Bowel complications in endometriosis surgery

Natural Orifice Specimen Extraction as a Promising Alternative for Minilaparotomy in Bowel Resection Due to Endometriosis: A Systematic Review and Meta-Analysis

OBJECTIVE

This study focuses on evaluating the effectiveness, safety and efficacy of 2 surgical tissue extraction methods for treating bowel endometriosis: natural orifice specimen extraction (NOSE) and minilaparotomy.

DATA SOURCES

A systematic search was conducted in MedLine, Embase, and Cochrane Library databases in October 2023, without date restrictions.

METHODS OF STUDY SELECTION

This study included studies that directly compared NOSE and minilaparotomy in colectomy patients due to endometriosis. Primary outcomes were defined as operation duration, length of hospital stay, intraoperative blood loss, and major postoperative complication rates. The Clavien-Dindo classification was used to categorize complications. Statistical analysis was performed using Review Manager Software by Cochrane, with a DerSimonian and Laird random-effects model to account for anticipated high heterogeneity. Subgroup analysis was conducted for patients undergoing full laparoscopic (L/S) resection.

TABULATION, INTEGRATION AND RESULTS

Out of 1236 identified studies, 6 met the inclusion criteria, comprising 372 patients. One study was a randomized controlled trial, and 5 were observational. Operation duration did not significantly differ between NOSE and minilaparotomy (MD: -10.85 min; 95% CI: [-23.33, 1.63]; p = .09). NOSE was associated with a significantly reduced length of hospital stay (MD: -0.76 day; 95% CI: [-1.21, -0.31]; p = .008). The major postoperative complication rates were 3.77% for NOSE and 5.55% for minilaparotomy, with no significant difference (OR: 0.84; 95% CI: [0.27, 2.60]; p = .76). Subgroup analysis revealed that Full L/S had significantly shorter operation duration (MD: -26.06 min; 95% CI: [-45.85, -6.27]; p = .01), reduced length of stay (MD: -0.75 day; 95% CI: [-1.25, -0.25]; p = .003), and lower blood loss (MD: -15.01 mL; 95% CI: [-29.64, -0.37]; p = .04).

CONCLUSION

NOSE emerged as a potentially safer alternative to minilaparotomy for tissue extraction in colectomy for bowel endometriosis. However, standardization of the procedure and additional randomized controlled trials are needed to validate these findings.

Is high-intensity focused ultrasound a magical solution to endometriosis? A systematic review

Background

Endometriosis presents a significant challenge in gynecological endocrinology, affecting approximately 1 in 10 women of reproductive age. Abdominal wall endometriosis (AWE) and rectosigmoid deep infiltrating endometriosis (DIE) pose unique clinical complexities. High-intensity focused ultrasound (HIFU) has emerged as a novel alternative for treating these conditions, offering a noninvasive option with potential therapeutic benefits.

Methods

A systematic review was conducted following PRISMA guidelines to investigate the safety and efficacy of HIFU therapy for AWE and rectosigmoid DIE. The literature search encompassed databases from inception to January 20, 2024. Eligible studies included observational studies, case reports, and clinical trials evaluating HIFU treatment for endometriosis. Data extraction and risk of bias assessment were performed following established protocols.

Results

Fourteen studies were included, comprising 330 patients with AWE and 28 patients with rectosigmoid DIE. HIFU treatment demonstrated significant efficacy, with many patients experiencing complete remission, and clinical effectiveness. Reductions in lesion volume posttreatment were consistent across studies. However, safety concerns were noted, including pain at the treatment site, hematuria, and skin burns. Adverse effects underscored the importance of careful patient selection and monitoring during HIFU therapy.

Conclusion

HIFU therapy shows promise as a noninvasive approach for managing AWE and rectosigmoid DIE. While efficacy outcomes are encouraging, safety considerations warrant attention. Further research, particularly randomized controlled trials with larger sample sizes, is needed to validate findings and optimize treatment protocols.

Deep Learning to Measure the Intensity of Indocyanine Green in Endometriosis Surgeries with Intestinal Resection

Endometriosis is a gynecological pathology that affects between 6 and 15% of women of childbearing age. One of the manifestations is intestinal deep infiltrating endometriosis. This condition may force patients to resort to surgical treatment, often ending in resection. The level of blood perfusion at the anastomosis is crucial for its outcome, for this reason, indocyanine green (ICG), a fluorochrome that green stains the structures where it is present, is injected during surgery. This study proposes a novel method based on deep learning algorithms for quantifying the level of blood perfusion in anastomosis. Firstly, with a deep learning algorithm based on the U-Net, models capable of automatically segmenting the intestine from the surgical videos were generated. Secondly, blood perfusion level, from the already segmented video frames, was quantified. The frames were characterized using textures, precisely nine first- and second-order statistics, and then two experiments were carried out. In the first experiment, the differences in the perfusion between the two-anastomosis parts were determined, and in the second, it was verified that the ICG variation could be captured through the textures. The best model when segmenting has an accuracy of 0.92 and a dice coefficient of 0.96. It is concluded that segmentation of the bowel using the U-Net was successful, and the textures are appropriate descriptors for characterization of the blood perfusion in the images where ICG is present. This might help to predict whether postoperative complications will occur during surgery, enabling clinicians to act on this information.

A review and guide to creating patient specific 3D printed anatomical models from MRI for benign gynecologic surgery

Background

Patient specific three-dimensional (3D) models can be derived from two-dimensional medical images, such as magnetic resonance (MR) images. 3D models have been shown to improve anatomical comprehension by providing more accurate assessments of anatomical volumes and better perspectives of structural orientations relative to adjacent structures. The clinical benefit of using patient specific 3D printed models have been highlighted in the fields of orthopaedics, cardiothoracics, and neurosurgery for the purpose of pre-surgical planning. However, reports on the clinical use of 3D printed models in the field of gynecology are limited.

Main text

This article aims to provide a brief overview of the principles of 3D printing and the steps required to derive patient-specific, anatomically accurate 3D printed models of gynecologic anatomy from MR images. Examples of 3D printed models for uterine fibroids and endometriosis are presented as well as a discussion on the barriers to clinical uptake and the future directions for 3D printing in the field of gynecological surgery.

Conclusion

Successful gynecologic surgery requires a thorough understanding of the patient’s anatomy and burden of disease. Future use of patient specific 3D printed models is encouraged so the clinical benefit can be better understood and evidence to support their use in standard of care can be provided.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

STUDY OBJECTIVE

To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance.

METHODS

This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail.

RESULTS

Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region.

CONCLUSION

Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.

Colorectal endometriosis: ample data without definitive recommendations

The preoperative work-up and optimal surgical approach to colorectal endometriosis is a highly studied topic lacking definitive recommendations. Synthesis of the available data can be extremely challenging for surgeons due to the heterogeneity of existing comparisons, a variety of studied surgical outcomes, and a predominant focus on operative complications. While these considerations are extremely important for surgeons performing such complex gynaecologic surgery there is still much to be desired with regards to evidence based guidelines for the preoperative assessment and surgical technique for colorectal endometriosis. Having an established guideline stating in which clinical situations endometriosis surgeons should performing rectovaginal shaving, versus discoid excision, versus segmental resection would be extremely important for all pelvic surgeons, even those operating in high-volume centres dedicated to the surgical management of complex endometriosis. This perspective highlights the shortcomings of the available data and attempts to create an algorithm surgeons can follow when performing surgery for colorectal endometriosis. This algorithm is based on our expert opinion after synthesising available data.

Rates of anastomotic leak and fistula following surgical management of bowel endometriosis: a comparison of shaving, discoid excision, and segmental resection

Endometriosis is a complex chronic inflammatory condition that can create a multitude of bothersome painful symptoms for women. Bowel endometriosis is often misdiagnosed or overlooked leading to years of suffering for many women. The surgical management of bowel endometriosis varies based on extent of disease as well as surgeon experience. Surgical treatment for bowel endometriosis is complex and a variety of intraoperative and postoperative complications must be considered. Two significant postoperative complications for bowel endometriosis include anastomotic leak and fistula formation. There is continued debate regarding the appropriate surgical treatment for bowel endometriosis. Aggressive surgery with segmental bowel resection is being utilized more cautiously, with an increase in less aggressive shaving or disc excision techniques. Historic beliefs regarding the limitations of shaving and disc excision are being challenged, and with a reduction in morbidity these less aggressive techniques are winning favor among gynecologic surgeons. Shaving, discoid excision, and segmental bowel resection are all feasible surgical management options for bowel endometriosis. Segmental resection is associated with the highest rates of both anastomotic leak and fistula formation, while shaving is associated with the lowest.

Association Between Bowel Obstruction or Intussusception and Endometriosis

OBJECTIVE

To evaluate the association between endometriosis and bowel obstruction or intussusception using a large population database.

METHODS

This was a population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from 2005 to 2014. We studied women aged 18 to 55 years without inflammatory bowel disease or cancer. Multivariate logistic regression was used to examine the association between endometriosis and bowel obstruction.

RESULTS

Of the 18 427 520 women who met the criteria for inclusion, 96 539 had experienced bowel obstruction, for an overall prevalence of 52 per 10 000, and 3825 had experienced intussusception, for an overall prevalence of 2 per 10 000. When adjusted for sociodemographic characteristics, women with pelvic endometriosis had a consistently higher likelihood of bowel obstruction (odds ratio [OR] 2.6; 95% confidendence interval [CI] 2.3-3.00, P <0.01). In particular, intestinal endometriosis was associated with a 14.6-fold increased risk of bowel obstruction (95% CI 11.4-18.8, P <0.01), while rectovaginal endometriosis was associated with a 2.00-fold increased risk (95% CI 1.5-2.6, P <0.01). Pelvic endometriosis was significantly associated with adhesive bowel obstruction (adjusted OR: 3.2; 95% CI 2.6-3.9) and non-adhesive bowel obstruction (adjusted OR 2.4; 95% CI 2.0-2.8). The rates of endometriosis among women with or without intussusception were comparable.

CONCLUSIONS

Pelvic endometriosis, in particular rectovaginal and intestinal endometriosis is strongly associated with bowel obstruction, independent of the presence of intra-abdominal adhesions. We did not find any association between pelvic endometriosis and intussusception.

Five-Month Follow-Up Assessing Defecography and Urodynamics after Laparoscopic Nerve-Sparing Colorectal Resection for Endometriosis

Introduction

Large resections may be necessary in cytoreductive surgery for endometriosis, which present risk of urinary and bowel complications. Presentation of Case. A 29-year-old woman underwent multidisciplinary laparoscopy for endometriosis in a private practice setting for acyclic pelvic pain and cyclic abdominal distension with changes in bowel habits and frequent sensation of incomplete defecation. After surgery, urodynamics remained normal and bowel function improved subjectively and objectively per dynamic magnetic resonance defecography (DMRD). The five-month follow-up found improvements in pain scores, bowel function, and health-related quality of life (assessed by the full versions of the Short Form 36 and Endometriosis Health Profile 30 scales). Discussion. Animus may contribute to the bowel symptoms in women with endometriosis. DMRD provides additional objective parameters for comparing pre- and postoperative functions.

Conclusion

A nerve-sparing segmental rectosigmoidectomy for endometriosis carefully executed by a multidisciplinary team can preserve the function of different pelvic organs.

Bowel resection for intestinal endometriosis

Over the last twenty years, segmental resection (SR) has been the technique most frequently used to treat bowel endometriosis. Nowadays, it is most commonly performed by laparoscopy; however, there is evidence that it can be safely performed by robotic-assisted laparoscopic surgery. Rectovaginal fistula and anastomotic leakage are the two major complications of SR; other complications include pelvic abscess, postoperative bleeding, ureteral damage, and anastomotic stricture. Several studies showed that SR causes improvement in pain and intestinal symptoms; nerve-sparing SR may improve the functional outcomes. The rates of postoperative recurrence of bowel endometriosis vary across the studies, possibly because of the different definitions of recurrence.

Bowel surgery for endometriosis: A practical look at short- and long-term complications

Endometriosis involving the bowel requires a thorough evaluation prior to deciding upon surgical treatment. Patient symptoms, treatment goals, extent and location of disease, surgeon experience, and anticipated risks all play a part in the preoperative decision-making process. Short- and long-term complications after bowel surgery for endometriosis are the focus of this article. Unfortunately, the literature to date has inherent limitations that prevent generalizability. Most studies are retrospective or prospective single-center case series. Publication bias is unavoidable with mainly large volume experts sharing their experience. As a result, there is a need for high-quality prospective studies that standardize inclusion criteria and outcome measures among various centers with an aim to present long-term outcomes. In the meantime, care for those with endometriosis involving the bowel requires a thorough preoperative plan to minimize risks and a need for early diagnosis and management of complications unique to bowel surgery.

Identification of a group with high risk of postoperative complications after deep bowel endometriosis surgery: a retrospective study on 164 patients

PURPOSE

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery.

METHODS

We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics.

RESULTS

164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96-221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74-188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43-159.18); p = 0.005].

CONCLUSION

The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

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

Background

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

Methods

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

Results

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

Conclusion

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

Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis

STUDY QUESTION

How should surgery for endometriosis be performed?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT IS KNOWN ALREADY

Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

STUDY DESIGN SIZE DURATION

A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

PARTICIPANTS/MATERIALS SETTING METHODS

This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.

TRIAL REGISTRATION NUMBER

na.

Deep Infiltrating Endometriosis: Making the Diagnosis

A case is described of a patient who presented with signs and symptoms suggestive of endometriosis. She underwent a diagnostic laparoscopy, which failed to identify any features of endometriosis. The patient subsequently underwent a 3D transvaginal sonogram that demonstrated evidence of a deep infiltrating endometriosis, affecting the right uterosacral ligament. This case demonstrates the diagnostic ability of 3D transvaginal sonography and, at the same time, the potential deficiency of laparoscopy to make the diagnosis of deep infiltrating endometriosis.

Prevention and management of bowel injury during gynecologic laparoscopy: an update

PURPOSE OF REVIEW

The current article aims to briefly review recent literature on bowel injury in gynecologic surgery with a focus on minimally invasive techniques, strategies for prevention, and management of injury.

RECENT FINDINGS

Recent reviews describe a low incidence of bowel injury that is likely affected by low rates of reporting and inconsistent definitions. The major risk factor for bowel injury is adhesive disease, and assessment and prevention techniques for the presence of adhesive disease are evolving. When bowel injury occurs, prompt diagnosis and intraoperative repair yields more favorable outcomes than delayed diagnosis. Repair can be performed by a gynecologic surgeon, with or without the help of a consultant depending on the extent of the injury and surgeon comfort.

SUMMARY

Bowel injury is a potentially catastrophic complication in gynecologic surgery, but its rarity presents a challenge in research. A high index of suspicion and meticulous surgical technique are the cornerstones of managing a bowel injury.

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.

Interrelationships among endometriosis-related pain symptoms and their effects on health-related quality of life: a sectional observational study

Objective

To assess the correlation between different pain symptoms and different domains of women's health-related quality of life (HRQoL).

Methods

Seventy-seven women with deep infiltrating endometriosis were successively enrolled between June 2011 and August 2013 while being prepared to undergo laparoscopy due to pain and/or infertility. We quantified the intensities of dysmenorrhea, deep dyspareunia, chronic pelvic pain, and dyschezia (menstrual and non-menstrual) using a 11-point visual analog scale (VAS: 0-10) and the validated full versions of the Short Form 36 (SF36) and Endometriosis Health Profile (EHP30) questionnaires to assess HRQoL. The pain symptoms were considered simultaneously in a hierarchical agglomerative clustering method (exploratory multivariate approach) and the associations among scores were tested by bivariate correlation.

Results

Dysmenorrhea showed the lowest similarity on to the multivariate cluster analysis and no statistically significant correlation with the other pain symptoms: deep dyspareunia (P=0.244), chronic pelvic pain (P=0.108), menstrual dyschezia (P=0.238), and non-menstrual dyschezia (P=0.380). Dysmenorrhea and chronic pelvic pain were the main symptoms correlated with all domains of the SF36 and the EHP30 (core instrument) questionnaires (P<0.05).

Conclusion

Dysmenorrhea and chronic pelvic pain were independent factors associated with HRQoL.

Inhibitory effect of curcumin in human endometriosis endometrial cells via downregulation of vascular endothelial growth factor

Endometriosis, which affects up to 10% of women of reproductive age, is defined as endometrial-like gland and stroma tissue growths outside the uterine cavity. Despite increasing research efforts, there are no current effective treatment methods for this disease, therefore investigations for therapeutic strategies are of primary concern. In preliminary work, the authors demonstrated that curcumin inhibits endometriosis in vivo. The present in vitro study aimed to investigate the association between endometriotic stromal cells and curcumin and to clarify the underlying mechanism of action. A total of 14 patients with endometriosis were enrolled in the present study. The purity of endometrial stromal cell cultures was proven by standard immunofluorescent staining of vimentin. The cell proliferation and curcumin effects on endometrial stromal cells were assessed by the MTT assay and Hematoxylin and Eosin staining. For cell cycle analysis, phase distribution was detected by flow cytometry. Vascular endothelial growth factor (VEGF) protein expression was examined using immunohistochemistry staining. Apoptosis was assessed using Annexin V‑fluorescein isothiocyanate staining. The results indicated that the treatment of curcumin decreased human ectopic and eutopic stromal cell growth. Following treatment with curcumin, human endometriotic stromal cells demonstrated an increased percentage of G1‑phase cells and decreased percentages of S‑phase cells, particularly in the group treated with 50 µmol/l curcumin. Treatment with curcumin additionally decreased expression of VEGF. The data provide evidence that curcumin reduces cell survival in human endometriotic stromal cells, and this may be mediated via downregulation of the VEGF signaling pathway.