High postoperative fertility rate following surgical management of colorectal endometriosis

Outcomes Following Surgery As the Main Intervention for Endometriosis in a Low Socioeconomic Setting

Background and Objective

To evaluate the perioperative and long-term outcomes of surgical management of patients with endometriosis at a community hospital in a low socioeconomic district.

Methods

A total of 39 patients underwent surgical management for endometriosis between October 2022 and November 2024. Thirty-six patients were followed up for 1-24 months.

Results

Among the 39 cases, 18 (42.6%) were identified incidentally in operations for other indications, while 21 (53.8%) were clinically diagnosed or confirmed with previous laparoscopy. Twelve (30.8%) cases were classified as stage I-II and 27 (69.2%) as stage III-IV. Surgical approaches included laparoscopy in 23 (59.0%) cases, robotic assistance in 13 (33.3%), and 2 cases were converted from laparoscopy to laparotomy. Advanced techniques utilized included ureterolysis, enterolysis, diaphragm resection, bowel shaving, bowel disc resection, segmental bowel resection, appendectomy, partial bladder cystectomy, and hypogastric nerve sparing. Intraoperative complications included 1 ureteral thermal injury and 1 bladder laceration. Postoperative complications consisted of 1 pyelonephritis and 1 incisional cellulitis. No complications related to urinary or bowel functional disorders occurred postoperatively. Among the 19 patients who regularly used pain medication before surgery, 16 patients discontinued pain medications, while 3 patients reduced their usage after surgery. Eight patients are actively trying to conceive, and 1 patient conceived spontaneously. Sixteen patients are receiving various forms of hormonal suppression.

Conclusion

With excellent skills and collaboration, the surgical management of endometriosis resulted in minimal complications and optimal postoperative outcomes, significantly benefiting patients in low socioeconomic areas.

Postoperative Reproductive Outcomes in Patients with Endometriosis-Associated Infertility: A Single-Center Retrospective Study

OBJECTIVES

Endometriosis is a chronic inflammatory disease known to contribute to infertility. Laparoscopic excision of endometriotic lesions represents a standard treatment modality for symptomatic women. Our study aims to assess the potential benefits of laparoscopic excision of endometriosis in patients experiencing infertility associated with the condition, as well as to define the clinical factors that may impact the cumulative pregnancy rate.

DESIGN

In this retrospective analysis, a total of 102 patients with endometriosis-related infertility were enrolled.

MATERIALS, SETTING, METHODS

All participants underwent reproductive surgery and were then categorized into two groups: those who conceived were assigned to group A, while those who did not were assigned to group B. The correlation between clinical factors and pregnancy rate was assessed using the log-rank test, and both univariate and multivariate analyses were conducted utilizing the Cox regression model.

RESULTS

The median age of the patients was 33.5 years, with a median follow-up duration of 70 months. Throughout the study period, 71 patients (69.6%) conceived (group A), while the remaining 31 patients (30.4%) did not conceive (group B), irrespective of the use of Assisted-Reproduction Technologies. The Cox regression model revealed that factors such as the duration of infertility, presence of deep infiltrating endometriosis, bowel endometriosis, rASRM stages, pelvic adhesions, and recurrent disease negatively impacted postoperative conception rates. Conversely, complete excision and coagulation of endometriotic lesions, as well as ablation of ovarian endometriomas, emerged as independent positive predictive factors for postoperative clinical pregnancy.

LIMITATIONS

Limitations of this study is retrospective design of the study, as well as a small number of patients.

CONCLUSIONS

Complete excision of endometriosis during reproductive surgery may yield a positive effect and optimize the likelihood of pregnancy in patients with endometriosis-related infertility.

Postoperative Pregnancy Outcomes Following Laparoscopic Surgical Management in Women with Stage III/IV Endometriosis: A Single-Center Follow-Up Study

Objectives

The effects of laparoscopic surgical management in women with stage III/IV endometriosis remain controversial. The standard extent of resection for stage III/IV endometriosis with deep endometriosis to treat endometriosis-associated infertility is debatable. This study aimed to assess the postoperative pregnancy outcomes following a routine surgical intervention for stage III/IV endometriosis patients.

Materials and Methods

Patients with stage III/IV endometriosis who underwent conservative laparoscopic surgery at our hospital between January 2010 and December 2018 were retrospectively analyzed. Statistical analyses were performed to determine the correlations between endometriosis features and postoperative pregnancy outcomes.

Results

Of 256 patients enrolled, 94 wished to conceive. Exclusion criteria: ≥40 years, adenomyosis, partners with infertility issues. Finally, 71 women were included. The overall postoperative pregnancy rate was 76.1% (n = 54): 49 and five from non-assisted reproductive technology (ART) and ART, respectively. The postoperative pregnancy rate in patients diagnosed with infertility presurgery (40/71) was 70.0% (n = 28): 24 (non-ART) and four (ART). The endometriosis fertility index (EFI) score was higher in the pregnant than in the nonpregnant group (P = 0.03). The EFI score and surgical score of EFI were higher in the non-ART than in the ART group (P = 0.04; P = 0.02); in the infertile group, they were higher in the pregnant than in the nonpregnant group (P = 0.018; P = 0.027).

Conclusion

Our postoperative pregnancy rate after conservative laparoscopic surgery for patients with stage III/IV endometriosis compared favorably with previous reports. EFI was a significant predictor of postoperative pregnancy. Our surgical approach to maintain a high surgical score of EFI might help treat endometriosis-associated infertility.

Deep Endometriosis and Infertility: What Is the Impact of Surgery?

In women with deep endometriosis, the spontaneous fertility rate might range from 2 to 10%. The optimal management of these women is still an area of debate. Therefore, this review aims to explore the literature on the impact of deep endometriosis surgery on reproductive outcomes and pregnancy rates in women with and without prior infertility. A total of 392 articles were identified through database searching. Twenty-three studies were eligible to be included in the review. A total of 1548 women were identified, 814 of whom became pregnant, with a mean pregnancy rate of 52.6% (95% CI 49.7-63%). Our review suggests that surgery may improve fertility outcomes. Due to the variability in the studies, it is impossible to stratify fertility outcomes of surgery by the localization of deep endometriosis. More investigations are needed to determine whether surgical management should be first-intention or limited to the failure of medically assisted reproduction treatment.

Reproductive and postsurgical outcomes of infertile women with deep infiltrating endometriosis

Background

This study aimed to summarize and analyze clinical characteristics and reproductive outcomes in postoperative deep infiltrating endometriosis (DIE).

Methods

This retrospective cohort study included 55 reproductive-aged patients who were diagnosed with DIE, wished to conceive and underwent resection surgery at the Obstetrics and Gynecology Hospital, Fudan University, from January 2009–June 2017. Those with any plausible infertility factor or abnormalities in the partner’s semen analysis were excluded. Patient characteristics, preoperative symptoms, infertility history, intraoperative findings and reproductive outcomes were followed up and recorded. Risk factors for reproductive outcomes were identified for women who became pregnant versus those who did not by univariate logistic regression. Additionally, pre- and postoperative endometriosis health profile questionnaire-30 (EHP-30), Knowles–Eccersley–Scott Symptom questionnaire (KESS), Cox Menstrual Symptom Scale (CMSS) and Female Sexual Function Index (FSFI) scores were used to evaluate the effect of DIE surgery on quality of life.

Results

The average age was 30.22 ± 3.62 years, with no difference between the pregnancy and nonpregnancy groups. The average follow-up time was 26.57 ± 14.51 months. There were 34 pregnancies (61.82%): 24 (70.59%) conceived spontaneously and 10 (29.41%) by in vitro fertilization (IVF). Twenty-eight patients (82.35%) had term deliveries. The interval between operation and pregnancy was 10.33 ± 5.6 (1–26) months. Univariate analysis showed that a lower endometriosis fertility index (EFI) score (EFI < 8) was a risk factor for infertility (OR: 3.17 (1.15–10.14), p = .044). For patients with incomplete surgery, postoperative gonadotropin-releasing hormone agonist (GnRHa) administration improved the pregnancy rate (p < 0.05). Regarding quality of life, there was significant improvement (p < 0.05) in the postoperative EHP-30, KESS and CMSS scores compared with preoperative scores in both groups. Although there was no obvious difference in FSFI scores, significant improvement in dyspareunia was observed (p < 0.05).

Conclusions

Overall, the postoperative pregnancy rate of DIE patients was 61.82%. Surgical management of DIE for patients with complaints of pain and with pregnancy intentions was feasible and effective. Long-term expectant treatment should not be advised for patients with lower EFI scores (EFI < 8), and postoperative IVF–ET may be a good choice. More cases should be enrolled for further study, and randomized studies are required.

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.

"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients

BACKGROUND

Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications.

METHODS

Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE.

RESULTS

Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated.

CONCLUSIONS

Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.

Laparoscopic surgery for endometriosis

BACKGROUND

Endometriosis is associated with pain and infertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy.

OBJECTIVES

To assess the effectiveness and safety of laparoscopic surgery in the treatment of pain and infertility associated with endometriosis.

SEARCH METHODS

This review has drawn on the search strategy developed by the Cochrane Gynaecology and Fertility Group including searching the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, reference lists for relevant trials, and trial registries from inception to April 2020.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) that compared the effectiveness and safety of laparoscopic surgery with any other laparoscopic or robotic intervention, holistic or medical treatment, or diagnostic laparoscopy only.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed selection of studies, assessment of trial quality and extraction of relevant data with disagreements resolved by a third review author. We collected data for the core outcome set for endometriosis. Primary outcomes included overall pain and live birth. We evaluated the quality of evidence using GRADE methods.

MAIN RESULTS

We included 14 RCTs. The studies randomised 1563 women with endometriosis. Four RCTs compared laparoscopic ablation or excision with diagnostic laparoscopy only. Two RCTs compared laparoscopic excision with diagnostic laparoscopy only. One RCT compared laparoscopic ablation or excision with laparoscopic ablation or excision and uterine suspension. Two RCTs compared laparoscopic ablation and uterine nerve transection with diagnostic laparoscopy only. One RCT compared laparoscopic ablation with diagnostic laparoscopy and gonadotropin-releasing hormone (GnRH) analogues. Two RCTs compared laparoscopic ablation with laparoscopic excision. One RCT compared laparoscopic ablation or excision with helium thermal coagulator with laparoscopic ablation or excision with electrodiathermy. One RCT compared conservative laparoscopic surgery with laparoscopic colorectal resection of deep endometriosis infiltrating the rectum. Common limitations in the primary studies included lack of clearly described blinding, failure to fully describe methods of randomisation and allocation concealment, and poor reporting of outcome data. Laparoscopic treatment versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic treatment on overall pain scores compared to diagnostic laparoscopy only at six months (mean difference (MD) 0.90, 95% confidence interval (CI) 0.31 to 1.49; 1 RCT, 16 participants; very low quality evidence) and at 12 months (MD 1.65, 95% CI 1.11 to 2.19; 1 RCT, 16 participants; very low quality evidence), where a positive value means pain relief (the higher the score, the more pain relief) and a negative value reflects pain increase (the lower the score, the worse the increase in pain). No studies looked at live birth. We are uncertain of the effect of laparoscopic treatment on quality of life compared to diagnostic laparoscopy only: EuroQol-5D index summary at six months (MD 0.03, 95% CI -0.12 to 0.18; 1 RCT, 39 participants; low quality evidence), 12-item Short Form (SF-12) mental health component (MD 2.30, 95% CI -4.50 to 9.10; 1 RCT, 39 participants; low quality evidence) and SF-12 physical health component (MD 2.70, 95% CI -2.90 to 8.30; 1 RCT, 39 participants; low quality evidence). Laparoscopic treatment probably improves viable intrauterine pregnancy rate compared to diagnostic laparoscopy only (odds ratio (OR) 1.89, 95% CI 1.25 to 2.86; 3 RCTs, 528 participants; I2 = 0%; moderate quality evidence). We are uncertain of the effect of laparoscopic treatment compared to diagnostic laparoscopy only on ectopic pregnancy (MD 1.18, 95% CI 0.10 to 13.48; 1 RCT, 100 participants; low quality evidence) and miscarriage (MD 0.94, 95% CI 0.35 to 2.54; 2 RCTs, 112 participants; low quality evidence). There was limited reporting of adverse events. No conversions to laparotomy were reported in both groups (1 RCT, 341 participants). Laparoscopic ablation and uterine nerve transection versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic ablation and uterine nerve transection on adverse events (more specifically vascular injury) compared to diagnostic laparoscopy only (OR 0.33, 95% CI 0.01 to 8.32; 1 RCT, 141 participants; low quality evidence). No studies looked at overall pain scores (at six and 12 months), live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. Laparoscopic ablation versus laparoscopic excision There was insufficient evidence to determine whether there was a difference in overall pain, measured at 12 months, for laparoscopic ablation compared with laparoscopic excision (MD 0.00, 95% CI -1.22 to 1.22; 1 RCT, 103 participants; very low quality evidence). No studies looked at overall pain scores at six months, live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy, miscarriage and adverse events. Helium thermal coagulator versus electrodiathermy We are uncertain whether helium thermal coagulator compared to electrodiathermy improves quality of life using the 30-item Endometriosis Health Profile (EHP-30) at nine months, when considering the components: pain (MD 6.68, 95% CI -3.07 to 16.43; 1 RCT, 119 participants; very low quality evidence), control and powerlessness (MD 4.79, 95% CI -6.92 to 16.50; 1 RCT, 119 participants; very low quality evidence), emotional well-being (MD 6.17, 95% CI -3.95 to 16.29; 1 RCT, 119 participants; very low quality evidence) and social support (MD 5.62, 95% CI -6.21 to 17.45; 1 RCT, 119 participants; very low quality evidence). Adverse events were not estimable. No studies looked at overall pain scores (at six and 12 months), live birth, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage.

AUTHORS' CONCLUSIONS

Compared to diagnostic laparoscopy only, it is uncertain whether laparoscopic surgery reduces overall pain associated with minimal to severe endometriosis. No data were reported on live birth. There is moderate quality evidence that laparoscopic surgery increases viable intrauterine pregnancy rates confirmed by ultrasound compared to diagnostic laparoscopy only. No studies were found that looked at live birth for any of the comparisons. Further research is needed considering the management of different subtypes of endometriosis and comparing laparoscopic interventions with lifestyle and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.

Excision versus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial

STUDY QUESTION

Is there a difference in functional outcomes and recurrence rate between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 5 years postoperatively?

SUMMARY ANSWER

No evidence was found that long-term outcomes differed when nodule excision was compared to rectal resection for deeply invasive endometriosis involving the bowel.

WHAT IS KNOWN ALREADY

Functional outcomes of nodule excision and rectal resection for deeply invasive endometriosis involving the bowel are comparable 2 years after surgery. Despite numerous previously reported case series enrolling patients managed for colorectal endometriosis, long-term data remain scarce in the literature.

STUDY DESIGN, SIZE, DURATION

From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Among them, 55 women were enrolled at one tertial referral centre in endometriosis, using a randomization list drawn up separately for this centre. Institute review board approval was obtained to continue follow-up to 10 years postoperatively. One patient requested to stop the follow-up 2 years after surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients underwent either nodule excision by shaving or disc excision, or segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of randomization results. 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), anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were values taken from the 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

Fifty-five patients were enrolled. Among the 27 patients in the excision arm, two were converted to segmental resection (7.4%). One patient managed by segmental resection withdrew from the study 2 years postoperatively, presuming that associated pain of other aetiologies may have jeopardized the outcomes. The 5 year-recurrence rate for excision and resection was 3.7% versus 0% (P = 1), respectively. For excision and resection, the primary endpoint was present in 44.4% versus 60.7% of patients (P = 0.29), respectively, while 55.6% versus 53.6% of patients subjectively reported normal bowel movements (P = 1). An intention-to-treat comparison of overall KESS, GIQLI, Wexner, USP and SF36 scores did not reveal significant differences between the two arms 5 years postoperatively. Statistically significant improvement was observed shortly after surgery with no further improvement or impairment recorded 1–5 years postoperatively. During the 5-year follow-up, additional surgical procedures were performed in 25.9% versus 28.6% of patients who had undergone excision or resection (P = 0.80), respectively.

LIMITATIONS, REASONS FOR CAUTION

The presumption of a 40% difference concerning postoperative functional outcomes in favour of nodule excision resulted in a lack of power for demonstration of the primary endpoint difference.

WIDER IMPLICATIONS OF THE FINDINGS

Five-year follow-up data do not show statistically significant differences between conservative and radical rectal surgery for long-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was received. Patient enrolment and follow-up until 2 years postoperatively was supported by a grant from the clinical research programme for hospitals in France. The authors declare no competing interests related to this study.

TRIAL REGISTRATION NUMBER

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

TRIAL REGISTRATION DATE

31 January 2011.

DATE OF FIRST PATIENT’S ENROLMENT

7 March 2011.

Fusion of Magnetic Resonance and Ultrasound Images for Endometriosis Detection

This paper introduces a new fusion method for magnetic resonance (MR) and ultrasound (US) images, which aims at combining the advantages of each modality, i.e., good contrast and signal to noise ratio for the MR image and good spatial resolution for the US image. The proposed algorithm is based on two inverse problems, performing a super-resolution of the MR image and a denoising of the US image. A polynomial function is introduced to model the relationships between the gray levels of the two modalities. The resulting inverse problem is solved using a proximal alternating linearized minimization framework. The accuracy and the interest of the fusion algorithm are shown quantitatively and qualitatively via evaluations on synthetic and experimental phantom data.

Endometriosis and Pregnancy: A Single Institution Experience

Endometriosis may compromise the physiological course of pregnancy. The aim of this prospective observational study was to evaluate whether endometriosis causes a higher prevalence of obstetric and neonatal complications as well as a higher risk of caesarean section and to detect a possible correlation between the presence, type, and location of endometriosis and obstetric complications, previous surgery, and pregnancy outcome, as well as the influence of pregnancy on the course of the disease. We compared two cohorts of women with spontaneous pregnancy, with and without endometriosis. Obstetric and neonatal outcomes, mode of delivery, presence, type, and location of endometriotic lesions and the effect of pregnancy on the disease were analyzed. A total of 425 pregnancies were evaluated: 145 cases and 280 controls. Patients with endometriosis showed a higher incidence of miscarriage, threatened miscarriage, threatened preterm labor, preterm delivery, placental abruption, and a higher incidence of caesarean section. A significant correlation with pregnancy-induced hypertension and preeclampsia was found in the presence of adenomyosis. No difference in fetal outcome was found. One case of hemoperitoneum during pregnancy was observed. Pregnancy in women with endometriosis carries a higher risk of obstetric complications, such as miscarriage, threatened miscarriage, preterm labor, preterm birth, and a higher caesarean section rate. Endometriosis does not seem to influence fetal well-being.