Double Disk Excision of Large Deep Endometriosis Nodules Infiltrating the Low and Mid Rectum: A Pilot Study of 20 Cases

STUDY OBJECTIVE

To report the technique of double disk excision of deep endometriosis nodules infiltrating the mid or low rectum and surgical outcomes.

DESIGN

A retrospective case series using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database.

SETTING

University tertiary referral center.

PATIENTS

Twenty women managed for large deep endometriosis nodules infiltrating the mid or low rectum.

INTERVENTIONS

Double disk excision using transanal end-to-end anastomosis circular stapler.

MEASUREMENTS AND MAIN RESULTS

Twenty women managed by double disk excision from May 2016 to September 2019 were included in the study. The mean time of intervention was 149 ± 74 minutes. The cumulated mean diameter of the excised rectal disks was 53.4 ± 19.1 mm, whereas in 85% of the women, it was ≥50 mm. The mean distance between the lowest margin of the disk and the anal verge was 66 mm. Vaginal infiltration was removed in 15 patients (75%), and in 6 patients (30%) it exceeded 30 mm in diameter. Owing to the presence of sigmoid colon nodules, 2 patients (10%) underwent concomitant segmental sigmoid resection of 4 cm and 6 cm in length, respectively. Transitory stoma was performed in 8 patients (40%) owing to concomitant vaginal excision >3 cm in size. After a follow-up varying from 3 months to 42 months, no digestive fistula was recorded. The rate of Clavien-Dindo 3 complications was 15%.

CONCLUSION

Double disk excision is suitable for excising large deep endometriosis nodules infiltrating the mid or low rectum and is associated with a low severe complication rate with good functional outcomes in women. Further studies are required to assess the improvement of functional outcomes in deep endometriosis nodules infiltrating the mid or low rectum in comparison with colorectal resection.

Risk of Postoperative Stenosis after Segmental Resection versus Disk Excision for Deep Endometriosis Infiltrating the Rectosigmoid: A Retrospective Study

STUDY OBJECTIVE

To assess the prevalence, risk factors, and management of bowel stenosis after surgery for deep infiltrating endometriosis of the rectosigmoid using either disk excision (DE) or segmental resection (SR).

DESIGN

Retrospective study using data from consecutive cases recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis database.

SETTING

University tertiary referral center.

PATIENTS

Four hundred thirty-one consecutive patients managed for rectosigmoid endometriosis were enrolled in our study.

INTERVENTIONS

Laparoscopic SR or DE.

MEASUREMENTS AND MAIN RESULTS

One hundred sixty-five patients underwent DE, and 266 patients underwent SR. Large nodules ≥3 cm in diameter were more frequent in the SR group (73.3% vs 66.1%), whereas nodules infiltrating the low rectum were 3 times more frequent in the DE group (35.9% vs 11.3%). The frequency of vaginal excision (67.9% vs 62%) and stoma (46.7% vs 44.4%) were comparable between the DE and SR groups. Twenty-three patients presented with postoperative colorectal stenosis after SR (8.6%) versus none after DE (p <.001). Treatment of colorectal stenosis involved dilatation in 20 (87%) cases and SR in 4 (17.4%) cases. For 1 patient, dilatation resulted in rectosigmoid injury requiring SR, followed by rectovaginal fistula. The logistic regression model identified a diverting stoma as the sole risk factor independently related to the risk of postoperative stenosis after SR.

CONCLUSION

Bowel stenosis after surgery for deep infiltrating endometriosis occurred in patients who underwent SR, most of them with a diverting stoma, whereas no cases of stenosis were reported in patients who underwent DE, with or without stoma.

Diagnosing Deep Endometriosis Using Transvaginal Elastosonography

Transvaginal ultrasound (TVUS) and MRI are currently two mainstream imaging techniques used to diagnose deep endometriosis (DE) with comparable accuracy, but there is still ample room for improvement. As endometriotic lesions progress to fibrosis concomitant with the increase in tissue stiffness, transvaginal elastosonography (TVESG) is well-suited for diagnosing DE. To test the hypothesis that lesional stiffness as measured by TVESG correlates with the extent of lesional fibrosis, the markers of progression, hormonal receptor expression, and vascularity, we recruited 30 patients suspected to have DE who went through pelvic examination, TVUS and/or MRI, and TVESG and were ultimately diagnosed by histology. Their lesional tissue samples were subjected to immunohistochemistry analysis of markers for epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), estrogen and progesterone receptors (ERβ and PR), microvessel density (MVD), and vascularity, as well as quantification of lesional fibrosis. We found that pelvic examination, TVUS, and MRI detected 83.3%, 66.7%, and 83.3% of all DE cases, respectively, while TVESG detected them all. The lesions missed by pelvic exam, TVUS and MRI were significantly smaller than those detected but nonetheless had higher lesional stiffness. Lesional stiffness correlated closely and positively with the extent of lesional fibrosis, negatively with the markers of EMT, MVD, vascularity, and PR expression, but positively with the marker for FMT and ERβ. Thus, through the additional use of information on differential stiffness between DE lesions and their surrounding tissues, TVESG improves diagnostic accuracy, provides a ballpark estimate on the developmental stage of the lesions, and may help clinicians choose the best treatment modality.

[Early postoperative complications in a multidisciplinary surgical center exclusively dedicated to endometriosis: A 491-patients series]

OBJECTIVE

The objective of our study is to present the activity volume and postoperative complications in a center exclusively destined to endometriosis surgery.

METHODS

Retrospective mono-centric study analyzing data collected prospectively in patients surgically managed for endometriosis from September 2018 to August 2019.

RESULTS

Four hundred and ninety-one patients underwent surgery for endometriosis during 12 consecutive months: 268 for colorectal localizations (54.6%), 51 for endometriosis of the urinary tract (10.4%), 17 for nodules of ileum and right colon (3.5%), 43 for nodules of parametriums (8.8%), 12 for nodules of sacral roots and sciatic nerves (2.4%), 7 for diaphragmatic localizations (1.4%). Among 268 patients with colorectal endometrioses, of which 48.1% concerned the low and mid rectum, shaving was performed in 102 cases, disc excision in 96 cases and colorectal resection in 100 cases. Stoma was performed in 13.1% of the cases. Patients could have 2 different procedures for multiple colorectal nodules. One hundred and ninety-nine ovarian endometriomas were managed by plasma energy ablation in 64.8%, sclerotherapy in 11.1%, cystectomy in 13.1%, oophorectomy in 11.1%. Major postoperative complications included 12 rectovaginal fistulas, while 18 other surgical procedures were carried out for various complications. In all, 38.1% of procedures involved a general surgeon and 5.3% an urologist.

CONCLUSION

The creation of centers exclusively destined to endometriosis surgery allows the multidisciplinary management of a high number of patients, with an over-representation of severe forms and rare locations of the disease, followed by satisfactory complication rates.

Frozen Pelvis Surgical Strategy in 10 Steps

STUDY OBJECTIVE

To describe a 10-step strategy to treat severe endometriosis with a frozen pelvis by laparoscopy.

DESIGN

Educational video.

SETTING

University Hospital of Strasbourg, France.

INTERVENTIONS

The patient was a 33-year-old nulliparous woman suffering from endometriosis. Because of pain and a desire for pregnancy, she was scheduled for surgery. After setting the patient in gynecologic position, we used a uterine manipulator to facilitate exposure. We assessed the global situation and discovered a frozen pelvis. To treat the myoma, the surgeon should use traction and countertraction as much as possible. We started with the caecum and sigmoid detachment. Then we performed a bilateral ureterolysis. Once the ureters were identified, we could perform safely the adhesiolysis of the bowel from the uterus. The adnexas could be freed and suspended with a T-Lift device to facilitate exposure. After identifying the utero sacral ligament, we opened the para rectal fossa, leading to the opening of the recto vaginal space. The anatomy was then restored, and we could define the specific surgical strategies.

CONCLUSION

Frozen pelvis is a situation where anatomy is distorted. The surgeon should find anatomic landmarks to restore anatomy and to establish specific strategies adapted to the patient.

Feasibility, Complications, and Recurrence after Discoid Resection for Colorectal Endometriosis: A Series of 93 Cases

Laparoscopic discoid colorectal resection is a surgical option for bowel endometriosis, 1 of the most severe forms of endometriosis. However, no study has clearly analyzed the feasibility or the complication and recurrence rates of the procedure in a homogeneous population with specific criteria for discoid resection. The aims of this study were to evaluate the rate of conversion to segmental resection, the need for double discoid resection, and the complication and recurrence rates. We conducted a prospective study of 93 consecutive patients who underwent discoid resection in Tenon University Hospital, Paris, France. The median follow-up was 20 months. We included patients with colorectal endometriosis (≤3 cm long and <90° of bowel circumference) experiencing failure of medical treatment or associated infertility. All the patients underwent a discoid colorectal resection using a transanal circular stapler. The primary end point was the rate of conversion to segmental resection (3.2%). The secondary end point was the rate of double discoid resection (6.5%). The overall complication rate was 24%, and the severe complication rate (i.e., Clavien-Dindo IIIB) was 3% (n = 4). Postoperative voiding dysfunction requiring bladder self-catheterization was observed in 16% (n = 15). The mean duration of bladder self-catherization was 30 days (range, 15-90) including 11 cases (74%) lasting less than 30 days and 4 cases lasting more than 30 days. No patients required bladder self-catheterization over 3 months. No difference in the complication rate or in voiding dysfunction was observed between double and single discoid resection. The low rate of conversion to radical resection confirms the satisfactory preoperative evaluation of bowel endometriosis. Few publications report the rate of conversion to radical surgery. This raises the crucial issue of the right indications for discoid resection. The present study confirms that discoid resection is probably the best option for small lesions because of its high feasibility and low complication rate. Further studies are required to evaluate the technique for larger colorectal endometriotic lesions.

Nomogram predicting the likelihood of complications after surgery for deep endometriosis without bowel involvement

Study Objective

To describe complications following surgery for deep endometriosis (DE) without bowel involvement and to develop a nomogram for predicting postoperative complications.

Design

Retrospective study

Setting

Tertiary referral university hospital and expert center in endometriosis

Patients

Two-hundred and twenty patients with DE without bowel involvement

Interventions

Laparoscopic resection for DE without bowel involvement

Measurements and Main Results

Operative complications were evaluated using the Clavien-Dindo classification. Voiding dysfunction was defined as a need for bladder self-catheterization lasting >1 month. Fifty-three patients (24%) had postoperative complications: 31 (14%) had a Clavien-Dindo grade I—II complication (3 grade I and 28 grade II); 11 (5%) had a grade III complication (2 grade IIIa and 9 grade IIIb); and 11 (5%) had voiding dysfunction. No grade IV—V complications were observed. Age, Enzian classification risk group, and previous surgery for endometriosis were significantly associated with postoperative complications. The predictive model had an AUC of 0.72 (95% CI, 0.70–0.74) before and 0.70 (95% CI, 0.68–72) after bootstrap sample correction. The average difference and maximal difference in predicted and calibrated probabilities of recurrence were 0.023 and 0.089% respectively

Conclusion

Surgery for DE without bowel resection is associated with a relatively high incidence of voiding dysfunction and postoperative complications mainly corresponding to Clavien-Dindo grade I—II. Age, risk group of Enzian classification, and previous surgery for endometriosis are significantly associated with postoperative complications and voiding dysfunction. Our results allowed us to build a nomogram which can be used to better inform patients about the risk of DE surgery without bowel involvement

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.

Choosing the right technique for deep endometriosis

The surgical management of bowel endometriosis is a real challenge. In addition to the fact that only symptomatic patients should undergo surgery, no consensus has been approved in the literature. Among the surgical techniques, the surgeon has to choose between rectal shaving, disc excision, or segmental colorectal resection. All those procedures are associated with complications, but the risk of rectovaginal fistula is higher if a disc excision or segmental colorectal resection is performed. It is therefore of utmost importance to evaluate preoperatively the bowel infiltration by several imaging techniques to estimate the feasibility of a deep rectal shaving with possible incomplete removal of the endometriotic lesions or to discuss with the patient about the indication of a segmental bowel resection. Because of the risk of major preoperative and postoperative complications, proper patient counseling is mandatory.

Are symptoms after a colorectal segmental resection in deep endometriosis really improved? The point of view of women before and after surgery

INTRODUCTION

Bowel endometriosis can cause debilitating symptoms. Surgical colorectal resection is often required for symptomatic relief. Aim of our study was to evaluate quality of life over a one-year follow-up period in patients submitted to a colorectal resection for the treatment of deep endometriosis. Change in intestinal and extra-intestinal symptoms, and reproductive outcome were also evaluated.

METHODS

A prospective observational study was conducted on a cohort of 20 women affected by intestinal endometriosis and submitted to a laparoscopic colorectal resection. The subjects completed a questionnaire about quality of life (SF-36), and they scored in a 100-point rank questionnaire gynecological, urinary and gastrointestinal symptoms, pre-operatively and one- year postoperatively.

RESULTS

Significant improvements were observed in all domains of the SF-36 throughout the study period. Dysmenorrhea, dyspareunia and not menstrual pelvic pain showed a significant decrease 1 year after surgery. There was also a decrease in abdominal pain, rectal bleeding and constipation but not of nausea, abdominal pain, defecation pain, tenesmus, diarrhea, mucorrhea. Also some urinary symptoms did not improve.

CONCLUSIONS

The radical surgical approach has a positive impact on quality of life, although it does not improve all the symptoms complained before surgery. Clear pre-surgical counseling and careful patient selection is suggested.

[Strategies and surgical management of endometriosis: CNGOF-HAS Endometriosis Guidelines]

The article presents French guidelines for surgical management of endometriosis. Surgical treatment is recommended for mild to moderate endometriosis, as it decreases pelvic painful complaints and increases the likelihood of postoperative conception in infertile patients (A). Surgery may be proposed in symptomatic patients with ovarian endometriomas which diameter exceeds 20mm. Cystectomy allows for better postoperative pregnancy rates when compared to ablation using bipolar current, as well as for lower recurrences rates when compared to ablation using bipolar current or CO₂ laser. Ablation of ovarian endometriomas using bipolar current is not recommended (B). Surgery may be employed in patients with deep endometriosis infiltrating the colon and the rectum, with good impact on painful complaints and postoperative conception. In these patients, laparoscopic route increases the likelihood of postoperative spontaneous conception when compared to open route. When compared to conservative rectal procedures (shaving or disc excision), segmental colorectal resection increases the risk of postoperative stenosis, requiring additional endoscopic or surgical procedures. In large deep endometriosis infiltrating the rectum (>20mm length of bowel infiltration), conservative rectal procedures do not improve postoperative digestive function when compared to segmental resection. In patients with bowel anastomosis, placing anti-adhesion agents on contact with bowel suture is not recommended, due to higher risk of bowel fistula (C). Various other recommendations are proposed in the text, however, they are based on studies with low level of evidence.

[Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]

Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.

[Management of assisted reproductive technology (ART) in case of endometriosis related infertility: CNGOF-HAS Endometriosis Guidelines]

The management of endometriosis related infertility requires a global approach. In this context, the prescription of an anti-gonadotropic hormonal treatment does not increase the rate of non-ART (assisted reproductive technologies) pregnancies and it is not recommended. In case of endometriosis related infertility, the results of IVF management in terms of pregnancy and birth rates are not negatively affected by the existence of endometriosis. Controlled ovarian stimulation during IVF does not increase the risk of endometriosis associated symptoms worsening, nor accelerate the intrinsic progression of endometriosis and does not increase the rate of recurrence. However, in the context of IVF management for women with endometriosis, pre-treatment with GnRH agonist or with oestrogen/progestin contraception improve IVF outcomes. There is currently no evidence of a positive or negative effect of endometriosis surgery on IVF outcomes. Information on the possibilities of preserving fertility should be considered, especially before surgery.

Familial deep endometriosis: A rare monogenic disease?

Endometriosis is a frequent cause of pelvic pain and subfertility in women of reproductive age. Presence of extra-uterine endometrial-like tissue is responsible for non-specific symptoms such as chronic pelvic pain, dysmenorrhea, dyspareunia, dyschesia and sometimes infertility. Three different phenotypes according to the location of the lesions are described, namely peritoneal, ovarian and deep infiltrating endometriosis. Deep endometriosis is considered as a distinct homogeneous disease. Heritability of endometriosis has been previously demonstrated. Despite extensive efforts to characterize candidate alleles contributing to genetic basis of endometriosis, these factors relevant to endometriosis pathophysiology remain unclear. No high penetrance pathogenic variant could be identified. We report herein two families with familial aggregation of severe deep infiltrating endometriosis, providing further evidence for monogenic mendelian inheritance of this form of endometriosis.

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.

[Detrusor sphincter disorders associated with deep endometriosis: Systematic review of the literature]

CONTEXT

Detrusor sphincter disorders impact quality of life in case of deep endometriosis. Surgery, which is one of the main treatments, is responsible of detrusor sphincter disorders. Since then, it is essential to look for those disorders and find the right medical care.

OBJECTIVE

To specify the detrusor sphincter disorders, its links with anatomical localisation of deep endometriosis and its prognosis after surgery.

METHODS

A literature review was carried out via PubMed^® with the followings keywords: "deep endometriosis", "urinary disorders", "voiding dysfunction" and "urinary dysfunction". Prospective and retrospective studies as well as previous reviews were analyzed.

RESULTS

Concerning bladder deep endometriosis, detrusor sphincter disorders are observed in more than 50%. Resection of the lesions allows a clear improvement or even a disappearance of the disorders. Concerning the deep endometriosis of the posterior part of the pelvis, disorders are highlighted even if women do not complain of urinary trouble. Detrusor sphincter disorders are observed in 2 to 50% and women with colorectal localisation have the highest rate. Resection of the lesions improves the symptoms described preoperatively but also provides de novo disorders of up to 47.5%. In terms of prevention, the nerve sparing surgery respects the pelvic nerve plexus, and reduces post-operative morbidity to less than 1%.

CONCLUSIONS

Detrusor sphincter disorders associated with deep endometriosis have a prognosis if their management is adapted. Well-conducted interviews and standardized questionnaires is necessary to diagnosis them. Urodynamic test may be discussed in case of bladder endometriosis, including for urinary asymptomatic patients. The management of the detrusor sphincter disorders requires a complete resection of the nodules of deep endometriosis. In the case of posterior endometriosis, a dissection must be performed respecting the retroperitoneal vegetative nerves.

Uterine artery pseudoaneurysm in the setting of deep endometriosis: an uncommon cause of hemoperitoneum in pregnancy

Uterine, ovarian, and placental pathologies are among the differential considerations for a pregnant woman presenting with abdominal and pelvic pain. Imaging plays a key role in the initial work-up of these patients. Sonography is often the first line test; however, evaluation of pelvic pathology can be limited in the gravid state, especially in mid- or late-term pregnancy. We present a case of a pregnant woman who came to the emergency room at 25 weeks with acute abdominal and pelvic pain. Both ultrasound and MR imaging findings revealed intraperitoneal hemorrhage, initially of unknown origin, as well as endometriomas and deep endometriosis. Only postpartum imaging confirmed a uterine artery pseudoaneurysm (PSA) presumably due to decidual reaction in deep endometriosis. We speculate the intraperitoneal hemorrhage was subsequently due to the PSA. This case demonstrates that if hemorrhage is not recognized promptly, it can lead to hemodynamic instability, as well as premature labor and delivery.

Combined laparoscopic and cystoscopic approach in large deep infiltrating endometriosis of the bladder

Resection of endometriosis nodules infiltrating the bladder is routinely performed by laparoscopy. However, laparoscopic resection may lead to inadvertent loss of healthy bladder tissue. Conversely, when bladder nodules are treated by cystoscopy alone, resection may be incomplete. A combined laparoscopic-cystoscopic approach allows safe and controlled resection. The video reports the procedure performed in a 33 year-old primipara who presented with a 40mm bladder nodule. The laparoscopic step is carried out by the gynecologist, who separates the bladder from the uterus and opens the vesico-vaginal space. Concomitantly, the urologist identifies and circumscribes the nodule's limits by cystoscopy. Then, the gynecologist identifies the circular incision previously performed, and completes the resection. The bladder defect is sutured. Early and mid-term postoperative outcomes were uneventful. In patients with large nodules of the bladder, combined laparoscopic-cystoscopic approach allows complete resection of endometriosis lesion, preserves healthy bladder tissue and avoids inadvertent injury of ureters.

MR imaging of endometriosis: Spectrum of disease

Endometriosis is a common gynecological disorder defined by the presence of endometrial tissue outside the uterus. It is the most common cause of chronic pelvic pain and typically affects the ovaries, uterine ligaments, peritoneum, tubes, rectovaginal septum and bladder. It may, however, be found at various extrapelvic sites, including the perineum, liver, pancreas, lung or even the central nervous system, and in such cases, diagnosis may be quite challenging. Even though definitive diagnosis requires laparoscopy, preoperative identification of endometriosis is important not only to differentiate it from other diseases with similar clinical presentations but also, for accurate presurgical mapping, since complete removal of all endometriotic foci is critical for the effective treatment of the patient's symptoms. Ultrasound is performed initially, but magnetic resonance imaging (MRI) is increasingly being used, particularly when sonographic findings are unclear, when deep pelvic endometriosis is suspected or when surgery is planned, as it provides better contrast resolution and a larger field of view compared to ultrasound. In this article, we will discuss distinctive MRI appearances of endometriotic foci and we will review common and uncommon locations of endometriosis within the body, in an attempt to familiarize radiologists with its wide spectrum of manifestations.

Surgical Outcomes of Urinary Tract Deep Infiltrating Endometriosis

OBJECTIVE

To report the outcomes of surgical management of urinary tract endometriosis.

DESIGN

Retrospective study based on prospectively recorded data (NCT02294825) (Canadian Task Force classification II-3).

SETTING

University tertiary referral center.

PATIENTS

Eighty-one women treated for urinary tract endometriosis between July 2009 and December 2015 were included, including 39 with bladder endometriosis, 31 with ureteral endometriosis, and 11 with both ureteral and bladder endometriosis. Owing to bilateral ureteral localization in 8 women, 50 different ureteral procedures were recorded.

INTERVENTION

Procedures performed included resection of bladder endometriosis nodules, advanced ureterolysis, ureteral resection followed by end-to-end anastomosis, and ureteroneocystostomy.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was the outcome of the surgical management of urinary tract endometriosis. Fifty women presented with deep infiltrating endometriosis (DIE) of the bladder and underwent either full-thickness excision of the nodule (70%) or excision of the bladder wall without opening of the bladder (30%). Ureteral lesions were treated by ureterolysis in 78% of the patients and by primary segmental resection in 22%. No patient required nephrectomy. Histological analysis revealed intrinsic ureteral endometriosis in 54.5% of cases. Clavien-Dindo grade III complications were present in 16% of the patients who underwent surgery for ureteral nodules and in 8% of those who underwent surgery for bladder endometriosis. Overall delayed postoperative outcomes were favorable regarding urinary symptoms and fertility. Patients were followed up for a minimum of 12 months and a maximum of 7 years postoperatively, with no recorded recurrences.

CONCLUSION

Surgical outcomes of urinary tract endometriosis are generally satisfactory; however, the risk of postoperative complications should be taken into consideration. Therefore, all such procedures should be managed by an experienced multidisciplinary team.

Spigelian hernia in gynaecology

Background

A Spigelian hernia is a rare hernia through the Spigelian fascia between the rectus muscle and the semilunar line. This hernia is well known in surgery. Symptoms vary from insidious to localised pain, an intermittent mass and/or a bowel obstruction.

Results

The Spigelian hernia is poorly known in gynaecology. Spigelian hernias may be causally related to secondary trocar insertion. This review is written to increase awareness in gynaecology and is illustrated by a case report in which the diagnosis was missed for 4 years even by laparoscopy. Smaller hernias risk not to be diagnosed and will thus not be treated. Even larger Spigelian hernias might not be recognised and treated appropriately.

Conclusions

The gynaecologist should consider a Spigelian hernia in women with localised pain in the abdominal wall lateral of the rectus muscle some 5 cm below the umbilicus. Smaller hernias can be closed by laparoscopy without a mesh. Larger hernias require a mesh repair.

Pelvic tuberculosis mimicking deep endometriosis

Pelvic tuberculosis is most frequently observed in developing countries and often leads to the misdiagnosis of pelvic malignancy. We report the first case of pelvic tuberculosis mimicking deep endometriosis.

Ten Principles for Safe Surgical Treatment of Ovarian Endometriosis

STUDY OBJECTIVE

To show a step-by-step laparoscopic approach for excision of an ovarian endometrioma following surgical principles for safety and maximal preservation of ovarian function.

DESIGN

Video. Medical management of ovarian endometriomas is not recommended. Operative laparoscopy is the treatment of choice. Although considered a simple procedure, ovarian cystectomy requires a precise and correct technique in order to preserve ovarian function.

SETTING

A private hospital.

PATIENT

An asymptomatic, 27-year-old woman with ultrasound imaging suggesting a 6.2 × 5.4 cm left endometrioma. Additional findings of endometriotic implants were noted in the posterior aspect of the left broad ligament, retrocervical region, Douglas pouch, and left round ligament.

INTERVENTIONS

After trocar insertion, standard inspection of the pelvic cavity with identification of endometriosis lesions and adhesions was performed. The endometrioma was drained with direct trocar puncture to avoid spillage of the endometriotic contents. Cyst aspiration and saline cleaning were executed. After drainage, a cold cut was performed at the puncture site for better identification of the cyst capsule. Through gentle traction and countertraction, the capsule was peeled from the ovarian cortex, preserving as much ovarian tissue as possible followed by careful hemostasis with a bipolar instrument. The ovary is fixed, anatomy re-established, and concomitant pelvic endometriosis resected. We aim for complete surgical excision in order to avoid leaving disease behind. The ovarian edges were reapproximated using simple interrupted stitches.

MEASUREMENTS AND MAIN RESULTS

The total procedure time was 40 minutes.

CONCLUSION

Laparoscopic endometrioma stripping offers an effective option for ovarian endometriosis treatment, reducing recurrence and being reproducible by gynecologic surgeons after proper training.

Endometriosis and Ascites: A Strategy to Achieve Pregnancy

Deep endometriosis presenting with ascites and preserved fertility is an unusual combination. This report describes a unique case of deep endometriosis and primary infertility, with a successful pregnancy after an optimal surgical approach and personalized ovarian stimulation protocol for in vitro fertilization, which shows the importance of a multidisciplinary approach in these patients.

Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study

Deep endometriosis involvement of the bladder is uncommon but it is symptomatic in most of the cases. Although laparoscopic excision is very effective, some patients with no pregnancy desire require a medical approach. We performed a pilot study on the effect of a new progestin dienogest on bladder endometriosis. Six patients were treated for 12 months with dienogest 2 mg/daily. Pain, urinary symptoms, quality of life, nodule volume and side effects were recorded. During treatment, symptoms improved very quickly and the nodules exhibit a remarkable reduction in size. Dienogest may be an alternative approach to bladder endometriosis.

New disc excision procedure for low and mid rectal endometriosis nodules using combined transanal and laparoscopic approach

AIM

Colorectal resection in women with endometriosis involving the low and mid rectum may result in a poorer outcome than conservative procedures. In this technical note we present a new technique for transanal full thickness disc excision of endometriosis nodules involving the rectum.

METHOD

The procedure is performed by combined laparoscopic and transanal routes. The former involves paring the area of the rectum infiltrated by the nodule, which is then made amenable to endoluminal removal using the Contour Transtar stapler to carry out a large disc excision.

RESULTS

The technique can remove a specimen as large as 80 mm in diameter and can be applied to patients with infiltrating rectal endometrial nodules up to 10 cm from the anal margin and 50-60% of the rectal circumference. The procedure is probably less likely to lead to rectal stenosis and denervation than colorectal resection.

CONCLUSION

This technique of transanal rectal disc excision using the Contour stapler is suitable in patients with infiltrating deep endometriosis nodules of the lower and mid rectum. It avoids a low rectal resection with its potential complications and unfavourable function.

Totally laparoscopic intracorporeal anastomosis with natural orifice specimen extraction (NOSE) techniques, particularly suitable for bowel endometriosis

The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.

[Urinary functional disorders bound to deep endometriosis and to its treatment: review of the literature]

Lower urinary tract disorders in case of deep endometriosis are common (up to 50% of patients), although often masked by pelvic pain. They result from damage to the pelvic autonomic nervous system by direct infiltration of these structures by endometriotic lesions or surgical trauma (especially in resection of the uterosacral ligaments, rectum or vagina). These are mainly sensory disturbances and bladder voiding dysfunction. They impact quality of life and could be responsible for long-term complications (recurrent urinary tract infections on a persistent residual urine or pelvic floor disorders due to chronic thrusting). It is therefore important to diagnose and treat early these troubles by well-conducted interviews or standardized questionnaires. Different drug treatments have been proposed, such as cholinergics or prokinetics, but their effectiveness has not been demonstrated yet. Neuromodulation of the superior hypogastric plexus for treatment of refractory atonic bladder with persistent urinary retention after surgery seems promising but should be confirmed by further studies. To date, standard treatment of urinary retention after surgery remains self-catheterization. In terms of prevention, surgical nerve sparing techniques have been developed in order to minimize intraoperative injury of pelvic nerve plexus and reduce postoperative morbidity.

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

Recurrence of deep endometriosis remains a major issue in the management of endometriosis. The main cause for recurrence appears to be an incomplete excisional surgery. Therefore, the goal of the primary surgery should be the complete resection of all endometriotic lesions. If surgical skills cannot meet this objective it seems preferable to refer the patient to a center with a recognized expertise in this field rather than performing an incomplete surgery. It seems also possible to tailor the indications according to the symptoms, especially when endometriosis affects the bladder in association with an asymptomatic vaginal and/or rectal involvement. This strategy does not increase the rate of recurrence. Postoperative medical treatment based on ovarian function suppression is attractive as it diminishes the recurrence rate. Facing the recurrence, appropriate assessment of the benefit risk balance must be performed. Medical treatment is an option. When surgery is chosen, it seems interesting to discuss carefully the indication of hysterectomy with bilateral oophorectomy, especially for women over 40 years old with no desire for pregnancy and/or symptomatic adenomyosis. Risks of induced ovarian castration must be taken into account.