A retrospective audit of 112 consecutive women undergoing laparoscopic surgery for rectovaginal endometriosis at Vincent Pallotti's Aevitas Fertility Clinic was undertaken. Women were identified from a surgical database using medical aid coding and a review of case notes. Patients were telephonically contacted to gather missing information and to assess further outcomes.

Results

The majority of surgeries were performed using the shaving technique, in keeping with international trends, whilst fourteen cases required a segmental resection owing to extensive disease. Complications included rectovaginal fistulas (3 cases), bowel injuries (2 cases), ureteric injury (1 case), a pelvic abscess (1 case), a blood transfusion (1 case) and the need for three urgent re-operations. Of the 71 patients desiring fertility, 39 (54.9%) fell pregnant. Twenty-seven (69.2%) were spontaneous conceptions.

Conclusions

Our outcomes are in keeping with complication rates quoted in the international literature. In trained hands, laparoscopic surgery at our unit is a valid option in the management of rectovaginal endometriosis with similar complication rates and outcomes to international standards.

Laparoscopic treatment of deep infiltrating endometriosis: results of the combined laparoscopic gynecologic and colorectal surgery

BACKGROUND

The short-term results of a retrospective consecutive series of multidisciplinary laparoscopic approach to deep infiltrating endometriosis with intestinal involvement requiring segmental bowel resection procedures are presented.

METHODS

Patients with radiologically or intraoperative-confirmed endometriosis, who underwent a combined laparoscopic segmental bowel resection by a team of gynecologists and colorectal surgeons, were retrospectively reviewed. The postoperative data were collected in a specific database and analyzed for short-term (30 days) postoperative outcomes with the comparison between two specimen's extraction methods.

RESULTS

Forty-one patients (median age of 36 years, range 25-44) have been operated by a combined team of gynecologist and colorectal surgeons. The median operative time was 247.5 min (range 155-375), and median estimated blood loss was 300 ml (range 100-1300). In 20 patients, the surgical specimens were extracted transvaginally, while in 21 cases, a sovrapubic transverse Pfannenstiel minilaparotomy was used. No intraoperative complications or conversion to laparotomy were reported. An acceptable cumulative rate of postoperative morbidity was observed (6/41, 15 %), without any postoperative deaths. Comparing the two subgroups of patients with different modalities of specimen retrieval, postoperative pain (assessed by visual analog scale) was significantly reduced in the transvaginal extraction group (median: 1 and range: 0-2 vs median: 3, 5 and range: 1-6; p = 0.002), without any statistically significant differences in terms of complications.

CONCLUSION

Laparoscopic bowel segmental resection combined with gynecologic surgery for deep infiltrating endometriosis with intestinal involvement is a valid treatment option with a low rate of postoperative complications. Transvaginal specimen extraction allows the same results of minilaparotomic incision, minimizing surgical trauma and warranting a clear benefit in terms of reduction of postoperative pain.

[Transvaginal specimen extraction after laparoscopic bowel resection in deeply infiltrating endometriosis]

The authors report a case of a 27-year-old patient who had deeply infiltrating endometriosis involving the rectum, sigmoid colon and the rectovaginal septum, which was removed by laparoscopic surgery. During surgery the affected bowel segment, the deeply infiltrating nodule of the rectovaginal septum and the posterior vaginal wall were resected and the 12 cm long specimen was removed transvaginally. Postoperative bleeding was noted in the first postoperative day, which was treated laparoscopically, as well. This case history confirms data from the literature showing that the natural orifice specimen extraction procedure can widely be applied during operations for deeply infiltrating endometriosis and that laparoscopic anterior resection is a safe and feasible method for the treatment of colorectal deeply infiltratnig endometriosis. Moreover, perioperative complications can be treated by means of laparoscopic surgery.

Feasibility and first long-term results after laparoscopic rectal segment resection and vaginal specimen retrieval for deep infiltrating endometriosis

INTRODUCTION

Radical resection of deep infiltrating endometriosis (DIE), including bladder and bowel resection, provides relief from pain in symptomatic patients. The laparoscopic approach to treatment is well established for bowel resection but normally requires additional abdominal incisions for specimen retrieval. Here we describe our technique of laparoscopically assisted rectal resection and transvaginal specimen retrieval (LARRT) and provide follow-up information on pain scores and complications.

MATERIALS AND METHODS

Retrospective observational monocentric study on all DIE patients with rectal infiltration treated between 2008 and 2010 with LATRR at our department. Follow-up was obtained for at least 3 years, including baseline 1-year and 3-year pain scores.

RESULTS

We identified four patients undergoing LARRT available for follow-up. DIE was confirmed by histology in all cases. There were no intraoperative complications. Two patients had transient postoperative urinary retention, one patient developed recto-vaginal fistula and required transient colostomy. One patient suffered from persistent vaginal dryness. All patients, however, reported persistent pain relief, including at the end of follow-up period.

CONCLUSION

LARRT is a feasible variation of laparoscopic bowel resection for DIE with rectal infiltration. In our study it has promising results with respect to pain control. Larger studies will, however, be required to determine the safety of this procedure.

Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy

Robotic-assisted surgery for the treatment of deep infiltrating bowel endometriosis appears to be feasible, effective, and safe.

Background and Objective:

Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis.

Methods:

Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes.

Results:

Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90–190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization.

Conclusion:

We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.

Chronic pelvic pain in endometriosis: an overview

Chronic pelvic pain (CPP) could be considered nowadays a deep health problem that challenges physicians all over the world. This because its aetiology is still unclear, the course of the disease could vary a lot among different patients and through time in the same patient, and the response to treatments is not every time successful. Among women who underwent laparoscopy for CPP, endometriosis is found in about 1/3 of the cases, while only 25% of women with histological confirmed endometriosis are asymptomatic. A wide range of variables may exert their influence on the resulting pain syndrome in endometriosis; for example, score according to American society for reproductive medicine (rASRM), size of the sub-peritoneal and pelvic wall implants, Douglas obliteration, previous surgery. It is widely accepted nowadays that central nervous system (CNS) and peripheral nervous system (PNS) seems to influence each other and this interconnection play a key role in pain modulation. Moreover, the phenomena induced by endometriosis in the pelvis, including the breakdown of peritoneal homeostasis and the induction of the production of proinflammatory and proangiogenic cytokines, are responsible of altered innervations and modulation of pain pathways in these patients. There are many proposed medical and surgical approach to treat this painful syndrome, although there is necessity of more efforts to create new non-invasive strategies that set a more accurate diagnosis of the causes of endometriotic-related CPP, and therefore facilitate its eradication.

Effects of Surgical Excision of Endometriosis regarding Quality of Life and Psychological Well-Being: A Review

The aim of the present work is to give a critical and detailed reflection on the effects of surgical resection of deep infiltrating endometriosis regarding reduction of symptoms, psychological well-being and quality of life. The current evidence strongly supports the effectiveness of radical laparoscopic resection in relieving endometriosis-associated symptoms and enhancing psychological well-being. In addition, studies suggest a general improvement of quality of life, however, further studies are needed to support this observation.

Long Term Surgical Outcomes after Segmental Colorectal Resection in Women with Severe Endometriosis

Purpose

The aim of this study is to assess post-operative complications, symptoms, patient satisfaction, and fertility outcome after a long-term follow-up period in patients with severe intestinal endometriosis.

Methods

In this retrospective study (January 1998 - December 2008) patients scheduled for a segmental colorectal resection by laparotomy were identified. Surgery was performed by a multidisciplinary team. Data were obtained from medical records and supplemented by a questionnaire.

Results

A total of 41 patients (median age 30 years [24–45]) were included with a mean follow-up of 50 months. Three patients were lost to follow-up. Chronic pelvic pain, dysmenorrhea, dyschezia, hematochezia, constipation, pencil like stool, diarrhea, and tenesmus decreased, respectively, in 24, 16, 31, 25, 26, 12, 11, and 21 patients. Post-operatively, one patient conceived naturally and eleven out of fifteen patients conceived after in vitro fertilization. The post-operative patient satisfaction rate (mean 7.4) was significantly higher compared to prior to surgery (mean 4.6). Four major complications were reported in the first year after surgery. The cumulative complication rate was 12%.

Conclusions

Segmental colorectal resection by laparotomy in patients with severe intestinal endometriosis effectively reduces symptoms and increases patient satisfaction with an acceptable risk on treatable complications.

Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial

BACKGROUND

The weight of surgical radicality, together with a lack of anatomical theoretical basis for surgery and inappropriate practical skills, can lead to serious impairments to bladder, rectal, and sexual functions after laparoscopic excision of deep infiltrating endometriosis. Although the "classical" laparoscopic technique for endometriosis excision involving segmental bowel resection has proven to relieve symptoms successfully, it is hampered by several postoperative long-term and/or definitive pelvic dysfunctions.

METHODS

In this prospective cohort study, we compare the laparoscopic nerve-sparing approach to the classical laparoscopic procedure in a series of 126 cases. Satisfactory data for bowel, bladder, and sexual function were considered as primary endpoints.

RESULTS

A total of 126 patients were considered for analysis: 61 treated with nerve-sparing radical excision of pelvic endometriosis with segmental bowel resection (group B), and 65 treated with the classical technique (group A). Intraoperative, perioperative, and postoperative complications were similar between the two groups. Mean days of self-catheterization were significantly lower in the nerve-sparing group (39.8 days) compared with the non-nerve-sparing group (121.1 days; p < 0.001). The relapse rate within 12 months after surgery was comparable between the two groups. Patients of group A suffered from urinary retention more frequently between 1 and 6 months (p = 0.035) compared with group B and did not experience any improvement between 6 months and 1 year (p = 0.018). Overall detection of severe bladder/rectal/sexual dysfunctions was significantly different between the two groups, and 56 patients of group A (86.2%) reported a significantly higher rate of severe neurologic pelvic dysfunctions vs. 1 patient (1.6%) of group B (p < 0.001).

CONCLUSIONS

Our technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, we believe that it should be performed only in selected reference centers.

Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review

The effect of rectovaginal endometriosis on fertility is unclear. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought spontaneous pregnancy. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (95% CI 35-43%; 223/571), but dropped to 24% (95% CI 20-28%; 123/510) in infertile patients who sought spontaneous conception (odds ratio 0.50, 95% CI 0.38-0.65%). Patients' selection significantly influences the estimate of the effect of rectovaginal endometriosis excision on infertility. This should be carefully taken into consideration at preoperative counselling. Rectovaginal endometriosis usually is associated with pain symptoms, but the effect of this disease form on fertility is uncertain, as burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pelvis may limit interference with fertilization processes. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought pregnancy spontaneously. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (223/571), but dropped to 24% (123/510) in infertile patients who sought conception spontaneously. The 15% difference is statistically significant. Infertile patients with rectovaginal endometriosis considering surgery, should be carefully informed of the real probability of post-operative conception avoiding generic overestimations.

Large bowel obstruction due to endometriosis

We report on three cases of premenopausal female patients with large bowel endometriosis causing intermittent obstruction.

Follow-up of dysfunctional bladder and rectum after surgery of a deep infiltrating rectovaginal endometriosis

PURPOSE

The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. Major goal of this review article is to compare different surgical techniques of deep infiltrating endometriosis and their follow-up results.

METHODS

The research strategy included the online search of databases [MEDLINE, EMBASE, SCOPUS] for the diagnosis of deep infiltrating endometriosis with the indication of an operative resection. The outcome of the follow-up terms were noticed and compared.

RESULTS

All in all, 16 trials could be identified with included follow-up. In all patients at least single-sided resection of the uterosacral ligaments were performed. Follow-up was heterogeneous in all trials ranging from 1 to 92 months. Postoperative symptoms, such as dysmenorrhoea, pelvic pain, and dyspareunia were commonly described in the majority of trials. Nevertheless, a tendency towards lower comorbidity after nerve sparing resection of endometriosis could be observed.

CONCLUSION

Identification of the inferior hypogastric nerve and plexus was feasible in the minority of trials. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis

OBJECTIVE

We sought to investigate the effectiveness of repeated transvaginal ultrasound-guided aspiration of endometriomas in infertile women with endometriosis.

STUDY DESIGN

A retrospective study was performed in our department of reproductive health on 129 infertile women who underwent monthly repeated transvaginal aspiration of endometriomas. The recurrence and pregnancy were monitored during a follow-up period of 24 months.

RESULTS

Recurrences of cysts were found in 118 (91.5%) patients in the first postaspirate month and 86 (66.7%) in the second, 60 (46.5%) in the third, 28 (21.7%) in the fourth, 12 (9.3%) in the fifth, 7 (5.4%) in the sixth, and 36 (27.9%) in the 24th postaspiration month. Mean 3.1 ± 2.8 times of aspirations per patient were performed without any adverse effect. There was a linear regression relationship between the change of times of aspirations and the chance of recurrence of cysts. Overall pregnancy rate of 43.4% (56/129) was obtained.

CONCLUSION

The repetitive aspiration of endometriomas is an effective therapeutic option in patients with endometriosis.

Bowel resection for deep endometriosis: a systematic review

BACKGROUND

deep endometriosis involving the bowel often is treated by segmental bowel resection. In a recent review of over 10000 segmental bowel resections for indications other than endometriosis, low rectum resections, in particular, were associated with a high long-term complication rate for bladder, bowel and sexual function.

OBJECTIVES

to review systematically segmental bowel resections for endometriosis for indications, outcome and complications according to the level of resection and the volume of the nodule.

SEARCH STRATEGY

all published articles on segmental bowel resection for endometriosis identified through MEDLINE, EMBASE and ISI Web of Knowledge databases during 1997-2009.

SELECTION CRITERIA

the terms 'bowel', 'rectal', 'colorectal', 'rectovaginal', 'rectosigmoid', 'resection' and 'endometriosis' were used. Articles describing more than five bowel resections for endometriosis, and with details of at least three of the relevant endpoints.

DATA COLLECTION AND ANALYSIS

data did not permit a meaningful meta-analysis.

MAIN RESULTS

thirty-four articles were found describing 1889 bowel resections. The level of bowel resection and the size of the lesions were poorly reported. The indications to perform a bowel resection were variable and were rarely described accurately. The duration of surgery varied widely and endometriosis was not always confirmed by pathology. Although not recorded prospectively, pain relief was systematically reported as excellent for the first year after surgery. Recurrence of pain was reported in 45 of 189 women; recurrence requiring reintervention occurred in 61 of 314 women. Recurrence of endometriosis was reported in 37 of 267 women. The complication rate was comparable with that of bowel resection for indications other than endometriosis. Data on sexual function were not found.

CONCLUSIONS

after a systematic review, it was found that the indication to perform a segmental resection was poorly documented and the data did not permit an analysis of indication and outcome according to localisation or diameter of the endometriotic nodule. Segmental resections were rectum resections in over 90%, and the postoperative complication rate was comparable with that of resections for indications other than endometriosis. No data were found evaluating sexual dysfunction.

Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules

BACKGROUND

The debate continues between advocates of the shaving technique and supporters of bowel resection in case of deep endometriosis with rectal muscularis involvement, despite little evidence for better improvement with bowel resection.

METHODS

We analyzed complication, pregnancy and recurrence rates after deep endometriotic nodule excision by shaving surgery. This is a prospective analysis of 500 cases (<40 years old) of deep endometriotic nodules.

RESULTS

Laparoscopic nodule resection was performed successfully in all cases. Major complications included: (i) rectal perforation in seven cases (1.4%); (ii) ureteral injury in four cases (0.8%); (iii) blood loss >300 ml in one case (0.2%); and (iv) urinary retention in four cases (0.8%). The median follow-up duration was 3.1 years (range 2-6 years). In our prospective series of 500 women, 388 wished to conceive. Of this number, 221 (57%) became pregnant naturally and 107 by means of IVF. In total, 328 women (84%) conceived. The recurrence rate was 8% among these 500 women, and it was significantly lower (P < 0.05) in women who became pregnant (3.6%) than in those who did not (15%). In women who failed to conceive, or were not interested in conceiving, severe pelvic pain recurred in 16-20% of patients.

CONCLUSION

In young women, conservative surgery using the shaving technique preserves organs, nerves and the vascular blood supply, yielding a high pregnancy rate and low complication and recurrence rates. There is a need, however, for further strong and energetic debate to weigh up the benefits of shaving (debulking surgery) versus rectal resection (radical surgery).

94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis

BACKGROUND

Endometriosis with bowel involvement is the most invasive form and can cause infertility, chronic pelvic pain and bowel symptoms. Effective surgical treatment of endometriosis requires complete excision of endometriosis and in same case may require segmental rectosigmoid resection.

METHODS

Between December 1997 and October 2003, 55 patients with rectovaginal endometriosis underwent a combined laparoscopic vaginal technique. 30 patients were found at a follow-up and underwent a telephone interview. The questionnaire covered questions about symptoms related to recurrences of intestinal endometriosis, dyspareunia, dysmenorrhea and pregnancy.

RESULTS

Twenty-seven of 30 (90%) women have no clinical symptoms of reported recurrence of endometriosis. Two patients (6.6%) had evidence of recurrence of bowel endometriosis. Dysmenorrhoea disappeared in 28 (93.3%), dyspareunia in 26 (86.7%) and pelvic pain in 27 (90%) patients. 17 patients (31%) tried to become pregnant and 11 of these patients (65%) became pregnant: 9 patients delivered healthy newborns, 18 pregnancies occurred and 19 healthy children were born.

CONCLUSIONS

Despite the small number of follow-up patients, our 94-month follow-up data demonstrated that endometriosis with bowel involvement and radical resection was associated with significant reductions in painful and dysfunctional symptoms, a low recurrence rate (6.6%) and high pregnancy rate (36.6%).

The early outcome of laparoscopic sigmoid and rectal resection for endometriosis

AIM

Deeply infiltrating endometriosis (DIE) is the most severe form of endometriosis and may affect the rectum and sigmoid colon. The most effective treatment is segmental resection. We report our results of rectal and sigmoid resection for this.

METHOD

The study comprises all patients who have had laparoscopic bowel resection for rectal or sigmoid endometriosis in the Päijät-Häme Central Hospital between 1 January 2004 and 31 May 2007. Patient demographics, operative details, complications and early postoperative recovery were prospectively collected and analysed.

RESULTS

A total of 31 patients were treated using a multidisciplinary approach. The mean age was 33.6 years (range 21.7-48.6) and body mass index 24.2 (17-40). The mean operation time was 253.5 min (range 56-484). There were three sigmoid and 28 rectal resections and 80 concomitant gynaecological procedures. Conversion to open surgery was not required. A total of 23 (74.2%) patients recovered without complications. There were two major complications, anastomotic leakage and rectovaginal fistula. Minor complications included transient urinary retention (2), wound infection (1), pneumonia (1) and undefined fever (2). The mean time to full peroral diet was 3.8 days (range 3-7), to first flatus 2.6 days (1-4), to first bowel movement 3.5 days (2-6) and to discharge 5.7 days (4-13).

CONCLUSION

Laparoscopic rectal and sigmoid resection for deep intestinal endometriosis is safe with few severe complications and rapid recovery. The long-term outcome on symptoms requires further study.

Laparoscopically Assisted Low Anterior Resection for Lower Rectal Endometriosis: Usefulness of Laparoscopic Surgery

A 34-year-old woman presented with pain during menstruation and was diagnosed with endometriosis of the lower rectum. Despite treatment with an LH-RH agonist, she was unable to become pregnant and surgical removal of her endometriosis was recommended. Preoperative magnetic resonance imaging revealed endometriosis localized between the neck of the uterus and rectum with indentation and scuffing. Laparoscopically assisted low anterior resection was performed. Exfoliation was started from the right side of the rectum to the presacral and retrorectal space, and the rectococcygeus ligament was transected. Exfoliation of the retrorectal space was continued to the levator ani muscle and mobilization of the right side of the rectum was performed. In front of the rectum, exfoliation was started posterior to the wall of the vagina, but layers became unclear near the tumor as the tissue was solid in this region. The left hypogastric nerve close to the tumor was inflamed and it was cut. The layer of the exfoliation was connected to the right side of the rectum, the tumor was isolated from the vagina, and the lower rectum was transected at a point 1 cm distal to the tumor with a 60-mm linear stapler. Reconstruction with a 31-mm circular stapler was performed using the double stapling technique. Operative time was 520 min with a blood loss of 320 ml. On the 9th post operative day, a rectovaginal fistula occurred, and ileostomy was performed. The patient was discharged from the hospital on the 25th postoperative day, and 4 months later, stoma closure was performed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review

Intestinal involvement in endometriosis is thought to occur in up to 12% of all endometriosis cases. While colorectal resection is being increasingly advocated as a feasible management option in patients with severe disease, there still remains significant resistance towards this surgery. This article aims to review the current literature to determine the pain and fertility outcomes following segmental bowel resection for colorectal endometriosis.

Rectal obstruction due to endometriosis

Although endometriosis is a disorder commonly found in reproductive-age women, it does not involve the bowel very often. The circumferential involvement of the rectum is rare and the obstructive symptoms can be difficult to differentiate from those of inflammatory or malignant diseases. We report two patients with rectal endometriosis whose first prominent symptoms were those of intestinal obstruction. A 26-year-old woman was admitted with obstructive symptoms. In order to alleviate the obstruction and extend the preoperative evaluation, a decompressive colostomy was done. The diagnosis of endometriosis was made by laparoscopy and biopsies of the thickened cul-de-sac peritoneum. Another woman, 40 years of age, was referred to us with a colostomy. She had undergone a laparotomy due to an obstructive acute abdomen a year before, and a frozen pelvis was found. Biopsy specimens had been collected and the pathological report revealed endometrioma. A rectosigmoidectomy, encompassing the stenotic rectal segment, was done along with primary anastomosis. The pathological examination confirmed rectal endometriosis. The conclusion is that, although rare, rectal endometriosis can cause significant stenosis of the organ, leading to obstructive symptoms. Despite its low frequency, it should always be considered in the differential diagnosis of rectal stenosis involving women of childbearing age.