Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification

Connecting the dots: Exploring appendiceal endometriosis in women with diaphragmatic endometriosis

OBJECTIVES

This study aims to ascertain the prevalence of appendiceal endometriosis (AppE) in patients diagnosed with diaphragmatic endometriosis (DiaE), compare it with the prevalence in patients without DiaE, and delineate the anatomical distribution of endometriotic lesions within these cohorts.

STUDY DESIGN

Comparison of the characteristics of patients with AppE and DiaE with the characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study.

SETTING

Tertiary referral center; endometriosis center.

PATIENTS

A cohort of 1765 patients with histologically confirmed endometriosis INTERVENTIONS: Evaluation of correlations between demographic, clinical, and surgical variables of AppE patients with DiaE and without DiaE. We performed appendectomies selectively, in the presence of gross abnormalities of the appendix, such as endometriotic implants, edema, tortuosity, and discoloration of the organ.

MEASUREMENTS

Patients' characteristics were evaluated using basic descriptive statistics (chi-square test or Fisher's exact test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between patient characteristics and the presence of DiaE and AppE.

MAIN RESULTS

Within a cohort of 1765 patients with histologically confirmed endometriosis, 31 were identified with AppE (1.8 %), and 83 with DiaE (4.7 %). The prevalence of DiaE was significantly elevated at 30.1 % (25/83), among patients with AppE compared to those without AppE, who showed a DiaE prevalence of 7.2 % (6/83). The calculated odds ratio for DiaE given the presence of AppE was 5.5, 95 % CI 2.1-14.4, p = 0.0004, and risk ratio was 4.2, 95 % CI 1.8-9.6, p = 0.0008, indicating a profound association. Surgical interventions did not lead to significant perioperative or postoperative complications. In the group with DiaE, the left ovary was affected in 96 % of cases (24/25), p < 0.05, the right ureter in 80 % of cases (20/25), p < 0.01 (in 19/25 only the serosa was affected, due to external compression of an endometriotic nodule of the parametrium). Concurrent AppE and right diaphragm was found in 92 % of cases (23/25 patients), p < 0.001. The concurrent presence of DiaE and AppE was often associated with severe endometriosis, rASRM IV 72 % OR = 3, 95 % CI (1.216-7.872).

CONCLUSION

The investigation delineates a marked association between AppE and DiaE, with an odds ratio of 5.5 and risk ratio of 4.2, suggesting a markedly increased likelihood of DiaE in patients with AppE. These statistics significantly substantiate the notion that AppE can serve as a predictive marker for DiaE, underscoring the necessity for a meticulous intraoperative assessment of diaphragmatic regions in patients diagnosed with AppE. The absence of a significant correlation between the depth of DiaE infiltration and the presence of AppE implies that the detection of AppE should prompt a thorough search for DiaE, regardless of the perceived severity of the endometriosis or preoperative results of diaphragmatic MRI.

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.

Correlation Between Surgical Phenotype and Pain Improvement After Endometriosis Surgery

STUDY OBJECTIVE

To examine pain improvement after endometriosis surgery and whether it can be predicted by the observed surgical phenotype.

DESIGN

Prospective longitudinal survey study.

SETTING

A University hospital.

PATIENTS

A total of 125 patients completed a preoperative questionnaire (response rate: n = 227 of 277, 81.9%), had surgically confirmed endometriosis (n = 202 of 227), and returned a second postoperative questionnaire (response rate: n = 125 of 202, 61.9%).

INTERVENTIONS

All patients underwent complete laparoscopic removal of the endometriotic lesions. Surgical phenotype was classified according to the rASRM and #Enzian classification.

MEASUREMENTS AND MAIN RESULTS

The intensity of 5 specific pain symptoms was questioned by postal paper-pencil questionnaires with a numerical rating scale (0-10) both preoperatively (3.01 ± 2.72 months before surgery) and one year after surgery (12.62 ± 1.59 months). A postoperative pain improvement score was computed (postoperative pain-preoperative pain) for each specific pain symptom (0-10) and for the overall/global pain sum score (0-50). The mean intensity of all pain scores was lower postoperatively as compared with preoperatively (p <.0001). A statistically significant weak correlation was observed between the surgical phenotype "rectovaginal endometriosis" and postoperative improvement of dyspareunia (r = .265; p = .003). The other 11 hypothesized correlations between surgical phenotype and postoperative improvement of pain intensity failed to reach statistical significance.

CONCLUSION

Clinicians can inform patients that surgery is effective in reducing endometriosis-related pain symptoms and the overall/global pain scores at 12 months postoperatively. From our data, we can conclude that patients with rectovaginal endometriosis might benefit the most from the reduction of their sexual pain. On the basis of these results, we could suggest that deep dyspareunia (even if present as an isolated symptom) might be a valid indication for surgery. Further research could explore the association between a certain surgical phenotype and more detailed assessments of sexual functioning, as well as explore whether feedback from the surgeon on expected pain improvement affects patient-reported outcomes.

The appendix in endometriosis

BACKGROUND

In the most severe stage of endometriosis, Stage IV, intestinal involvement is common. The true prevalence of endometriotic disease of the appendix in this population is not well described. A macroscopically normal looking appendix may harbour endometriosis.

AIMS

Our study aims to assess the role of routinely performing appendicectomy in Stage IV endometriosis surgery, and the histopathological prevalence of true appendiceal endometriosis in this population.

METHODS

This is a retrospective study of women undergoing surgery for Stage IV endometriosis between 2018 to 2022 in a tertiary public hospital in New South Wales, Australia. Patient demographics, age and post-operative complications were retrospectively retrieved from hospital medical records. Inclusion criteria were women with Stage IV endometriosis who underwent routine appendicectomy as part of their endometriosis surgery. Exclusion criteria were women who did not have Stage IV endometriosis, those who had cancer surgery or emergency surgery for endometriosis. The primary outcome of this study was to determine the incidence of appendiceal endometriosis. Secondary outcomes included post-operative complications and length of stay.

RESULTS

Sixty-seven patients were included. The mean age was 36 years. All patients also underwent bowel resection for colorectal endometriosis. There were 35.8% who had confirmed appendiceal endometriosis on histopathology. Post-operative complications included port site infections, colitis, urinary tract infection and ureteric injury. There were no complications related to appendicectomy. Mean length of stay was 4.4 days.

CONCLUSION

Laparoscopic appendicectomy can be safely performed at time of laparoscopic surgical excision of Stage IV endometriosis and should be routinely considered in a subset of Stage IV endometriosis patients with colorectal involvement undergoing surgery.

Molecular analysis suggests oligoclonality and metastasis of endometriosis lesions across anatomically defined subtypes

OBJECTIVE

To investigate the heterogeneity of somatic cancer-driver mutations within patients and across endometriosis types.

DESIGN

A single-center cohort, retrospective study.

SETTING

Tertiary specialist-care center at a university hospital.

PATIENT(S)

Patients with surgically and histologically confirmed endometriosis of at least 2 anatomically distinct types (ovarian, deep infiltrating, and superficial).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Specimens were analyzed for the presence or absence of somatic cancer-driver mutations using targeted panel sequencing with orthogonal validation using droplet digital polymerase chain reaction and mutation-surrogate immunohistochemistry.

RESULT(S)

It was found that 13 of 27 patients had informative somatic driver mutations in endometriosis lesions; of these 13 patients, 9 had identical mutations across distinct lesions. Endometriomas showed a higher mutational complexity, with functionally redundant driver mutations in the same gene and within the same lesions.

CONCLUSION(S)

Our data are consistent with clonality across endometriosis lesions, regardless of subtype. Further, the finding of redundancy in mutations within the same gene and lesions is consistent with endometriosis representing an oligoclonal disease with dissemination likely to consist of multiple epithelial clones traveling together. This suggests that the current anatomically defined classification of endometriosis does not fully recognize the etiology of the disease. A novel classification should consider genomic and other molecular features to promote personalized endometriosis diagnosis and care.

Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery

Background

Up to 28% of endometriosis patients do not get pain relief from therapeutic laparoscopy but this subgroup is not defined.

Objectives

To identify any prognostic patient-specific factors (such as but not limited to patients’ type or location of endometriosis, sociodemographics and lifestyle) associated with a clinically meaningful reduction in post-surgical pain response to operative laparoscopic surgery for endometriosis.

Search strategy

PubMed, Cochrane and Embase databases were searched from inception to 19 May 2020 without language restrictions. Backward and forward citation tracking was used.

Selection criteria, data collection and analysis:

Cohort studies reporting prognostic factors, along with scores for domains of pain associated with endometriosis before and after surgery, were included. Studies that compared surgeries, or laboratory tests, or outcomes without stratification were excluded. Results were synthesised but variation in study designs and inconsistency of outcome reporting precluded us from doing a meta-analysis.

Main results

Five studies were included. Quality assessment using the Newcastle–Ottawa scale graded three studies as high, one as moderate and one as having a low risk of bias. Four of five included studies separately reported that a relationship exists between more severe endometriosis and stronger pain relief from laparoscopic surgery.

Conclusion

Currently, there are few studies of appropriate quality to answer the research question. We recommend future studies report core outcome sets to enable meta-analysis.

Lay summary

Endometriosis is a painful condition caused by displaced cells from the lining of the womb, causing inflammation and scarring inside the body. It affects 6–10% of women and there is no permanent cure. Medical and laparoscopic surgical treatments are available, but about 28% of patients do not get the hoped-for pain relief after surgery. Currently, there is no way of predicting who gets better and who does not. We systematically searched the world literature to establish who may get better, in order to improve counselling when women choose treatment options. We identified five studies of variable quality showing: More complex disease (in specialist hands) responds better to surgery than less, but more studies needed.

Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study

OBJECTIVE

To compare the effectiveness of two different treatment regimens of dydrogesterone in the management of endometriosis-related chronic pelvic pain.

DESIGN

Observational, prospective cohort study over six months.

SETTING

Twenty gynecology clinics in the Russian Federation.

PATIENT(S)

Three hundred fifty women from 18 to 45 years of age with endometriosis and chronic pelvic pain with or without dysmenorrhea.

INTERVENTION(S)

Dydrogesterone 10 mg 2 or 3 times daily, either between the 5th and 25th days of the menstrual cycle (prolonged cyclical treatment regimen) or continuously (continuous treatment regimen). For all patients, the data cutoff was at six months of treatment.

MAIN OUTCOME MEASURE(S)

Intensity of chronic pelvic pain on the 11-point numerical rating scale (after 6 months).

RESULT(S)

A marked reduction in chronic pelvic pain was observed with both the prolonged cyclical and continuous treatment regimens (mean ± standard deviation change from baseline -3.3 ± 2.2 and -3.0 ± 2.2, respectively), with no significant difference between the two groups. With both regimens, patients experienced significant improvements in the intensity of chronic pelvic pain, number of days in which analgesics were required, severity of dysmenorrhea, sexual well-being, and health-related quality-of-life parameters. A favorable safety profile of dydrogesterone was confirmed, and no serious adverse drug reactions were reported during the study.

CONCLUSION(S)

Prolonged cyclical and continuous treatment regimens of dydrogesterone therapy both demonstrated a pronounced and similar reduction in the severity of chronic pelvic pain and dysmenorrhea and led to marked improvements in all study parameters related to quality of life and sexual well-being.

REGISTRATION NUMBER

NCT03690765.

Obliterated Posterior Cul-de-sac Laparoscopic Surgical Simulation

BACKGROUND

Obliteration of the posterior cul-de-sac is a challenging, often unexpected surgical finding. Developing the dissection skills required to manage this finding during laparoscopy is essential for optimizing treatment of many pain disorders during hysterectomy or ovarian surgery; however, exposure of trainees to cul-de-sac dissection is variable. Currently, there are no widely available simulation models for teaching and practicing this technique.

METHOD

Our aim is to design a low-cost and high-fidelity laparoscopic simulation model that represents key anatomical structures and emphasizes skills for laparoscopic dissection of an obliterated posterior cul-de-sac.

EXPERIENCE

A three-dimensional model was created and is described. Nine experts (gynecologic surgery fellows and attendings) and 17 residents completed a single 30-minute simulation session and completed several assessments to begin establishing the face validity of this model.

CONCLUSION

Experts and residents rated the obliterated cul-de-sac simulation as highly realistic and useful. Residents showed a statistically significant increase in comfort with the dissection, from a median Likert score of 1 out of 5 (interquartile range 1-1) to 3 out of 5 (interquartile range 2-3) (P<.001). Experts scored better than residents on blinded video grading of model performance (P<.001). This low-cost and easily reproducible model fills a critical gap in gynecologic surgery education.

Ultrasound of the Uterosacral Ligament, Parametrium, and Paracervix: Disagreement in Terminology between Imaging Anatomy and Modern Gynecologic Surgery

Ultrasound is an effective tool to detect and characterize lesions of the uterosacral ligament, parametrium, and paracervix. They may be the site of diseases such as endometriosis and the later stages of cervical cancer. Endometriosis and advanced stages of cervical cancer may infiltrate the parametrium and may also involve the ureter, resulting in a more complex surgery. New functional, surgical anatomy requires the complete diagnostic description of retroperitoneal spaces and tissues that contain vessels and nerves. Most endometriosis lesions and cervical cancer spread involve the cervical section of the uterosacral ligament, which is close to tissues, namely the parametrium and paracervix, which contain vessels and important nerves and nerve anastomoses of the inferior hypogastric plexus. Efferent fibers of the plexus travel to the rectum, uterus, rectovaginal ligament, deep vesicouterine ligament, and bladder. These efferent fibers are essential for bladder and rectal functionality so tailored nerve-sparing surgery became a standard approach for treating deep infiltrating endometriosis and cervical cancer. An accurate diagnosis by ultrasound has significant clinical impact and is important for appropriate treatment. In this article, we try to establish a common terminology between imaging diagnostic and modern surgical anatomy.

Dienogest and the Risk of Endometriosis Recurrence Following Surgery: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials.

METHODS OF STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as "dienogest," "endometriosis," and "recurrence" were used to identify relevant studies.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43-3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66-31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds -1.96, CI, -2.53 to -1.38, p <.001).

CONCLUSION

Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.

Safety of the laparoscopic management of patients with deep infiltrative endometriosis in a reference center in Pereira, Colombia. Retrospective cohorte, 2007-2016

Objective

Describe the intraoperative findings, procedures and the safety of laparoscopic surgical management of Deep Infiltration Endometriosis (DIE).

Materials and methods

A descriptive historical cohort study of patients with suspected pre-surgical diagnosis of DIE due to clinical findings, pelvic ultrasound or magnetic resonance imaging and histological confirmation of the disease. The patients were taken to minimally invasive surgery between 2007 and 2016 in a reference health institution located in Pereira, Colombia. Sociodemographic, clinical, intraoperative findings, types of procedure performed, intra and postoperative complications and post-surgical pain levels at 6 weeks were evaluated. A descriptive analysis was performed.

Results

One hundred and sixty seven patients were included. The most frequent location of the disease was the recto-vaginal septum (85.7 %). A total of 83 patients (49.7 %) had bowel endometriosis. Of these, 86 % had a shaving and 13.2 % segmental bowel resection. Four patients (2.4 %) had intraoperative complications. One was converted to laparotomy and other five (2.9 %) had post-surgical infection.

Conclusions

Laparoscopic management of DIE is an option to be considered with a 5% of complication frequency. Randomized studies with a control group are required for a better evaluation of safety and efficacy.

Intestinal endometriosis: Diagnostic ambiguities and surgical outcomes

BACKGROUND

Endometriosis is a common disease for women of reproductive age. However, when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose.

AIM

To analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases.

METHODS

We retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January 2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes.

RESULTS

Twenty-three (76.6%) patients showed symptoms associated with endometriosis, with dysmenorrhea being the most common (n = 9, 30.0%). Thirteen patients (43.3%) had a history of pelvic surgeries. Ten patients (33.3%) had a history of treatment for endometriosis. Only 4 patients (13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients (43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients (56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine (n = 8, 26.7%), followed by malignancies of the colon/rectum (n = 3, 10.0%) and ovary (n = 3, 10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9 (0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis.

CONCLUSION

Intestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings, intestinal endometriosis should be included in the differential diagnosis.

Is training sufficient for ultrasound operators to diagnose deep infiltrating endometriosis and bowel involvement by transvaginal ultrasound?

OBJECTIVES

To assess and compare the diagnostic accuracy of transvaginal ultrasonography (TVUS) by trained or untrained ultrasound operators in deep infiltrating endometriosis (DIE) imaging, for diagnosing DIE and bowel involvement.

METHODS

This was an observational study of patients with clinically suspected DIE operated in a reference center. TVUS was performed pre-operatively by a trained or/and untrained ultrasound operator to search for DIE and rectal involvement. During surgery, DIE was diagnosed according to macroscopic and histological criteria. Sensitivity (Se), specificity (Sp) and c-index were calculated with 95% confidence intervals for trained and untrained operators, if TVUS results were significantly predictive of DIE and rectal involvement at p<0.05.

RESULTS

115 patients were included: 100 (87%) had DIE and 34 (29.6%) had bowel involvement. TVUS was performed by a trained ultrasound operator for 70 patients and by an untrained one for 56 patients. When performed by a trained operator, TVUS significantly predicted DIE with a Se of 58% (95% CI, 46-70), a Sp of 87.5% (95% CI, 63-100) and a c-index of 0.73 (95% CI, 0.59-0.87). TVUS performed by an untrained operator was not significantly predictive of DIE (p=0.58). Rectal involvement was significantly predicted by TVUS performed by a trained operator with a Se of 40% (95% CI, 23-59), a Sp of 93% (95% CI, 86-100) and a c-index of 0.67 (95% CI, 0.56-0.77). None of the untrained ultrasound operators diagnosed a bowel involvement.

CONCLUSION

TVUS is not sufficient to diagnose DIE and bowel involvement, in particular when performed by untrained ultrasound operators.

Surgery and Endometriosis

Care of the endometriosis patient today can be complex and difficult. Once medical management has been exhausted and symptoms persist patients desire further treatment options. This chapter takes an evidence-based approach at discussion of patient surgcical options for treatment of endometriosis symptoms. Surgical techniques, success rates, patient satisfaction, and risks must be discussed and understood at depth before planning patient surgical intervention. This chapter provides reference to current surgical management options and symptom relief following those interventions.

[Urinary tract involvement by endometriosis. Techniques and outcomes of surgical management: CNGOF-HAS Endometriosis Guidelines]

Urinary tract involvement by endometriosis is reported in 1% of endometriosis patients (NP3). Consequences range from pelvic pain for bladder localizations to silent kidney loss in case of chronic ureteral obstruction (NP3). The feasibility of laparoscopic management was widely proven (NP3) and may reduce hospital stay length (NP4). Radical surgery with partial cystectomy for bladder localizations was shown to significantly and durably reduce pain symptoms with low risk of a severe postoperative complications (NP3). Medical hormonal treatment also shows short-term reduction of pain symptoms (NP4). Transureteral resection of bladder endometriosis nodule is not recommended (grade C) because of a high postoperative recurrence rate (NP4). Given a high risk of silent kidney loss, it is recommended that patients with ureteral involvement by endometriosis are managed by a multidisciplinary team considering urinary and potential extra-urinary localizations of endometriosis (grade C). No recommendation can be made on which technique to prefer between conservative (ureterolysis) or radical surgical techniques or on benefit and length of ureteral stents in case of ureteral involvement. Surgical management of bladder and ureteral localizations of endometriosis do not seem to be associated with altered or improved postoperative fertility (NP4). Since late postoperative ureteral anastomosis stenosis were reported with silent kidney loss, repeated postoperative imaging monitoring is justified (expert opinion).

Evaluation of the Impact of Endometriotic Lesions on Patient'S Pelvic Pain Symptoms

Purpose

To verify if different endometrial lesions determine the diagnostic symptom panel for a specific symptom.

Methods

We recruited 537 women with endometriosis who underwent laparoscopic surgery. Data on patient characteristics, severity of pelvic pain symptoms, disease stage and anatomical characteristics of endometriotic lesions were collected and analyzed by univariate analysis, followed by multiple logistic regression.

Results

We observed a strong inverse relationship between pain symptoms and, respectively, the age of women at surgery (OR 0.885; p<0.05) and nulliparity (OR 5.6; p<0.05). A significant association between dysmenorrhea and nulliparity (OR 10.1; p< 0.01) and dysmenorrhea and rAFS stage (OR 4.7; p<0.05) was also confirmed. Finally a strong relationship was found between the presence of a rectovaginal endometriotic nodule and pain symptoms: dyspareunia (OR 13.8, p<0.001) and dysmenorrhea (OR 2.3, p<0.05). Significant relationships were found between the presence of peri-annexial adherences and, respectively, bilateral endometrioma (p<0.01) and size of endometrioma (p<0.05); between the presence of pelvic adherential syndrome and, respectively, bilateral ovarian cyst (p<0.01), size of ovarian cyst (p<0.01) and rectovaginal nodule (p<0.01). A strong relationship was found also between a rectovaginal nodule and the presence of entero-uterine adherences (p<0.01) and Douglas obliteration (p<0.01). Conclusions: It was not possible determine a precise relationship between a specific pain symptom and the anatomic-surgical characteristics of endometriotic lesions, even though a strong association was seen between a rectovaginal endometriotic nodule and deep dyspareunia. Typical clinical features of endometriosis are probably determined by the association of different characteristics of lesions and different pathogenic mechanisms.

Endometriosis: Diagnosis and Management

Objective

To improve the understanding of endometriosis and to provide evidence-based guidelines for the diagnosis and management of endometriosis.

Outcomes

Outcomes evaluated include the impact of the medical and surgical management of endometriosis on women's experience of morbidity and infertility.

Methods

Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology background. The committee reviewed all available evidence in the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC.

Results

This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of endometriosis. The resulting recommendations may be adapted by individual health care workers when serving women with this condition.

Conclusions

Endometriosis is a common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle modifications, medications, and allied health services should be used to limit the impact of this condition on activities of daily living and fertility. In some circumstances surgery is required to confirm the diagnosis and provide therapy to achieve the desired goal of pain relief or improved fecundity. Women who find an acceptable management strategy for this condition may have an improved quality of life or attain their goal of successful pregnancy.

Evidence

Medline and Cochrane databases were searched for articles in English and French on subjects related to endometriosis, pelvic pain, and infertility from January 1999 to October 2009 in order to prepare a Canadian consensus guideline on the management of endometriosis.

Values

The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table 1.

Benefits, harms, and costs

Implementation of the guideline recommendations will improve the care of women with pain and infertility associated with endometriosis.

Evaluation of sexual function in women with deep infiltrating endometriosis

INTRODUCTION

The influence of deep infiltrating endometriosis (DIE) on sexual function has been poorly studied. The aim of this study was to evaluate the impact of DIE on sexual function by administering questionnaires to women.

METHODS

Women with a clinical and ultrasound diagnosis of DIE and histological confirmation of endometriosis were included in the study. In interview, women were asked to rate five pain symptoms, dysmenorrhea, dyspareunia, dyschezia, dysuria and Cronic Pelvic Pain (CPP), on a visual analogue scale (VAS), and sexual function was assessed using the Female Sexual Function Index (FSFI).

RESULTS

A total of 170 women with DIE were identified. A VAS score of 7 or more was taken to indicate that a symptom was 'severe'. Dysmenorrhea was reported to be severe by 66.5% of the sample, dyspareunia by 41.8%, dyschezia by 32.4% and dysuria by 6.5%. Mean FSFI scores did not differ significantly between women with and without endometriosis lesions at particular sites, except for rectovaginal nodules, which were found to be associated with more impaired sexual activity and sexual function.

CONCLUSIONS

Women with DIE had significant impairment of sexual activity when a partial or total infiltration of the rectovaginal septum occurred. Particular attention should be given to women with this kind of lesion.

Anxiety and depression in patients with endometriosis: impact and management challenges

Endometriosis is one of the most common gynecological diseases and affects ~10% of women in reproductive age. The most common clinical signs of endometriosis are menstrual irregularities, chronic pelvic pain (CPP), dysmenorrhea, dyspareunia and infertility. Symptoms of endometriosis often affect psychological and social functioning of patients. For this reason, endometriosis is considered as a disabling condition that may significantly compromise social relationships, sexuality and mental health. Considering this point, the aim of this narrative review is to elucidate the impact of anxiety and depression in the management of women with endometriosis. Psychological factors have an important role in determining the severity of symptoms, and women who suffer from endometriosis report high levels of anxiety, depression and other psychiatric disorders. In addition, endometriosis is one of the most important causes of CPP; women with endometriosis suffer from a wide range of pelvic pain such as dysmenorrhea, dyspareunia, nonmenstrual (chronic) pelvic pain, pain at ovulation, dyschezia and dysuria. Several studies have underlined the influence of CPP on quality of life and psychological well-being of women with endometriosis. Data suggest that the experience of pelvic pain is an important component of endometriosis and may significantly affect emotive functioning of affected women. It has been demonstrated that high levels of anxiety and depression can amplify the severity of pain. Further studies are needed to better understand the relationship between psychological factors and perception of pain. Treatment of endometriosis may be hormonal or surgical. Surgery is the primary treatment for more severe forms of endometriosis. There are few data in the literature about the influence of psychological factors and psychiatric comorbidities on the effectiveness of treatments. It is important to evaluate the presence of previous psychiatric diseases in order to select the most appropriate treatment for the patient.

Visualization of endometriosis: comparative study of 3-dimensional robotic and 2-dimensional laparoscopic endoscopes

The main objective of this study was to compare results of using the robotic 3D/HD scope and the 2D/HD laparoscope for visual detection of histologically confirmed endometriosis. Three surgeons from different practices enrolled premenopausal women ≥18 years who had elected to undergo robotic-assisted endometriosis resection. Patients were randomized to receive 2D/HD laparoscopic visualization either before or after 3D/HD robotic visualization. Resections then proceeded robotically. The number of histologically confirmed lesions overall and by abdomino-pelvic location, appearance and size was compared by scope type used. During the study, 598 lesions were visualized in 98 patients. Average number of lesions per patient using either scope was 6.1. Mean age was 31 years and 77% were disease stage I/II. On histopathology, 58.4% of lesions resected were consistent with endometriosis. All (100%) of these lesions were detected using the robotic 3D/HD scope and 77.9% using the 2D/HD laparoscope (p < 0.001). Compared to laparoscopic, robotic visualization resulted in detection of more confirmed lesions in all anatomic locations and for most appearances, including the cul-de-sac (100 vs. 79%), atypical appearance (100 vs. 71.3%) and width <5 mm (100 vs. 62%), p's < 0.001). Logistic regression indicated that use of the 3D/HD robotic scope was independently associated with 2.36 times the likelihood (95% CI 1.20, 4.66; p = 0.014) of detecting a confirmed lesion, compared to the 2D/HD laparoscope. Large-scale, long-term studies are needed to substantiate these findings in multiple practice settings and to determine whether 3D robotic versus 2D laparoscopic resection has a beneficial impact on symptomatology, recurrence and fertility outcomes.

Bladder Endometriosis: A Systematic Review of Pathogenesis, Diagnosis, Treatment, Impact on Fertility, and Risk of Malignant Transformation

CONTEXT

The bladder is the most common site affected in urinary tract endometriosis. There is controversy regarding the pathogenesis, clinical management (diagnosis and treatment), impact on fertility, and risk of malignant transformation of bladder endometriosis (BE).

OBJECTIVE

To systematically evaluate evidence regarding the pathogenesis, diagnosis, medical and surgical treatment, impact on female fertility, and risk of malignant transformation of BE.

EVIDENCE ACQUISITION

A systematic review of PubMed/Medline from inception until October 2016 was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/prospero; CRD42016039281). Eighty-seven articles were selected for inclusion in this analysis.

EVIDENCE SYNTHESIS

BE is defined as the presence of endometrial glands and stroma in the detrusor muscle. Ultrasonography is the first-line technique for assessment of BE owing to its accuracy, safety, and cost. Clinical management can be conservative, using hormonal therapies, or surgical. When conservative treatment is preferred, estrogen-progestogen combinations and progestogens should be chosen because of their favorable profile that allows long-term therapy. Surgery should guarantee complete removal of the bladder nodule to minimize recurrence, so transurethral surgery alone should be avoided in favor of segmental bladder resection. There is not a strong rationale for hypothesizing a detrimental impact of BE per se on fertility. Furthermore, current evidence does not support the removal of bladder endometriotic lesions because of the potential risk of malignant transformation since this phenomenon is exceedingly rare.

CONCLUSIONS

BE is a challenging condition, and the common coexistence of other types of endometriosis means that clinical management of BE should involve collaboration between gynecologists and urologists.

PATIENT SUMMARY

In this article we review available knowledge on bladder endometriosis. The review provides a useful tool to guide physicians in the management of this complex condition.

Retroperitoneal anatomy during excision of pelvic side wall endometriosis

Surgical management of endometriosis has been shown to improve dysmenorrhea at all disease stages and is recommended in severe disease for treatment of infertility. Deeply infiltrating endometriosis (DIE) produces thick inflammatory tissue that precludes visualization of anatomical landmarks and distorts normal anatomy. Excision of DIE poses several technical and surgical challenges that mandate a clear understanding of the anatomy of the pelvic sidewall. This review details relevant surgical anatomy and addresses the principles of safe retroperitoneal entry, ureterolysis and excision of endometriotic lesions. Proper use of these techniques should facilitate safe and successful surgery for management of DIE.

Surgical treatment of deep infiltrating rectal endometriosis: in favor of less aggressive surgery

Deep infiltrating endometriosis of the rectum is a severe disease concerning young women of reproductive age. Because it is a benign condition, aggressive surgical treatment and subsequent complications are not always accepted by young patients. Two surgical approaches exist: the radical approach, employing colorectal resection; and the conservative approach, based on rectal shaving or full-thickness disc excision. At present, the majority of patients with rectal endometriosis worldwide are managed by the radical approach. Conversely, as high as 66% of patients with colorectal endometriosis can be managed by either rectal shaving or full-thickness disc excision. Most arguments that used to support the large use of the radical approach may now be disputed. The presumed higher risk of recurrence related to conservative surgery can be balanced by a supposed higher risk of postoperative bowel dysfunction related to the radical approach. Bowel occult microscopic endometriosis renders debatable the hypothesis that more aggressive surgery can definitively cure endometriosis. Although most surgeons consider that radical surgery is unavoidable in patients with rectal nodules responsible for digestive stenosis, conservative surgery can be successfully performed in a majority of cases. In multifocal bowel endometriosis, multiple conservative procedures may be proposed, provided that the nodules are separated by segments of healthy bowel of longer than 5 cm. Attempting conservation of a maximum length of rectum may reduce the risk of postoperative anterior rectal resection syndrome and subsequent debilitating bowel dysfunction and impaired quality of life. Promotion of less aggressive surgery with an aim to better spare organ function has become a general tendency in both oncologic and benign pathologies; thus the management of deep colorectal endometriosis should logically be concerned, too.

[Retroperitoneal endometriosis : When a rare form of endometriosis becomes a urological disease]

BACKGROUND

Retroperitoneal endometriosis is a common benign disease, which requires an interdisciplinary approach. In the clinical practice diagnosis is often delayed for years after onset of the unspecific symptoms so that increased awareness is necessary for detection of the presence of the disease.

OBJECTIVE

This article provides a description of the disease including the symptoms and pathogenesis, an introduction to the complexity of diagnostic investigations and the current therapy recommendations.

MATERIAL AND METHODS

Comparison of current therapy recommendations according to the guidelines under consideration of individual studies and background research. Assessment of studies and the accompanying interpretations with the intention of presenting an introduction to the topic with therapy recommendations.

RESULTS

From a urological point of view retroperitoneal endometriosis is a benign disease affecting the ureters and urinary bladder. Involvement of the ureters leading to hydronephrosis caused by ureteral compression represents an absolute indication for therapy. Recurrent macrohematuria can also necessitate treatment. Treatment includes surgical excision of the focal point of endometriosis as the first line therapy. Various operative procedures and access routes are available but when possible a minimally invasive procedure should be used. A second line drug therapy is also possible.

CONCLUSION

Surgical excision of a clinically significant focus of endometriosis is the gold standard for therapy. This procedure should take place in a specialized center within an interdisciplinary consensus. Due to the fact that endometriosis is primarily a benign disease, medical clarification for the patient concerning the benefits and risks of therapy is absolutely necessary. An individual therapy concept under consideration of factors, such as the specific clinical relevance and psychological stress is recommended and in close cooperation with the patient.

Complications and their management in endometriosis surgery

Endometriosis is a common chronic disease mostly seen in young women. Endometriosis surgery may be considered as rather challenging in gynecology. In this article, we tried to emphasize on basic concepts of endometriosis surgery, the best surgical method that should be applied and the complications and the management of the complications.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Endometriosis: Survey of Current Diagnostic and Therapeutic Options and Latest Research Work

Endometriosis is one of the most frequent benign diseases in women of child-bearing age. The main symptoms are chronic upper abdominal pain and infertility. However, the aetiology and pathogenesis of endometriosis are as yet insufficiently clarified. Thus, therapy is mainly symptomatic with laparoscopic surgery being the gold standard. The aim of drug therapy is to achieve a hypo-oestrogenic condition. In cases of severe endometriosis and a desire to have children there is often an indication for assisted reproduction. The present article illustrates almost all current aspects on the diagnosis of and therapy of endometriosis. From the clinical viewpoint, emphasis is placed on the rare cases of deeply infiltrating endometriosis that are, however, accompanied with a high morbidity. Current therapeutic options in cases of infertility are also presented in more detail. Furthermore, special attention is paid to the latest research results from both clinical and basic research fields in order to demonstrate our current knowledge on the pathogenesis and, where possible, potentially related therapeutic options.

Systematic review of endometriosis pain assessment: how to choose a scale?

BACKGROUND

Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain.

METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336).

RESULTS

A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID.

CONCLUSIONS

When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response.

[Endometriosis: increasing concentrations of serum interleukin-1β and interleukin-1sRII is associated with the deep form of this pathology]

OBJECTIVES

To assess interleukin-1β (IL-1β) and its inhibitory soluble interleukin-1 receptor type II (IL-1sRII) levels into the serum of patients with various forms of endometriosis and normal women, and investigate the correlation with disease activity.

PATIENTS AND METHODS

In this prospective laboratory study (2005-2010), 510 women with histologically proven endometriosis and 93 endometriosis-free controls have been enrolled. Laparoscopic complete exploration of the abdominopelvic cavity and blood samples have been performed in each patient. For each serum, IL-1β and IL-1sRII have been evaluated using Elisa.

RESULTS

IL-1β and IL-1sRII have been respectively detectable in 64% and 54.6% of serum samples from all 603 women studied. IL-1β was higher in women with deep infiltrating endometriosis (DIE) (mean 10.0pg/mL [0.005-416.2]) than in endometriosis-free women (mean 0.5pg/mL [0.01-1.7], P<0.01) or in women with superficial endometriosis (SUP) (mean 0.6pg/mL [0.1-2.9], P<0.01). Also, IL-1sRII was higher in DIE (mean 236.7pg/mL [0.9-6975]) than in the witness group (mean 85.0pg/mL [1-235.2], P<0.05) or in SUP (mean 85.1pg/mL [0.6-302], P<0.01).

CONCLUSION

This study highlights both a marked significant increase in serum IL-1β and IL-1sRII levels in DIE compared to SUP and normal women and suggests that a defect in the control of IL-1 can impact the pathophysiology of endometriosis.

Endometriosis: Does Surgery Offer Long-Term Improvement in Quality of Life?

Introduction

Endometriosis is a common, estrogen-dependent, benign disease that affects women of reproductive age. Endometriosis frequently presents with pain and can result in infertility. The symptoms of the disease have a negative impact on physical and mental aspects of life, contribute to reduction of social contacts and lead to a significant reduction in quality of life. In this study, we investigated quality of life of patients with endometriosis. Moreover, we examined whether surgical management could be beneficial for those patients in terms of improving quality of life.

Material and methods

In this prospective study, we included patients undergoing gynecological operations due to endometriosis-associated problems between 2008 and 2014. All patients were assessed preoperatively and 30 months postoperatively. The survey form chosen to achieve the aims of the study was the Greek version of SF-36.

Results

The results showed that both physical and mental health were highly compromised in patients affected by endometriosis, and surgical management significantly improved patients’ quality of life, as all of the SF-36 scores were higher postoperatively (p<0.05).

Discussion

Endometriosis represents an important medical problem in women, with a high impact on their quality of life, and surgical management can reverse the impact of endometriosis on patients’ health and restore their quality of life.

Dyspareunia and quality of sex life after surgical excision of endometriosis: a systematic review

Dyspareunia, a common symptom of endometriosis, severely affects quality of sex life in affected women. The objective of the present work was to review the effect of surgical resection of endometriosis on pain intensity and quality of sex life. MEDLINE and EMBASE databases were searched for papers investigating the outcome after surgical endometriosis resection on dyspareunia and quality of sex life measured via VAS/NAS respectively via standardised measuring instruments. Data did not permit a meaningful meta-analysis. Out of 64 papers, three studies fulfilled the predefined inclusion criteria involving 128 patients with endometriosis and dyspareunia preoperatively. All included studies showed a significant postoperative reduction (p<0.05) of dyspareunia after a follow-up period of 12 up to 60 months. Sex life also improved significantly (p<0.05), and predominantly evaluated parameters like quality of life and mental health. Intra- and postoperative complications were described in two out of three studies. Surgical excision of deep infiltrating endometriosis is feasible and improves dyspareunia and quality of sex life significantly.