[Recurrence of pain after surgery for deeply infiltrating endometriosis: How does it happen? How to manage?]

Lesion distribution characteristics of deep infiltrating endometriosis with ovarian endometrioma: an observational clinical study

Background

To investigate the characteristics of deep infiltrating endometriosis (DIE) lesion distribution when associated with ovarian endometrioma (OEM).

Methods

The present study analyzed retrospective data obtained by the First Affiliated Hospital of Sun Yat-sen University, between June 2008 to June 2016. A total of 304 patients underwent laparoscopic surgery for complete removal of endometriosis by one experienced surgeon, and histological confirmation of OEM associated with DIE was conducted for each patient. Clinical data were recorded for each patient from medical, operative and pathological reports. Patients were then divided into two groups according to unilateral or bilateral OEM. Patients with unilateral OEM were subsequently divided into two subgroups according to OEM location (left- or right-hand side) and the diameter of the OEM (≤50 and > 50 mm). The distribution characteristics of DIE lesions were then compared between the groups.

Results

DIE lesions were widely distributed, 30 anatomical sites were involved. Patients with associated unilateral OEM (n = 184 patients) had a significantly increased number of DIE lesions when compared with patients with bilateral OEM (n = 120 patients; 2.76 ± 1.52 vs. 2.33 ± 1.34; P = 0.006). Compared with bilateral OEM with DIE, there was a higher rate of intestinal (39.1% vs. 18.3%; P < 0.01) and vaginal (17.4% vs. 6.7%; P < 0.01) infiltration by DIE lesions in unilateral OEM with DIE. The mean number of DIE lesions was not significantly correlated with the location or size of the OEM (2.83 ± 1.56 vs. 2.74 ± 1.53; P = 0.678; and 2.65 ± 1.42 vs. 2.80 ± 1.43; P = 0.518, respectively). There was no significant difference between the groups with OEM ≤50 mm and > 50 mm.

Conclusion

Lesion distribution characteristics in women diagnosed with histologically proven OEM associated with DIE were frequently multifocal and severe.

A Multicenter International Temporal and External Validation Study of the Ultrasound-based Endometriosis Staging System

STUDY OBJECTIVE

The aim of this study was to validate temporally and externally the ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis.

DESIGN

A multicenter, international, retrospective, diagnostic accuracy study was carried out between January 2016 and April 2018 on women with suspected pelvic endometriosis.

SETTING

Four different centers with advanced ultrasound and laparoscopic services were recruited (1 for temporal validation and 3 for external validation).

PATIENTS

Women with pelvic pain and suspected endometriosis.

INTERVENTIONS

All women underwent a systematic transvaginal ultrasound and were staged according to the UBESS system, followed by classification of laparoscopic level of complexity according to the Royal College of Obstetricians and Gynaecologists (RCOG) levels 1 to 3.

MEASUREMENTS AND MAIN RESULTS

UBESS I, II, and III were then correlated with RCOG levels 1, 2, and 3, respectively. A comparison between temporal and external sites (skipping "A") and between each site was performed in terms of the diagnostic accuracy of UBESS to predict RCOG laparoscopic skill level. A total of 317 consecutive women who underwent laparoscopy with suspected endometriosis were included. Complete transvaginal ultrasound and laparoscopic surgical outcomes were available for 293/317 (92.4%). At the temporal site, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of UBESS I to predict RCOG level 1 were 80.0%,73.8%, 94.9%, 97.2%, 60.2%, 14.5%, and 0.3%, respectively; of UBESS II to predict RCOG level 2 were 81.0%, 70.6%, 82.0%, 26.7%, 96.8%, 3.9%, and 0.3%, respectively; of UBESS III to predict RCOG level 3 were 91.0%, 85.7%, 92.4%, 75.0%, 96.1%, 11.3%, and 0.2%, respectively. At the external sites, the results of UBESS I to predict RCOG level 1 were 90.3%, 92.0%, 88.4%, 90.2%, 90.5%, 7.9%, and 0.1% respectively; UBESS II to predict RCOG level 2 were 89.2%, 100.0%, 88.5%, 37.5%, 100.0%, 8.7%, and 0.0%, respectively; and UBESS III to predict RCOG level 3 were 86.0%, 67.6%, 98.2%, 96.2%, 82.1%, 37.8%, and 0.3%, respectively. When patients requiring ureterolysis (i.e., RCOG level 3) in the absence of bowel endometriosis were excluded (n = 54), the sensitivity of UBESS III to correctly classify RCOG level 3 increased from 85.7% to 96.7% at the temporal site (n = 42) and from 67.6% to 96.0% at the external sites (n = 12) (p <.005).

CONCLUSION

The results from this external validation study suggest that UBESS in its current form is not generalizable unless there is either or both bowel deep endometriosis and cul-de-sac obliteration present. The major limitation appears to be the misclassification of women who require surgical ureterolysis in the absence of bowel endometriosis.

Pelvic endometriosis: Refer to the surgeon at the right moment: Pelvic endometriosis: When refer to the surgeon?

BACKGROUND

As endometriosis is not a single condition but different morphological types, it is easy to conceive that its management allow for a diversity of approaches. The objective of this literature review is about a simplified pathway through care for patients with endometriosis, and to target the right time for surgical treatment.

METHODS

Through a literature and references review, the different surgical care arrangements according to attainment, to symptoms and to the patients demands and expectations are reviewed.

RESULTS

An existing literature and recommendations synthesis has been done, and it was found that an optimum medical or surgical care rely on a multidisciplinary approach. Asymptomatic patients should not have surgery, and the medical treatment precede surgical treatment in numerous indications. In case of a surgical need, the right moment is determined by the recommendations, as noted in this article. Different aspects are necessary, the symptomatology, the intend to be pregnant and the recurrence of lesions in particular, but also the use of medically assisted reproduction or not.

CONCLUSION

In order to optimize the surgical treatment of patients with endometriosis, it is advisable to not refer these patients to the surgeon not too soon and not too late, furthermore if he's an expert. In all cases the treatment is multidisciplinary, and the most difficult cases are referred to multidisciplinary consultative reunion. The surgical treatment relies on "centre of expertise's" existence for some specific forms of deep endometriosis. The surgical treatment is a question of both pathology and timing.

BRIEF SUMMARY

In order to optimize the surgical treatment of endometriosis, it is advisable to refer patients to the surgeon at the right moment.

[Interest of hysterectomy with or without bilateral oophorectomy in the surgical treatment of endometriosis: CNGOF-HAS Endometriosis Guidelines]

OBJECTIVE

In women with symptomatic endometriosis and no desire for pregnancy, hysterectomy with or without bilateral oophorectomy is often presented as a definitive solution to their symptoms. Despite this radical treatment, it should be known that nearly 15% of these patients will have persistent pain. Thus the objective of this review was to determine the interest of total hysterectomy with or without bilateral oophorectomy for the treatment of deep endometriosis.

METHOD

The research was conducted from the US National Library of Medicine's National Institutes of Health from the following keywords: endometriosis, hysterectomy, oophorectomy, ovariectomy, radical treatment. Only articles written in English have been selected.

RESULTS AND RECOMMENDATIONS

Hysterectomy with or without bilateral oophorectomy, associated with endometriotic lesions exeresis could decrease the rate of recurrence and surgical reoperations compared to resection alone endometriosis lesions (NP4). In women with no desire for pregnancy, the benefit-risk balance of a hysterectomy, with or without bilateral oophorectomy, may be discussed in order to reduce the risk of recurrence of endometriotic disease (Expert Agreement). Taking into account the multiple adverse effects of early menopause on expectancy and quality of life (NP2), ovarian preservation should be discussed with the patient in case of hysterectomy for deep endometriosis (Expert Agreement). The use of menopausal hormone therapy (THM) does not appear to increase the symptoms of endometriosis after surgical castration (NP3). THM is not contraindicated in postmenopausal women with endometriosis (grade C).

Long-Term Vaginal Danazol Treatment in Fertile Age Women with Adenomyosis

Background

The aim of the study was to evaluate the clinical efficacy of long-term vaginal danazol treatment in fertile age women with adenomyosis on pain symptoms and abnormal uterine bleeding (AUB).

Methods

A retrospective study on 66 young women with dysmenorrhea and/or dyspareunia, AUB and 2D-ultrasound diagnosis of adenomyosis was conducted at University Hospital of Siena (Italy). Women included were treated with a daily low-dose vaginal danazol (200 mg) for 6 months, followed by 2 different schedules: group A) continuous treatment for further 18 months (n = 30); group B) cyclic intermittent treatment with 3 months’ therapy followed by 3 months’ interval for further 18 months (n = 36). A visual analog scale (VAS) for pain symptoms, a pictorial blood-loss assessment chart (PBAC) for uterine bleeding, 2D-ultrasound signs of adenomyosis and quality-of-life measures were assessed at baseline and after both vaginal progestin regimens.

Results

The pain symptoms, PBAC score and uterine volume were significantly reduced (p<0.0001) after 6 months, and the reduction persisted in both group of patients until the end. Mental and physical index score values increased (p<0.0001) in both groups at the end of treatment, with significantly higher mental index scores in intermittent than in continuous treatment (p<0.0001), associated with some drop-out (10%).

Conclusions

A long-term treatment with vaginal danazol is effective to control pain and AUB in women with adenomyosis. The 6 months’ treatment followed by a cyclic 3 months’ treatment for further 18 months has the best compliance in symptomatic patients with adenomyosis.

Performance of ultrasound-based endometriosis staging system (UBESS) for predicting level of complexity of laparoscopic surgery for endometriosis

OBJECTIVE

To develop and assess the performance of a preoperative ultrasound-based endometriosis staging system (UBESS) to predict the level of complexity of laparoscopic surgery for endometriosis.

METHODS

This was a multicenter prospective and retrospective cohort study on consecutive women with suspected endometriosis who underwent laparoscopy between June 2009 and July 2013. Each woman underwent a systematic transvaginal ultrasound evaluation to assess the pelvis for different phenotypes of endometriosis, and the diagnostic performance of ultrasound for these different phenotypes was evaluated relative to the gold standard, laparoscopy. A three-stage preoperative UBESS was developed to assess the severity of pelvic endometriosis, based on the histological phenotypes of endometriosis, the anatomical locations of deep infiltrating endometriosis and their sonographic markers of local invasiveness. The three stages of UBESS (I-III) were then correlated with the three levels of complexity of laparoscopic surgery for endometriosis described by the Royal College of Obstetricians and Gynaecologists (Levels 1-3). The end-points were the diagnostic performance of UBESS to predict the level of complexity of laparoscopic surgery for endometriosis, i.e. UBESS stage I to predict Level-1 laparoscopic surgery, UBESS stage II to predict Level-2 laparoscopic surgery and UBESS stage III to predict Level-3 laparoscopic surgery.

RESULTS

The analysis included 192 women, with a mean ± SD age at diagnosis of endometriosis of 23.7 ± 9.3 years and a mean duration of symptoms prior to presentation of 42 months. Predominant reported locations of pelvic pain were left iliac fossa (32%), right iliac fossa (29.5%) and lower abdomen (61%) and predominant symptoms included dyspareunia (57.5%), dysmenorrhea (58.5%) and dyschezia (41.5%). The accuracy, sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios of UBESS I for predicting a requirement for Level-1 laparoscopic surgery were: 87.5%, 83.3%, 91.7%, 90.9%, 84.6%, 10 and 0.182; those of UBESS II for predicting Level-2 surgery were: 87.0%, 73.7%, 90.3%, 65.1%, 93.3%, 7.6 and 0.292; and those of UBESS III for predicting Level-3 surgery were: 95.3%, 94.8%, 95.5%, 90.2%, 97.7%, 21.2 and 0.054, respectively.

CONCLUSION

UBESS could be utilized to predict the level of complexity of laparoscopic surgery for endometriosis. It has the potential to facilitate the triage of women with suspected endometriosis to the most appropriate surgical expertise required for laparoscopic endometriosis surgery. UBESS needs to be validated externally in multiple centers to assess its general applicability. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Diagnosis, management, and long-term outcomes of rectovaginal endometriosis

Rectovaginal endometriosis is the most severe form of endometriosis. Clinically, it presents with a number of symptoms including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and rectal bleeding. The gold standard for diagnosis is laparoscopy with histological confirmation; however, there are a number of options for presurgical diagnosis, including clinical examination, transvaginal/transrectal ultrasound, magnetic resonance imagining, colonoscopy, and computed tomography colonography. Treatment can be medical or surgical. Medical therapies include birth control pills, oral progestins, gonadotropin-releasing hormone agonists, danazol, and injectable progestins. Analgesics are often used as well. Surgery improves up to 70% of symptoms. Surgery is either ablative or excisional, and is conducted via transvaginal, laparoscopic, laparotomy, or combined approaches. Common surgical techniques involve shaving of the superficial rectal lesion, laparoscopic anterior discoid resection, and low anterior bowel resection and reanastomosis. Outcomes are generally favorable, but postoperative complications may include intra-abdominal bleeding, anastomotic leaks, rectovaginal fistulas, strictures, chronic constipation, and the need for reoperation. Recurrence of rectal endometriosis is a possibility as well. Other outcomes are improved pain-related symptoms and fertility. Long-term outcomes vary according to the management strategy used. This review will provide the most recent approaches and techniques for the diagnosis and treatment of rectovaginal endometriosis.

Surgical Therapy of Endometriosis: Challenges and Controversies

Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.