ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose

Posterior Deep Infiltrating Endometriotic Nodules: Operative Considerations according to Lesion Size, Location, and Geometry, during One's Learning Curve

We conducted this prospective cohort study to standardize our laparoscopic technique of excision of posterior deep infiltrating endometriosis (DIE) nodules, according to their size, location, and geometry, including 36 patients who were grouped, according to principal pelvic expansion of the nodule, into groups with central (group 1) and lateral (group 2) lesions, and according to nodule size, into ≤2 cm (group A) and >2 cm (group B) lesions, respectively. In cases of group 1 the following operative steps were more frequently performed compared to those of group 2: suspension of the rectosigmoid, colpectomy, and placement of bowel wall reinforcement sutures. The opposite was true regarding suspension of the adnexa, systematic ureteric dissection, and removal of the diseased pelvic peritoneum. When grouping patients according to nodule size, almost all of the examined parameters were more frequently applied to patients of group B: adnexal suspension, suspension of the rectosigmoid, systematic ureteric dissection, division of uterine vein, colpectomy, and placement of bowel wall reinforcement sutures. Nodule size was the single most important determinant of duration of surgery. In conclusion, during the building-up of one's learning curve of laparoscopic excision of posterior DIE nodules, technique standardization is very important to avoid complications.

Theories on the pathogenesis of endometriosis

Endometriosis is a common, chronic inflammatory disease defined by the presence of extrauterine endometrial tissue. The aetiology of endometriosis is complex and multifactorial, where several not fully confirmed theories describe its pathogenesis. This review examines existing theories on the initiation and propagation of different types of endometriotic lesions, as well as critically appraises the myriad of biologically relevant evidence that support or oppose each of the proposed theories. The current literature suggests that stem cells, dysfunctional immune response, genetic predisposition, and aberrant peritoneal environment may all be involved in the establishment and propagation of endometriotic lesions. An orchestrated scientific and clinical effort is needed to consider all factors involved in the pathogenesis of this multifaceted disease and to propose novel therapeutic targets to reach effective treatments for this distressing condition.

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.

Endometriosis Fertility Index: is it better than the present staging systems?

PURPOSE OF REVIEW

Endometriosis is a complex disease, one aspect being the existence of multiple staging systems. The recent Endometriosis Fertility Index (EFI) is compared with other endometriosis infertility staging systems and three new studies assessing the EFI are reported.

RECENT FINDINGS

The revised American Fertility Society classification system has historically been most widely used but does not predict pregnancy rates. The ENZIAN classification system is designed to describe more severe disease as an adjunct to the ASRM system, but does not predict pregnancy rates. The American Association of Gynecological Laparoscopists (now named AAGL) is developing a categorization system more focused on pain. Novel research in imaging, biomarkers, histology and the human genome may provide useful information to develop future classification systems. The EFI has recently been published as a validated prospective staging system that predicts non-assisted reproductive technology pregnancy rates in infertility patients following surgical diagnosis. Three other investigators have now validated the EFI.

SUMMARY

The only validated endometriosis classification system that predicts a clinical outcome is the EFI. The EFI has now been validated by three additional investigators. Renewed interest in the importance and utility of classification systems will hopefully result in novel classification systems that are useful for other clinical presentations of endometriosis.

Elevated immunoreactivity of RANTES and CCR1 correlate with the severity of stages and dysmenorrhea in women with deep infiltrating endometriosis

Deep infiltrating endometriosis (DIE) is typically characterized by multifocal locations. It has been shown that CCR1, combined highly with RANTES, contributes to the enhanced recruitment of inflammatory cells at endometriotic sites. As an estrogen-dependent disorder, estrogen receptors are also crucial to the growth of endometriotic tissues. In this study we report the immunohistochemical analysis of RANTES, CCR1, ER-α and ER-β in 48 histological lesions prepared from women with DIE undergoing surgery. Immunohistochemical analysis of RANTES, CCR1, ER-α and ER-β was conducted at different sites of DIE lesions. RANTES was immunolocalized in the cytoplasm and CCR1 in cytomembranes of endometriotic cells. ER-α and ER-β extensively immunostained the nuclei of endometrial glandular, and stromal cells. Immunoreactivity in DIE lesions, similar to the widespread ERs, showed higher expression of RANTES and CCR1 in three types of DIE lesions. There was a significant correlation, independent of cyclic changes, between the expression of RANTES/CCR1 and DIE lesions. RANTES/CCR1 increased significantly according to the severity of dysmenorrhea. RANTES and CCR1 together may provide a potential biomarker for DIE-related pain and inflammatory response in endometriotic lesions of patients with DIE.

Defining future directions for endometriosis research: workshop report from the 2011 World Congress of Endometriosis In Montpellier, France

Endometriosis, defined as estrogen-dependent lesions containing endometrial glands and stroma outside the uterus, is a chronic and often painful gynecological condition that affects 6% to 10% of reproductive age women. Endometriosis has estimated annual costs of US $12 419 per woman (approximately €9579), comprising one-third of the direct health care costs with two-thirds attributed to loss of productivity. Decreased quality of life is the most important predictor of direct health care and total costs. It has been estimated that there is a mean delay of 6.7 years between onset of symptoms and a surgical diagnosis of endometriosis, and each affected woman loses on average 10.8 hours of work weekly, mainly owing to reduced effectiveness while working. To encourage and facilitate research into this debilitating disease, a consensus workshop to define future directions for endometriosis research was held as part of the 11th World Congress on Endometriosis in September 2011 in Montpellier, France. The objective of this workshop was to review and update the endometriosis research priorities consensus statement developed following the 10th World Congress on Endometriosis in 2008.(1) A total of 56 recommendations for research have been developed, grouped under 6 subheadings: (1) diagnosis, (2) classification and prognosis, (3) clinical trials, treatment, and outcomes, (4) epidemiology, (5) pathophysiology, and (6) research policy. By producing this consensus international research priorities statement, it is the hope of the workshop participants that researchers will be encouraged to develop new interdisciplinary research proposals that will attract increased funding support for work on endometriosis.

Efficacy of the revised Enzian classification: a retrospective analysis. Does the revised Enzian classification solve the problem of duplicate classification in rASRM and Enzian?

PURPOSE

The most widely accepted classification for endometriosis is the Revised American Society for Reproductive Medicine (rASRM) system, but this does not take deeply infiltrating endometriosis (DIE) into account. The Enzian classification enables clinicians to classify DIE. Due to complexity and partial overlap with rASRM, it was revised for a second time in February 2011. Using both the systems to classify lesions would be inappropriate, as they refer to different locations. The aim of this study was to analyze whether the revised Enzian classification is easier to use and avoids duplicate classifications.

METHODS

Retrospective study of 460 women admitted for endometriosis.

RESULTS

One hundred and eighty-seven of 460 patients (41 %) had histologically confirmed DIE based on the revised Enzian classification. Further classification of these 187 patients using Enzian revealed 270 retroperitoneal lesions, as some patients had several DIE-type lesions simultaneously: 66 in compartment A (rectovaginal septum, vagina), 112 in compartment B (sacrouterine ligaments, pelvic wall), 58 in compartment C (bowel), 15 with adenomyosis uteri, 7 with bladder involvement, 8 with intrinsic involvement of the ureter, and 4 with bowel involvement. All 270 lesions were classified using Enzian alone and not with the rASRM score. There were no duplicate classifications (rASRM and Enzian).

CONCLUSIONS

The revised Enzian classification is an excellent complement to the rASRM score for morphological description of DIE.

Endometriosis classification: an update

PURPOSE OF REVIEW

Endometriosis remains an enigmatic disease for many reasons, not the least being a continued inability to stage its clinical presentation so that prognosis and treatment for both pain and infertility patients can be facilitated. This article reviews issues with current staging systems.

RECENT FINDINGS

The revised American Fertility Society (rAFS) classification system has historically been the only classification system. Recently, the ENZIAN classification system, developed as an adjunct to the rAFS to describe more severe disease, has been introduced but is rarely used. More recently, the Endometriosis Fertility Index (EFI) that has been validated to predict pregnancy rates in infertility patients following surgical diagnosis and treatment of endometriosis was published. Currently, the AAGL is developing a categorization system that will be more focused on pain. Novel research in imaging, biomarkers, histology, and the human genome may provide useful information to develop future classification systems.

SUMMARY

The only validated endometriosis classification system that predicts a clinical outcome is the EFI. It is to be hoped that renewed interest in the importance and utility of classification systems will result in novel classification systems that are clinically useful.

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.

Value of transvaginal ultrasound in assessing severity of pelvic endometriosis

OBJECTIVE

The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis.

METHODS

Consecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. The severity of endometriosis was assessed preoperatively using TVS and the findings were compared with the results obtained by laparoscopy using the American Society for Reproductive Medicine (ASRM) classification.

RESULTS

In total, 201 women had preoperative TVS and laparoscopies. Of these, no endometriosis was found at laparoscopy for 62/201 (30.8%; 95% CI, 24.8-37.5), whereas 33/201 (16.4%; 95% CI, 11.9-22.2) had minimal endometriosis, 31/201 (15.4%; 95% CI, 11.1-21.1) had mild endometriosis, 27/201 (13.4%; 95% CI, 9.4-18.8) had moderate endometriosis and 48/201 (23.9%; 95% CI, 18.5-30.2) had severe endometriosis. The sensitivity and specificity of the TVS diagnosis of severe pelvic endometriosis were 0.85 (95% CI, 0.716-0.934) and 0.98 (95% CI, 0.939-0.994), respectively, and the positive and negative likelihood ratios were 43.5 (95% CI, 14.1-134) and 0.15 (95% CI, 0.075-0.295), respectively. Overall, there was a good level of agreement between ultrasound and laparoscopy in identifying absent, minimal, mild, moderate and severe disease (quadratic weighted kappa = 0.786). The mean ASRM score difference between TVS and laparoscopy in assessing severity of endometriosis was -2.398 (95% CI, -4.685 to -0.1112) and the limits of agreement were -34.62 (95% CI, -38.54 to -30.709) to 29.83 (95% CI, 25.91-33.74).

CONCLUSIONS

TVS is a good test for assessing the severity of pelvic endometriosis. TVS is particularly accurate in detecting severe disease, which could facilitate more effective triaging of women for appropriate surgical care.

Estrogen and progestogen receptor positive endometriotic lesions and disseminated cells in pelvic sentinel lymph nodes of patients with deep infiltrating rectovaginal endometriosis: a pilot study

BACKGROUND

Deep infiltrating endometriosis (DIE) shows similarities to malignant diseases. A recent study involving DIE patients found endometriosis in mesorectal lymph nodes (LNs) after segmental bowel resection. However, it is unclear whether this observation is a local phenomenon or a sign of systemic disease. Therefore, we conducted a prospective study to investigate the occurrence of endometriosis in pelvic sentinel lymph nodes (SLNs) in patients with DIE.

METHODS

Fourteen patients underwent primary surgery for symptomatic DIE. Combined vaginal laparoscopic-assisted resection of the rectovaginal septum was performed. Dye was injected into the visible/palpable nodule. SLNs were removed from the iliac region. In order to identify endometriotic cells, immunohistochemical analysis of estrogen and progestogen receptors, CD10 and cytokeratin was performed.

RESULTS

In 12 out of 14 patients with DIE, SLNs were detected. The localization of the SLN followed the typical LN spread of the upper vagina. In three patients, we could detect typical endometriotic lesions in the LNs. Ten out of 12 (83.3%) SLNs showed disseminated estrogen and/or progestogen positive cells.

CONCLUSIONS

By using immunohistochemistry, we could demonstrate endometriotic lesions and endometriotic-like cells in pelvic SLNs of patients with DIE suggesting the potential for lymphatic spread of the disease.

Konservative Therapie der Endometriose

Endometriosis is the second most frequent benign disease of the female of reproductive age. In spite of extensive research, the etiology of this disease is still largely enigmatic. A causal therapy has not been found yet. Several drug therapy approaches are available but none offers a permanent cure of endometriosis. In addition, the range of side effects of the particular drug therapies has to be considered individually. The treatment of patients with endometriosis cannot be standardized but has to differentiate the individual factors and life circumstances of the patients.