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Centini G, Labanca L, Giorgi M, Martire FG, Catania F, Zupi E, Lazzeri L. The implications of the anatomy of the nerves and vessels in the treatment of rectosigmoid endometriosis. Clin Anat 2024; 37:270-277. [PMID: 37165994 DOI: 10.1002/ca.24059] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/30/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023]
Abstract
Endometriosis is a common benign gynecological disease characterized by the presence of endometrial glands and stroma outside the uterus. It can be defined as endometrioma, superficial peritoneal endometriosis or deep infiltrating endometriosis (DIE) depending on the location and the depth of infiltration of the organs. In 5%-12% of cases, DIE affects the digestive tract, frequently involving the distal part of the sigmoid colon and rectum. Surgery is generally recommended in cases of obstructive symptoms and in cases with pain that is non-responsive to medical treatment. Selection of the most optimal surgical technique for the treatment of bowel endometriosis must consider different variables, including the number of lesions, eventual multifocal lesions, as well as length, width and grade of infiltration into the bowel wall. Except for some major and widely accepted indications regarding bowel resection, established international guidelines are not clear on when to employ a more conservative approach like rectal shaving or discoid resection, and when, instead, to opt for bowel resection. Damage to the pelvic autonomic nervous system may be avoided by detection of the middle rectal artery, where its relationship with female pelvic nerve fibers allows its use as an anatomical landmark. To reduce the risk of potential vascular and nervous complications related to bowel resection, a less invasive approach such as shaving or discoid resection can be considered as potential treatment options. Additionally, the middle rectal artery can be used as a reference point in cases of upper bowel resection, where a trans mesorectal technique should be preferred to prevent devascularization and denervation of the bowel segments not affected by the disease.
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Affiliation(s)
- Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Luca Labanca
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Francesco Giuseppe Martire
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Francesco Catania
- Department of Surgical Sciences, Gynecological Unit, Valdarno Hospital, Montevarchi, Italy
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, Siena, Italy
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Martire FG, Giorgi M, D’Abate C, Colombi I, Ginetti A, Cannoni A, Fedele F, Exacoustos C, Centini G, Zupi E, Lazzeri L. Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression. J Clin Med 2024; 13:550. [PMID: 38256683 PMCID: PMC10816815 DOI: 10.3390/jcm13020550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.
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Affiliation(s)
- Francesco Giuseppe Martire
- Gynecological Unit, Department of Surgical Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy; (F.G.M.); (C.E.)
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Claudia D’Abate
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Irene Colombi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Alessandro Ginetti
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Alberto Cannoni
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Francesco Fedele
- Department of Obstetrics and Gynecology, Fondazione “Policlinico-Mangiagalli-Regina Elena” University of Milan, 20122 Milan, Italy;
| | - Caterina Exacoustos
- Gynecological Unit, Department of Surgical Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy; (F.G.M.); (C.E.)
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy; (M.G.); (C.D.); (I.C.); (A.G.); (A.C.); (G.C.); (L.L.)
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Martire FG, Piccione E, Exacoustos C, Zupi E. Endometriosis and Adolescence: The Impact of Dysmenorrhea. J Clin Med 2023; 12:5624. [PMID: 37685691 PMCID: PMC10488856 DOI: 10.3390/jcm12175624] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
Endometriosis affects approximately 10% of premenopausal women worldwide. Despite its impact on quality of life, the delay in diagnosing this chronic disease is well known. Many patients with endometriosis report having suffered from dysmenorrhea and chronic pelvic pain in adolescence or at a young age. However, this painful symptom is often highly underestimated and considered a normal and transient symptom in young women. The real prevalence of endometriosis in adolescence remains uncertain. Some authors recently described at least one ultrasound feature of endometriosis in 13.3% of a general population of adolescent girls, which increased to 35.3% in young girls with severe dysmenorrhea. Dysmenorrhea is classified as primary dysmenorrhea or secondary dysmenorrhea. Primary dysmenorrhea is defined as a menstrual pain without organic disease, while secondary dysmenorrhea is defined as a menstrual pain associated with organic pelvic pathology. Since endometriosis represents the main cause of secondary dysmenorrhea in adolescents and young women, it is important to determine whether the patient has primary dysmenorrhea or additional suggestive symptoms related to endometriosis. Endometriosis in adolescent patients is a challenging problem with clinical and pathological differences compared with its presentation in premenopausal women. Adolescents and young women with dysmenorrhea and painful symptoms that suggest endometriosis should be referred to dedicated endometriosis centers for an early diagnosis and appropriate medical and surgical management. This paper aims to describe the role of dysmenorrhea in adolescents and the management of these young patients to confirm or exclude endometriosis.
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Affiliation(s)
- Francesco G. Martire
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome “Tor Vergata”, 00133 Rome, Italy;
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy;
| | - Emilio Piccione
- Department of Surgical Sciences, Catholic University “Our Lady of Good Counsel”, 1000 Tirane, Albania
| | - Caterina Exacoustos
- Department of Surgical Sciences, Section of Gynecology and Obstetrics, University of Rome “Tor Vergata”, 00133 Rome, Italy;
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy;
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Selntigia A, Neri B, Russo C, Martire FG, Soreca G, Biasutto D, Matteo FMD, Exacoustos C. A Rare Sigmoid-Colon Schwannoma in a Premenopausal Woman: A Case Report. Acta Med Litu 2023; 30:188-193. [PMID: 38516511 PMCID: PMC10952420 DOI: 10.15388/amed.2023.30.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 03/23/2024] Open
Abstract
Background Schwannomas of the gastrointestinal tract are a rare type of spindle cell tumor of peripheral nerve. Commonly, schwannomas are discovered incidentally, as they are usually asymptomatic. Case 46-year-old female patient, suffering from secondary amenorrhea and nonspecific intermittent pelvic pain associated with constipation. During gynecological visit an ultrasonographic systematic transvaginal examination was performed. At the sigmoid-rectal level an intraluminal solid mass was described and an urgent colonoscopy was prescribed. Endoscopic submucosal dissection was performed with en-bloc resection. On immunohistochemical analysis, S100 was strongly positive in tumor cells. Finally, a benign schwannoma of the sigmoid colon was diagnosed. Conclusion Our case highlights the importance of an adequate transvaginal pelvic examination with the evaluation of all pelvic organs. It could be challenging to make diagnosis in an early stage on asymptomatic patients.
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Affiliation(s)
- Aikaterini Selntigia
- Department of Surgical Sciences, Obstetric/Gynecological Clinic, University of Rome “Tor Vergata”, Italy
| | - Benedetto Neri
- Department of Systems Medicine, Gastroenterological Unit, University “Tor Vergata” of Rome, Italy
| | - Consuelo Russo
- Department of Surgical Sciences, Obstetric/Gynecological Clinic, University of Rome “Tor Vergata”, Italy
| | - Francesco Giuseppe Martire
- Department of Surgical Sciences, Obstetric/Gynecological Clinic, University of Rome “Tor Vergata”, Italy
| | - Giorgia Soreca
- Department of Surgical Sciences, Obstetric/Gynecological Clinic, University of Rome “Tor Vergata”, Italy
| | - Dario Biasutto
- Operative Endoscopy Department, Campus Bio-Medico, University Hospital, Rome, Italy
| | | | - Caterina Exacoustos
- Department of Surgical Sciences, Obstetric/Gynecological Clinic, University of Rome “Tor Vergata”, Italy
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Martire FG, Russo C, Selntigia A, Siciliano T, Lazzeri L, Piccione E, Zupi E, Exacoustos C. Transvaginal ultrasound evaluation of the pelvis and symptoms after laparoscopic partial cystectomy for bladder endometriosis. J Turk Ger Gynecol Assoc 2022; 23:145-153. [PMID: 36065973 PMCID: PMC9450928 DOI: 10.4274/jtgga.galenos.2022.2022-5-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To evaluate transvaginal sonography (TVS) findings after laparoscopic partial cystectomy for bladder endometriosis and to correlate postsurgical ultrasound findings with symptoms. Material and Methods: A retrospective study including women who underwent laparoscopic partial cystectomy for bladder endometriosis. Within 12 months after surgery, TVS examination was conducted in all patients to evaluate the bladder morphology, and the presence of any postsurgical sonographic findings of the pelvis. Painful symptoms were assessed using a visual analogue scale. Results: A total of 40 women were included. At the follow-up visit, 25 patients were receiving medical treatment while 15 had declined post-surgical therapy and had tried to conceive. The presence of bladder deep-infiltrating endometriosis (DIE) was found in nine (22.5%), fibrotic thickening of the bladder wall was found in 15 (37.5%), and normal bladder morphology was observed in 16 (40%). There was a correlation between anterior adenomyosis and bladder DIE, and fibrotic thickening of the bladder. Patients with TVS signs of bladder DIE and anterior adenomyosis suffered more dysmenorrhea and dysuria than patients with normal bladder. Conclusion: Post-operative TVS can detect the alteration of pelvis and could explain the causes of the persistence of symptoms.
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Affiliation(s)
- Francesco Giuseppe Martire
- Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy
| | - Consuelo Russo
- Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy
| | - Aikaterini Selntigia
- Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy
| | - Terry Siciliano
- Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Division of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Emilio Piccione
- Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy,Postgraduate School of Obstetrics and Gynecology, Catholic University Our Lady of Good Counsel, Tirana, Albania
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Division of Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Caterina Exacoustos
- Department of Surgical Sciences, Obstetrics and Gynecology of Unit, University of Rome Tor Vergata, Rome, Italy
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Stratopoulou CA, Camboni A, Donnez J, Dolmans MM. Identifying Common Pathogenic Features in Deep Endometriotic Nodules and Uterine Adenomyosis. J Clin Med 2021; 10:4585. [PMID: 34640603 PMCID: PMC8509556 DOI: 10.3390/jcm10194585] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 02/06/2023] Open
Abstract
Increasing imaging data point to a link between deep endometriotic nodules (DENs) and uterine adenomyosis (AD). The study aimed to investigate this link at the histological level and detect potential features shared by the two diseases. We collected formalin-fixed paraffin-embedded tissue (endometrium and lesions) from women with DENs of the rectovaginal septum (n = 13), AD (n = 14), and control subjects (n = 14). Immunohistochemical analyses of CD41 and CD68 were conducted to explore the roles of platelets and macrophages, respectively. Picrosirius red staining was carried out to gather evidence of fibrosis. Vascular endothelial growth factor (VEGF) was assessed, and total numbers of CD31-positive vessels were calculated to investigate the mechanism governing angiogenesis. Double immunohistochemistry for CD31 and alpha smooth muscle actin (αSMA) was performed to discern stable vessels. Platelet aggregation was significantly decreased in both types of lesions compared to their corresponding eutopic endometrium and healthy controls. Macrophage numbers were higher in both lesions than in their corresponding endometrium and healthy subjects. Significantly higher rates of collagen accumulation were detected in DENs and AD lesions compared to their corresponding eutopic and healthy endometrium. VEGF expression was downregulated in the stromal compartment of AD lesions compared to the healthy endometrium. The total number of vessels per area was significantly higher in DENs and AD lesions than in the healthy endometrium. Rates of αSMA-surrounded vessels were decreased in DENs and AD lesions compared to their corresponding eutopic and healthy endometrium. We report common pathogenic mechanisms between DENs and AD, namely excessive macrophage accumulation, fibrosis, and irregular angiogenesis. Our results further support the notion of DENs and AD being linked at the histological level.
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Affiliation(s)
- Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (A.C.)
| | - Alessandra Camboni
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (A.C.)
- Anatomopathology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l’Infertilité, 1150 Brussels, Belgium;
- Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (A.C.)
- Gynecology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
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