Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach

Robotic Surgery for Severe Endometriosis: A Preliminary Comparative Study of Cost Estimation

STUDY OBJECTIVE

To compare the postoperative outcomes and the overall expenses between conventional laparoscopy and robotic surgery, in a series of consecutive patients managed for only severe endometriosis in our institute.

DESIGN

A cohort comparative study.

SETTING

Center of Excellence in Multidisciplinary Endometriosis Care.

PATIENTS

A total of 175 symptomatic patients undergoing surgery for only severe endometriosis from March 2021 to August 2022.

INTERVENTIONS

We treated patients with endometriosis involving the digestive tract such as rectum, sigmoid colon, and ileocecal junction by rectal shaving, discoid resection, or segmental resection (141 surgeries) with or without bladder (23 surgeries), sacral plexus (19 surgeries), and diaphragm involvements (14 surgeries).

MEASUREMENTS AND MAIN RESULTS

Postoperative outcomes were evaluated in terms of total surgical time (total surgical room occupancy time and total operating time), hospitalization period, postoperative complications, rehospitalization, and second surgical procedures. A statistically higher total surgical room occupancy (203 minutes vs 151 minutes) and operating time (150 minutes vs 105 minutes) were observed in the robotic group (p = .001). No differences in terms of mean hospital stay (p = .06), postoperative complications (p = .91), rehospitalization (p = .48), and secondary surgical treatment (p = .78) were identified. Concerning the cost analysis only for disposable supply, the cost of colorectal resection was totaled at 2604 euros for the laparoscopic conventional approach vs 2957 euros for the robotic approach (+352.6 euros, +14%). The cost of rectal disc excision was 1527 euros for the laparoscopic conventional approach vs 1905.85 euros (+378 euros, +25%).

CONCLUSIONS

Our study confirms the feasibility of the robotic approach for the treatment of severe endometriosis, with however a higher cost of robotic approach. Next studies should identify specific indications for robotic surgery, where technical advantages provided by the technology are followed by objective improvement of patients' outcomes.

A Case of Rectal Endometriosis Misdiagnosed as Rectal Malignancy on Three Colonoscopies and Biopsies Sharing a Combined Literature Review

Background

Endometriosis involves the intestine, and its clinical manifestations are nonspecific and lack of etiological manifestations. The diagnosis is difficult, which often leads to misdiagnosis. We report a case of endometriosis which was misdiagnosed as intestinal malignant tumor after colonoscopy and three biopsies.

Case Presentation

We reported a 42-year-old woman who went to see a doctor because of anal distension. She was examined by three gastrointestinal endoscopists at different levels in different hospitals and underwent biopsy at the same time. Combined with clinical manifestations, imaging examination, endoscopic examination and pathological examination, she was misdiagnosed as intestinal malignant tumor, and partial intestinal resection was performed according to the surgical principle of malignant tumor.

Conclusion

Although there are advanced gastrointestinal endoscopy and imaging techniques, intestinal endometriosis is still easy to be misdiagnosed. As our case report shows, after three colonoscopy and biopsy, it is still misdiagnosed as intestinal malignant tumor. Further research is needed to improve the ability of preoperative diagnosis, which deserves the attention of gastroenterologists and obstetricians and gynecologists.

Robotic-assisted versus conventional laparoscopic approach in patients with large rectal endometriotic nodule: the evaluation of safety and complications

AIM

The aim was to compare postoperative complications in patients undergoing the excision of a rectal endometriotic nodule over 3 cm by a robotic-assisted versus a conventional laparoscopic approach.

METHODS

We conducted a retrospective cohort study evaluating prospectively collected data. The main interventions included rectal shaving, disc excision or colorectal resection. All the surgeries were performed in one endometriosis reference institute. To evaluate factors significantly associated with the risk of anastomosis leakage or fistula and bladder atony, we conducted a multivariate logistic regression model.

RESULTS

A total of 548 patients with rectal endometriotic nodule over 3 cm in diameter (#ENZIAN C3) were included in the final analysis. The demography and clinical characteristics of women managed by the robotic-assisted (n = 97) approach were similar to those of patients who underwent conventional laparoscopy (n = 451). The multivariate logistic regression demonstrated that the surgical approach (robotic-assisted vs. laparoscopic) was not associated with the rate of anastomosis leakage or fistula (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 0.3-4.0) and bladder dysfunction (aOR 0.5, 95% CI 0.1-1.8). A rectal nodule located lower than 6 cm from the anal verge was significantly associated with anastomosis leakage (aOR 4.1, 95% CI 1.4-10.8) and bladder atony (aOR 4.3, 95% CI 1.5-12.3). Anastomosis leakage was also associated with smoking (aOR 3.2, 95% CI 1.4-7.4), significant vaginal infiltration (aOR 2.7, 95% CI 1.2-6.7) and excision of nodules involving sacral roots (aOR 5.6, 95% CI 1.7-15.5).

CONCLUSION

The robotic-assisted approach was not associated with increased risk of main postoperative complications compared to conventional laparoscopy for the treatment of large rectal endometriotic nodules.

Deep pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group

PURPOSE

The purpose of this consensus article was to develop guidelines by a focused panel of experts to elaborate a lexicon of image interpretation, and a standardized region-based reporting of deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Evidence-based data and expert opinion were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of pelvic compartment delineation and reporting template were collected; responses were analyzed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS

Consensus regarding pelvic compartment delineation and DIE reporting was attained using the RAND-UCLA Appropriateness Method. The pelvis was divided in nine compartments and extrapelvic lesions were assigned to an additional (tenth) compartment. A consensus was also reached for each structure attributed to a compartment and each reporting template item among the experts. No consensus was reached for a normal aspect of uterosacral ligament, but a consensus was reached for an unequivocal involvement leading to a positive diagnosis and an equivocal involvement leading to uncertain diagnosis. Tailored MRI lexicon and standardized region-based report were proposed.

CONCLUSION

These consensus recommendations should be used as a guide for DIE reporting and staging with MRI. Standardized MRI compartment-based structured reporting is recommended to enable consistent accuracy and help select the best therapeutic approach.

Lower gastrointestinal function after surgery for deep endometriosis: A prospective cohort study

OBJECTIVE

To prospectively compare long-term lower gastrointestinal function before and after laparoscopic surgery for deep endometriosis (DE).

METHODS

In this prospective observational study we followed 149 patients with confirmed DE who were treated surgically. Patients completed the International Consultation on Incontinence Questionnaire Anal Incontinence Symptoms and Quality of Life Module (ICIQ-B) before surgery, and 6 weeks, 6 months, and 12 months after surgery. Bowel pattern, bowel control, and bowel impact on quality of life summary scores were compared before and after surgery.

RESULTS

Bowel pattern score showed an increasing improvement at all time points after surgery, from a mean pre-operation score of 4.8 ± 2.0 to 4.4 ± 1.8 at 6 weeks, 4.2 ± 1.8 at 6 months, and 4.2 ± 1.2 at 12 months. Bowel impact on quality of life significantly improved from pre-surgery mean score of 5.5 ± 6.0 to 4.2 ± 5.5 at 6 weeks and 4.4 ± 5.4 at 6 months. Direct lower gastrointestinal endometriosis involvement and worse initial function were associated with larger improvements in scores following surgery.

CONCLUSIONS

Lower gastrointestinal function significantly improved after surgical treatment of DE. Further research is needed to confirm our findings and to better characterize the sub-groups of patients for whom surgery will have a beneficial effect on their bowel function.

Conservative versus Radical Surgery for Women with Deep Infiltrating Endometriosis: Systematic Review and Meta-analysis of Bowel Function

OBJECTIVE

To assess bowel function in women with deep infiltrating endometriosis according to surgical approach (radical vs conservative).

DATA SOURCES

Five databases were searched from 1970 to September 2021 to retrieve studies comparing radical (colorectal segmental resection) and conservative (shaving or discoid excision) surgery for bowel function in women with deep infiltrating endometriosis.

METHODS OF STUDY SELECTION

No language restriction was applied. Two reviewers extracted and combined data from the included studies, applying a meta-analytic model with random effects in all calculations. Results are expressed in risk ratio (RR) with 95% confidence interval (CI). Assessment of risk of bias and quality of evidence was performed by the Newcastle-Ottawa and Grading of Recommendations, Assessment, Development and Evaluation, respectively.

TABULATION, INTEGRATION, AND RESULTS

We included 13 studies in our meta-analysis, and most of them were of nonrandomized design. Conservative surgery had fewer events of constipation and frequent bowel movements when compared with radical surgery (RR, 2.31; 95% CI, 1.21-4.43; I2 = 0%; 3 studies; RR, 2.80; 95% CI 1.17-6.75; I2 = 0%; 2 studies, respectively). Defecation pain, anal incontinence loss, minor and major lower anterior resection syndrome, and Clavien-Dindo complications grade I to IV showed no statistically significant difference between surgeries. Grading of Recommendations, Assessment, Development and Evaluation assessment was low to very low for all outcomes.

CONCLUSION

Conservative surgery (shaving or discoid excision) presented fewer events of constipation and frequent bowel movements than colorectal segmental resection. There was a very low quality of evidence to provide recommendations regarding bowel function.

Quality of Life in Women after Deep Endometriosis Surgery: Comparison with Spanish Standardized Values

The quality of life (QoL) of women who have been surgically treated for endometriosis may be severely impaired. Therefore, QoL can be a determining factor in the recovery of these patients. The aims of this study were to evaluate if the QoL of women surgically treated for deep endometriosis differs from a healthy age-matched population from Catalonia (Spain) and to analyze the QoL of these women considering concomitant events. This is an observational cross-sectional study, where 112 women (between 18 and 48 years old), with endometriosis treated by surgery at Hospital Universitario La Paz (Madrid, Spain), were enrolled to assess the QoL using the second version of the 12-item short form (SF-12) questionnaire. The QoL in these women were tested against a reference population of healthy women using a standardized one-sample comparison method. In addition, the QoL was compared according to the pathophysiology and type of surgery. In women with endometriosis, the physical health component, but not mental health component, was positively correlated with age (r = 0.19; p-Value = 0.048). In addition, physical (20.3 ± 29.2) and social functions (29.7 ± 38.3) and the overall physical health component (37.8 ± 19.4) were significantly lower than the reference population. On the contrary, the body pain (64.1 ± 41.2), emotional role (62.5 ± 42.2), mental health (54.4 ± 26.0), vitality (59.3 ± 31.2), and the overall mental health component (59.4 ± 26.6) had significantly higher scores than the reference. The anatomical compartment of endometriosis, reintervention, bowel nodule resection, and fertility preservation did not show statistical differences in QoL. Women with deep endometriosis had worse physical and social functions, and the overall physical health, compared to the norm in Spanish women. Bodily pain, emotional role, vitality, and the overall mental health improved. These areas could be considered protective factors in this disease. Considering the importance of QoL in adjustments in mental and physical health, it would be necessary to improve these areas of QoL in women surgically treated for deep endometriosis.

Differences in intensity and quality of bowel symptoms in patients with colorectal endometriosis : An observational cross-sectional study

BACKGROUND

Patients suffering from colorectal deep endometriosis (DE) experience gastrointestinal symptoms with almost the same frequency as gynecological pain symptoms. Preoperatively existing gastrointestinal symptoms may translate into pathological gastrointestinal quality of life index (GIQLI) and low anterior resection syndrome scores (LARS). This prospective questionnaire-based case control study aims to assess the prevalence of gastrointestinal complaints reflected by changes in LARS and GIQLI scores in patients with colorectal deep endometriosis prior to surgical treatment and compare those to a healthy control group.

METHODS

The study was conducted at the Hospital St. John of God in Vienna and included a total of 97 patients with histologically confirmed colorectal DE with radical surgical treatment and 96 women in whom DE was excluded via transvaginal sonography (TVS) or visually. Gastrointestinal symptoms reflected by LARS and GIQLI scores were evaluated presurgically and in controls.

RESULTS

A total of 193 premenopausal patients were included in this study. A mean GIQLI of 90.7 ± 22.0 and 129.4 ± 11.1 was observed among patients and controls, respectively, showing a significantly higher morbidity concerning gastrointestinal symptoms and decreased quality of life (QoL) compared to healthy controls (p < 0.001). The LARS score results demonstrated that 18.6% of the patients with bowel DE presented with a major LARS and 27.8% with a minor LARS presurgically compared to 2.1% and 9.4% of control patients, respectively (p < 0.001).

CONCLUSION

Patients with colorectal DE experience a quality of gastrointestinal symptoms translating into a decreased QoL and pathological GIQLI and LARS scores already presurgically. As a consequence, these instruments should be interpreted with caution.

Rectosigmoid endometriosis: Diagnostic pitfalls and management – A case report

Endometriosis constitutes a benign condition, occurring in 10%–12% of menstruating women. Bowel involvement is estimated to occur in 5%–12% with the rectosigmoid region involved in up to 90% of these cases. We present the case of a 45‐year‐old Caucasian female patient with rectosigmoid endometriosis.

Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis

OBJECTIVE

To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis.

METHODS

An observational prospective cohort study was performed by enrolling all endometriosis women scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), levator-ani muscle (LAM)-coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups [only ovarian and deep infiltrating endometriosis (DIE)].

RESULTS

87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, a higher prevalence of LAM-coactivation compared to women without CC. In ovarian-subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva and higher prevalence of LAM-coactivation compared to non-CC patients. In DIE-subgroup, TPU did not significantly differ between CC and non-CC patients.

CONCLUSION

TPU signs of pelvic floor muscle hypertone are more frequent in endometriosis patients with CC compared to those without constipation, particularly in women affected by isolated ovarian endometriosis.

SURGICAL TECHNIQUES FOR THE TREATMENT OF RECTAL ENDOMETRIOSIS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS AND OBSERVATIONAL STUDIES

BACKGROUND

Endometriosis is a common disease in reproductive-age women and it is estimated to occur in up to 50% of those with infertility. Intestinal involvement is reported in up to a third of the cases. This condition is related to chronic pain and loss of quality of life, resulting in emotional, social and economic costs. Treatment consists of hormonal block and surgical resection, with variable side effects and efficacy. The best choice for surgical treatment for rectal endometriosis is a matter of discussion regarding the indication and the best technique to be employed.

OBJECTIVE

To summarize data on indications, results and complications of surgical techniques for the treatment of rectal endometriosis.

METHODS

This comprehensive systematic review is a compilation of the available literature and discussion, carried out by a team with experience in the surgical treatment of intestinal endometriosis. Data regarding indications, results and complications of conservative and radical techniques for the surgical treatment of rectal endometriosis was carefully reviewed. Searches of PubMed, EMBASE, and CENTRAL up to May 2021 were performed to identify randomized controlled trials (RCTs) and observational studies that compared at least two of the three surgical techniques of interest (i.e., shaving, discoid resection, segmental resection).

RESULTS

One RCT and nine case series studies with a total of 3,327 patients met the eligibility criteria. Participants ages ranged from a mean of 30.0 to 37.9 years old. Mean follow-up ranged from 1.2 to 42.76 months. With regards the methodological quality, overall the included studies presented a low risk of bias in the majority of the domains. Surgical treatment of rectal endometriosis is indicated for patients with obstructive symptoms and those with pain scores above 7/10. Patients with disease involving beyond muscularis propria of the rectum, documented in magnetic resonance imaging or transvaginal pelvic ultrasound with intestinal preparation, are candidates for discoid or segmental resection. The presence of multifocal disease, extension greater than 3 cm and infiltration greater than 50% of the loop circumference favor the radical technique. The distance from the lesion to the anal verge, age, symptoms and reproductive desire are other factors that influence the choice of the technique to be employed. The risk of complications and unfavorable functional results seems to be directly related to the complexity of the procedure.

CONCLUSION

The choice of surgical technique performed for the treatment of rectal endometriosis is a matter of discussion and depends not only on the preoperative staging, but also on the patient's expectations, risks and potential complications, recurrence rates and the expertise of the multidisciplinary team.

Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement - a discrete choice experiment

Objective

To study the preferences of women with deep endometriosis (DE) with bowel involvement when they have to choose between conservative (medication) or surgical treatment.

Design

Labelled discrete choice experiment (DCE).

Setting

Dutch academic and non‐academic hospitals and online recruitment.

Population or Sample

A total of 169 women diagnosed with DE of the bowel.

Methods

Baseline characteristics and the fear of surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression.

Main Outcome Measures

The following attributes – effect on/risk of pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms – were used in this DCE.

Results

In the ranking, osteoporosis was ranked with low importance, whereas in the DCE, a lower chance of osteoporosis was one of the most important drivers when choosing a conservative treatment. Women with previous surgery showed less fear of surgery compared with women without surgery. Low anterior resection syndrome was almost equally important for patients as the chance of pain reduction. Pain reduction had higher importance than improving fertility chances, even in women with desire for a future child.

Conclusions

The risk of developing low anterior resection syndrome as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear of surgery compared with women without a surgical history.

Tweetable Abstract

First discrete choice experiment in patients with deep endometriosis.

First discrete choice experiment in patients with deep endometriosis.

Evolution of bowel complaints after laparoscopy endometriosis surgery: a 1497 women comparative study

STUDY OBJECTIVE

To assess what degree can digestive symptoms improve after endometriosis surgery for different localisations?

DESIGN

A comparative retrospective study employing data prospectively recorded in The North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018.

SETTING

Two referral centres Patients: 1,497 women undergoing surgery due to pelvic endometriosis were divided into three groups: superficial endometriosis (Group 1, n=396), deep endometriosis sparing the bowel (Group 2, n=337), and deep endometriosis involving the bowel (Group 3, n=764).

INTERVENTIONS

Surgery for endometriosis.

MEASUREMENTS AND MAIN RESULTS

Preoperative and postoperative gastrointestinal symptoms were evaluated with standardised questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardised questionnaires GIQLI, KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms.

CONCLUSION

Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints.

Patient-Reported Outcome Measures in Endometriosis

Patient Reported Outcome Measures (PROM) evoke measurements that allow capturing patients’ perspectives on their condition. In endometriosis care, physicians’ understanding of the effect of the disease and the treatment on patients is often poor. The use of PROMs in endometriosis clinical practice can facilitate patient-provider communication and the implementation of patient-centered care, improve patients’ quality of life, as well as provide a tool for patients’ self-management of the disease. Today, PROMs are extensively used in research and clinical trials, however they are barely used in clinical practice. The development of digital tools facilitating capturing PROMs can contribute to their use by physicians in routine endometriosis care. However, all PROMs are not adapted to be used in routine care in the context of endometriosis. The objective of this study was to present a catalogue of available PROMs for routine endometriosis care and evaluate them according to selected criteria. To do so, we explored the different PROMs currently in the literature. Consequently, 48 PROM were identified as tools used to evaluate various dimensions of the impact of endometriosis on patients. The selected PROMs were evaluated for their potential to be used as a standard in clinical practice in endometriosis. The selected catalogue of PROMs is the starting point for the integration of digital tools to capture PROMs and the development of patient-centered dashboards to be used by patients and clinicians in endometriosis care and self-management to improve care processes, patient satisfaction, quality of life, and outcomes.

Urinary Function after Surgery for Deep Endometriosis: A Prospective Study

STUDY OBJECTIVE

To compare urinary function before and after surgery in patients undergoing laparoscopy for deep endometriosis and to measure the rate of postoperative deterioration in urinary function after surgery.

DESIGN

Prospective questionnaire-based observational cohort study.

SETTING

Tertiary university-affiliated hospital.

PATIENTS

Included were 149 women who underwent surgery for deep endometriosis.

INTERVENTIONS

Participants completed the international consultation on incontinence female lower urinary tract symptoms long-form questionnaire before surgery and 6 weeks, 6 months, and 12 months after surgery.

MEASUREMENTS AND MAIN RESULTS

Bladder filling, voiding, and urinary incontinence summary scores were compared before and after surgery with mixed-effects linear regression analysis (correlated observations). Individual domains comprising the summary scores and their bother scores were also compared before and after surgery. Filling score at 6 weeks (3.7 ± 2.6), 6 months (3.2 ± 2.2), and 12 months (3.4 ± 2.2) improved from presurgery scores (4.2 ± 2.6) (p-value for the difference between before and after surgery: p <.001, p = .009, and p = .02 for 6 weeks, 6 months, and 12 months, respectively). No change was observed after surgery in bladder voiding score. Incontinence score improved at 6 weeks after surgery (presurgery and 6-week scores: 2.5 ± 3.3 and 1.6 ± 2.2, respectively, p <.001) but not thereafter. Patients with low preoperative summary scores had higher summary scores (worse function) after surgery, and patients with high preoperative scores had lower summary scores (improved function) after surgery.

CONCLUSION

Urinary function improved after laparoscopy for deep endometriosis. Greatest improvement was found in patients with worse preoperative function, whereas postoperative deterioration in urinary function was found for patients with initially normal function. More research is needed to better identify the subpopulations in whom surgical intervention provides symptomatic benefit or deterioration.

"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients

BACKGROUND

Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications.

METHODS

Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE.

RESULTS

Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated.

CONCLUSIONS

Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum-The Rouen Technique

The complete excision of low rectovaginal deep endometriosis is a demanding surgery associated with an increased risk of intra- and postoperative complications, which can impact the quality of life. Given the choices of optimal surgery procedures available, we would like to emphasize that a minimally invasive approach with plasma medicine and a transanal disc excision could significantly improve surgery for deep endometriosis, avoiding the lateral thermal damage of vascular and parasympathetic fibers of roots S2–S5 in the pelvic plexus. The management of low rectal deep endometriosis is distinct from other gastrointestinal-tract endometriosis nodules. Suggestions and explanations are presented for this minimal approach. These contribute to individualized medical care for deep endometriosis. In brief, a laparoscopic transanal disc excision (LTADE; Rouen technique) was performed through a laparoscopic deep rectal dissection, combined with plasma energy shaving, and followed by a transanal disc excision of the low and mid-rectal deep endometriotic nodules, with the use of a semi-circular stapler. LTADE is indicated as the first-line surgical treatment for low and mid-rectal deep endometriotic nodule excisions, because it can preserve rectal length and innervation. This technique requires a multidisciplinary team with surgical colorectal training.

Rectal endometriosis: predictive MRI signs for segmental bowel resection

OBJECTIVE

To retrospectively determine the accuracy of MRI rectal and pararectal signs in predicting the necessity for segmental resection in the case of lesions located in the rectum.

METHODS

MR images of consecutive patients treated for rectal endometriosis over a 5-year period were reviewed in consensus by two blinded readers. A systematic analysis of 7 rectal (lesion length, transverse axis, thickness and circumference, and presence of a convex base, submucosal oedema and hyperintense cystic areas) and 4 pararectal (posterior vaginal fornix, parametrial, ureteral and sacro-recto-genital septum involvements) signs was performed for each lesion. MRI results were compared to the surgical procedure performed (shaving versus segmental resection).

RESULTS

Among 61 patients studied, 32 received a segmental resection and 29, a shaving. Receiver operating characteristic curve analysis allowed determining cut-off values for length (≥ 32 mm), transverse axis (≥ 22 mm), thickness (≥ 14 mm) and circumference (≥ 3/8 radii). The 7 rectal signs, and only the sacro-recto-genital septum pararectal sign, were significantly associated with segmental resection in univariate analysis, nodular thickness ≥ 14 mm and circumference ≥ 3/8 radii being the most predictive signs (odds ratio 94.5 and 60.4, respectively). These 2 signs remained positively associated with segmental resection in multivariate analysis and, when combined, were predictive of segmental resection with an accuracy of 90.2%.

CONCLUSION

Assessing MRI rectal and pararectal signs may accurately predict the need for segmental resection versus a more conservative approach such as shaving for rectal lesion management.

KEY POINTS

• MRI analysis of rectal endometriosis, taking into account rectal and pararectal signs, may assist surgeons in the decision-making process, in counselling patients regarding the surgical procedure and in adequately allocating resources. • Among rectal signs, nodular thickness ≥ 14 mm and a circumference ≥ 38% were the most predictive signs of segmental resection. • Among pararectal signs, only the sacro-recto-genital septum involvement was significantly associated with segmental resection.

Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes.

DATA SOURCES

We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications").

METHODS OF STUDY SELECTION

Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations.

TABULATION, INTEGRATION, AND RESULTS

Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I² = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I² = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I² = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I² = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I² = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I² = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I² = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I² = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I² = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I² = 71%).

CONCLUSION

Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Surgery-related complications and long-term functional morbidity after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT morb)

PURPOSE

Segmental resection has been generally associated with increased peri-operative risk of major complications. While major complications are widely acknowledged, minor complications, such as slight, to moderate infections, peripheral sensory disturbances, bladder voiding dysfunction, postoperative urinary obstruction, and sexual disorders are less reported. The aim of this study is to investigate the surgery-related complications and functional disorders, as well as to evaluate their persistence after long-term follow-up in women undergone segmental resection for deep infiltrating endometriosis. Special attention is given to evaluating impairments of bowel, bladder, and sexual function.

METHODS

All clinical data obtained from medical records of women who underwent segmental resection for intestinal endometriosis between October 2005, and November 2017, in Catholic University Institutions. Perioperative morbidity was classified by Extended Clavien-Dindo classification. Postoperative intestinal, voiding, and sexual morbidity was estimated by the compilation of specific questionnaires.

RESULTS

Fifty women were included in the study. Forty-three high colorectal resections (86%), 6 low resections (12%), and 1 ultra-low resection (2%) were performed, while in 3 cases (6%) multiple resections were needed. The overall complication rate was 44%. Nineteen women (38%) experienced early complications and 3 women (6%) late complications. Long-term functional postoperative complications were composed of intestinal in 30%, urinary in 50%, and sexual in 64% of the study population. Median follow-up was 55.5 months.

CONCLUSIONS

Segmental resection, when indicated, offers a radical and feasible approach for bowel deep infiltrating endometriosis, resulting in an improved general quality of life. The bowel and bladder complications appear to be acceptable and often reversible. Postoperative sexual dysfunctions, such as anorgasmia and insufficient vaginal lubrication, appear to persist over time. Surgeons and women have to be aware of the incidence of this kind of complications.

Rectosigmoid Endometriosis Vascular Patterns at Intraoperative Indocyanine Green Angiography and their Correlation with Clinicopathological Data

Introduction. The objective of the study was to evaluate the presence of different rectosigmoid endometriosis (RSE) vascular patterns using intraoperative indocyanine green (ICG) angiography and their correlation with clinicopathological data. Material and Methods. A prospective pilot study on 30 consecutive symptomatic women affected by RSE and scheduled for minimally invasive surgery between May 2018 and January 2019. ICG was used for the intraoperative evaluation of RSE vascularization. Perfusion grade was classified as follows: 0-1 = no or low fluorescence (hypovascular pattern); 2 = regular fluorescence, similar to healthy surrounding rectosigmoid tract (isovascular pattern); and 3-4 = diffuse or abundant fluorescence (hypervascular pattern). Results. Thirty women were intravenously injected with ICG after nodule exposure. No adverse effects related to ICG use were noted. After a 5- to 50-s latency from ICG injection, the real-time direct visualization of RSE perfusion showed diffuse or abundant fluorescence in 12/30 (40%) women, while in the remaining 18/30 (60%), fluorescence was poor or absent. No statistical differences were observed between the 2 groups regarding preoperative, intraoperative, and histological variables analyzed, except for a maximum diameter of bowel lesions and microvessel density (MVD). Hypovascular nodules had a larger maximum diameter (39.5 ± 15.6 mm vs 30.3 ± 11.4 mm, P < .05) and lower MVD (154.6+/43.6 vs 281.1+/-77.4, P < .05) than hypervascular ones. Conclusions. ICG angiography is a feasible and safe technique to intraoperatively assess RSE vascularization. The majority (60%) of endometriotic nodule presented a hypovascular pattern. The hypovascular pattern seems to be associated with a larger nodule size and lower MVD.

Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis

INTRODUCTION

Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms.

MATERIAL AND METHODS

We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea.

RESULTS

Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group.

CONCLUSIONS

Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.

Bowel Endometriosis: Current Perspectives on Diagnosis and Treatment

Endometriosis is a chronic condition primarily affecting young women of reproductive age. Although some women with bowel endometriosis may be asymptomatic patients typically report a myriad of symptoms such as alteration in bowel habits (constipation/diarrhoea) dyschezia, dysmenorrhoea and dyspareunia in addition to infertility. To date, there are no clear guidelines on the evaluation of patients with suspected bowel endometriosis. Several techniques have been proposed including transvaginal and/or transrectal ultrasonography, magnetic resonance imaging, and double-contrast barium enema. These different imaging modalities provide greater information regarding presence, location and extent of endometriosis ensuring patients are adequately informed whilst also optimizing preoperative planning. In cases where surgical management is indicated, surgery should be performed by experienced surgeons, in centres with access to multidisciplinary care. Treatment should be tailored according to patient symptoms and wishes with a view to excising as much disease as possible, whilst at the same time preserving organ function. In this review article current perspectives on diagnosis and management of bowel endometriosis are discussed.

Levator ani evaluation at transperineal elastography in women with deep infiltrating endometriosis postoperatively

OBJECTIVE

To explore whether operation can change the elasticity of levator ani in deep infiltrating endometriosis (DIE) with operation and pharmacotherapy using transperineal elastography.

METHODS

Total thirty-four patients who were diagnosed as DIE were included in the study. Transperineal elastography were performed in all cases preoperatively and postoperatively. The levator ani was evaluated by means of the scoring system and strain ratio (SR) values on maximal Valsalva and quiescent condition, respectively.

RESULTS

On quiescent condition, the preoperative mean elastography scores and SR of the levator ani were statistically significantly higher than the postoperative ones in both shaving technique group and segmental colorectal resection group. And on maximal Valsalva, the preoperative mean elastography scores and SR of the levator ani were statistically significantly lower than the postoperative ones in both groups. After surgery and 6 cycles of GnRHa therapy, the mean elastography score and SR of the levator ani were statistically significantly lower than before GnRHa therapy in shaving technique group on quiescent condition. And on maximal Valsalva, the mean elastography score and SR were statistically higher than before GnRHa therapy. However, in segmental colorectal resection group, the differences were not observed before and following 6 cycles of GnRHa therapy.

CONCLUSION

The elasticity of levator ani of DIE was changed by both shaving technique and segmental colorectal resection. And transperineal elastography could access the alterations.

Quality of life in women with endometriosis: a narrative overview

Endometriosis is a very complex condition and has a significant impact on the quality of life, psychological wellbeing and interpersonal relationships of affected women. Endometriosis symptoms progressively impair the woman's ability to carry out some daily activities and result in a perception of worsening health status and overall well-being. The impact of these symptoms has been only partially investigated, and further studies and clinical insights are needed to fully understand the extent of this condition. It has been shown that endometriosis is associated with considerable direct and indirect costs, comparable to those of major worldwide chronic diseases such as diabetes. In addition, endometriosis-related symptoms substantially interfere with the employment of affected women, resulting in many cases in several working days missed. In this scenario, the aim of this narrative review is to provide a general overview of the psychological and social impact of this disease, as well as the effects of different therapeutic options, on quality of life and general well-being.

Sexuality in women with endometriosis: a critical narrative review

Endometriosis is a chronic gynecological disease that generally affects young and sexually active women in different stages of their development and sexual life. Because endometriosis affects about 5-10% of women in reproductive age, it is possible to estimate that about 2-4% of those who are sexually active may suffer from sexual dysfunction caused by this disease. Surgical and pharmacological treatments of endometriosis can improve the patient's sexual function in the medium and long term, but not necessarily lead to a definitive resolution of the sexual issue. For this reason, the ideal treatment should be conducted by a multidisciplinary team, with the aim to improve overall sexual functioning and not only to reduce the painful symptoms during intercourse. In light of these considerations, the aim of this narrative review was to provide a general overview about the impact of endometriosis on sexuality of women affected and the effectiveness of surgical and pharmacological treatments in improving sexual function.

Recurrent endometriosis: a battle against an unknown enemy

Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.

Conservative treatment of rectosigmoid endometriosis: A prospective study

INTRODUCTION

Deep infiltrating endometriosis is a common cause of pelvic pain. However, some patients have limited problems that may be controlled by medical treatment, so avoiding the potentially severe complications of major surgery. This approach requires detailed knowledge on quality of life and clinical symptoms over time. The aim of the study was to monitor these parameters in patients with rectosigmoid endometriosis treated with oral contraceptives, oral gestagens, and/or the levonorgestrel-releasing intrauterine device. Moreover, nodule size measurements performed with transvaginal sonography were correlated to severity of symptoms.

MATERIAL AND METHODS

Conservatively treated patients on oral contraceptives, oral gestagens, or the levonorgestrel-releasing intrauterine device underwent transvaginal sonography and answered a self-administered questionnaire regarding clinical symptoms and quality of life (Short Form 36 and Endometriosis Health Profile 30) at baseline, and 6 and 12 months later.

RESULTS

Eighty women completed the follow up. Scores of quality of life were comparable to normative data for Danish women of similar age and did not change with time. No association between change in size of the rectosigmoid nodule and change in symptoms was seen.

CONCLUSIONS

This study supports that simple treatment with oral contraceptives, oral gestagens, or the levonorgestrel-releasing intrauterine device represents a viable therapeutic approach to rectosigmoid Deep infiltrating endometriosis, provided that proper selection of patients in need of surgery exists.

Transvaginal sonography with vs without bowel preparation in diagnosis of rectosigmoid endometriosis: prospective study

OBJECTIVES

The primary aim of this study was to compare the diagnostic accuracy of transvaginal sonography (TVS) with vs without bowel preparation (BP) in detecting the presence of rectosigmoid endometriosis. Secondary objectives were to compare the diagnostic accuracy of the two techniques in estimating infiltration of the submucosa, length of the largest rectosigmoid nodules, distance of the nodules from the anal verge and presence of multifocal disease.

METHODS

This was a prospective study of patients with symptoms of pelvic pain for more than 6 months and/or suspicion of endometriosis referred to our institution between October 2016 and April 2018. Participants underwent a first TVS without BP followed by TVS with BP within a time interval of 1 week to 3 months. The examinations were performed independently and blindly by two sonographers. Only patients who underwent laparoscopy within the 6 months following the second ultrasound examination were included. Ultrasound results using the two techniques were compared with surgical and histological findings.

RESULTS

Of the 262 patients included in the study, 118 had rectosigmoid endometriosis confirmed at surgery. There was no significant difference in accuracy between TVS with and that without BP in diagnosing the presence of rectosigmoid endometriosis (93.5% vs 92.3%; P = 0.453). No significant difference was observed in accuracy between TVS with and that without BP in diagnosing submucosal infiltration (88.8% vs 84.6%; P = 0.238) and multifocal disease (97.2% vs 95.2%; P = 0.727) in patients diagnosed sonographically with rectosigmoid endometriosis. The accuracy of TVS with BP was similar to that of TVS without BP in estimating the maximum diameter of the largest nodule (P = 0.644) and the distance between the more caudal rectosigmoid nodule and the anal verge (P = 0.162).

CONCLUSION

BP does not improve the diagnostic performance of TVS in detecting rectosigmoid endometriosis and in assessing characteristics of endometriotic nodules. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Nanotechnology for the treatment of deep endometriosis: uptake of lipid core nanoparticles by LDL receptors in endometriotic foci

OBJECTIVE

Rapidly dividing cells in multiple types of cancer and inflammatory diseases undergo high low density lipoprotein (LDL) uptake for membrane synthesis, and coupling an LDL-like nanoemulsion, containing lipid nanoparticles (LDE) to a chemotherapeutic agent efficiently targets these cells without significant systemic effects. This was a prospective exploratory study that evaluated the uptake of a radioactively labeled LDE emulsion by receptors of endometriotic foci and the capacity of the LDE for cellular internalization.

METHODS

The lipid profile of each patient was determined before surgery, and labeled LDE were injected into fourteen patients with intestinal or nonintestinal endometriosis. The radioactivity of each tissue sample (intestinal endometriosis, nonintestinal endometriosis, healthy peritoneum, or topical endometrium) was measured.

RESULTS

The group with intestinal endometriosis presented higher levels of plasma LDL but lower LDE uptake by foci than the nonintestinal group, suggesting less cell division and more fibrosis. The uptake of LDE was highest in the topical endometrium, followed by the healthy peritoneum, and lowest in the endometriotic lesion. Since the endometriotic foci showed significant LDE uptake, there was likely increased consumption of LDL by these cells, similar to cells in cancers and inflammatory diseases. Plasma cholesterol levels had no influence on LDE uptake, which showed that the direct delivery of the nanoemulsion to target tissues was independent of serum lipoproteins. There were no significant differences in the parameters (p>0.01) because of the small sample size, but the findings were similar to those of previous studies.

CONCLUSION

Nanotechnology is a promising therapeutic option for surgery and hormonal blockage for deep endometriosis, with a lower complication rate and no systemic side effects.

Combination of microwave endometrial ablation and postoperative dienogest administration is effective for treating symptomatic adenomyosis

AIM

Menorrhagia and dysmenorrhea are common symptoms. Uterine adenomyosis is one of the causes of menorrhagia and dysmenorrhea. These symptoms often decrease the quality of life in women. Microwave endometrial ablation (MEA) is a recently developed procedure that enables endometrial ablation. Dienogest has long been used to suppress endometrium development and reduce adenomyosis-related dysmenorrhea. However, some cases could be resistant to dienogest. In this study, we evaluated the efficacy of a combination of MEA and postoperative dienogest in reducing adenomyosis-related dysmenorrhea and menorrhagia.

METHODS

Ten patients with hormone treatment-resistant symptomatic adenomyosis underwent MEA and were administered oral dienogest after the procedure. The primary endpoints were reduction in pain recurrence and anemia. The secondary endpoint was a change in the adenomyosis lesion and its symptomatic recurrence.

RESULTS

Statistically significant improvements were seen in the visual analog scale score and hemoglobin levels in women post-treatment. The difference in myometrial thickness pre- and post-MEA was statistically significant. There were no cases of symptomatic recurrence.

CONCLUSION

The combination of MEA and postoperative dienogest is useful for treating uterine adenomyosis with menorrhagia and dysmenorrhea.

Fluorescence of Deep Infiltrating Endometriosis During Laparoscopic Surgery: A Preliminary Report on 6 Cases

BACKGROUND

The standard treatment of rectovaginal deep infiltrating endometriosis nodules (RVDIEN) consists in their surgical removal. RVDIEN are anatomically neovascularized. Indocyanine green (ICG) reveals vascularized structures when becoming fluorescent after exposure to near-infrared (NIR) light. This study aims to evaluate if fluorescence-guided surgery can improve the laparoscopic resection of RVDIEN, thus avoiding a rectal perforation.

MATERIALS AND METHODS

Patients with a symptomatic RVDIEN, scheduled for a laparoscopic rectal shaving, were enrolled in the study. Technically, the RVDIEN was targeted and removed with the help of the NIR imager device Image 1 Spies (Karl Storz GmBH & Co KG, Tuttlingen, Germany) or Visera Elite II (Olympus Europe SE & Co KG, Hamburg, Germany), after an intraoperative, intravenous injection of ICG (0.25 mg/kg).

RESULTS

Six patients underwent a fluorescence-guided laparoscopic shaving procedure for the treatment of a nonobstructive RVDIEN. Fluorescence of the RVDIEN was observed in all the patients. In one patient, once the main lesion was removed, the posterior vaginal fornix still appeared fluorescent and was removed. No intraoperative rectal perforation occurred. The postoperative hospital stay was 2 days. No postoperative rectovaginal fistula occurred within a median follow-up of 16 months (range = 2-23 months).

CONCLUSION

In this preliminary study, fluorescence-guided laparoscopy appeared to help in separating the RVDIEN from the healthy rectal tissue, without rectal perforation. Moreover, this technique was helpful in deciding if the resection needed to be enlarged to the posterior vaginal fornix.

Diagnostic accuracy of magnetic resonance imaging, transvaginal, and transrectal ultrasonography in deep infiltrating endometriosis

To determine the diagnostic accuracy of pelvic magnetic resonance imaging (MRI), transvaginal sonography (TVS), and transrectal sonography (TRS) in diagnosis of deep infiltrating endometriosis (DIE).This diagnostic accuracy study was conducted during a 2-year period including a total number of 317 patients with signs and symptoms of endometriosis. All the patients were evaluated by pelvic MRI, TVS, and TRS in the same center. The criterion standard was considered to be the laparoscopy and histopathologic examination.Of 317 patients being included in the present study, 252 tested positive for DIE. The sensitivity, specificity, positive predictive value, and negative predictive value of TVS was found to be 83.3%, 46.1%, 85.7%, and 41.6%, respectively. These variables were 80.5%, 18.6%, 79.3%, and 19.7% for TRS and 90.4%, 66.1%, 91.2%, and 64.1% for MRI, respectively. MRI had the highest accuracy (85.4%) when compared to TVS (75.7%) and TRS (67.8%). The sensitivity of TRS, TVS, and MRI in uterosacral ligament DIE was 82.8%, 70.9%, and 63.6%, respectively. On the contrary, specificity had a reverse trend, favoring MRI (93.9%, 92.8%, and 89.8% for TVS and TRS, respectively).The results of the present study demonstrated that TVS and TRS have appropriate diagnostic accuracy in diagnosis of DIE comparable to MRI.

Laparoscopic surgery with urinary tract reconstruction and bowel endometriosis resection for deep infiltrating endometriosis

Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.

Does Computed Tomography-Based Virtual Colonoscopy Improve the Accuracy of Preoperative Assessment Based on Magnetic Resonance Imaging in Women Managed for Colorectal Endometriosis?

STUDY OBJECTIVE

To evaluate whether combining computed tomography-based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis.

DESIGN

Retrospective study using prospectively recorded data (Canadian Task Force classification II-2).

SETTING

University tertiary referral center.

PATIENTS

Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016.

INTERVENTIONS

Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used.

MEASUREMENTS AND MAIN RESULTS

Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned.

CONCLUSION

Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

Long-term evaluation of painful symptoms and fertility after surgery for large rectovaginal endometriosis nodule: a retrospective study

INTRODUCTION

Optimal surgical treatment of rectovaginal endometriosis remains a controversial topic. The objective of this study was to evaluate long-term postoperative outcomes after rectal shaving or colorectal resection for rectovaginal endometriosis.

MATERIAL AND METHODS

195 patients underwent surgery (172 managed by shaving, 23 by colorectal resection) between January 2000 and June 2013 for rectovaginal endometriosis (>2 cm) involving at least the serosa of the rectum. Primary outcome measures were pain and fertility. Secondary outcome measures were complications, recurrence rates and quality of life.

RESULTS

Mean follow-up was 60 ± 42 months in the shaving group and 67 ± 47 months in the resection group. The mean VAS score for pelvic pain between the pre and postoperative period decreased from 5.5 ± 3.5 (shaving group) and 7.3 ± 2.9 (resection group) to 2.3 ± 2.4 (p < 0.001) and 2.0 ± 1.8 (p < 0.001), respectively. For dysmenorrhea, the mean baseline VAS score fell postoperatively from 7.7 ± 2.8 (shaving group) and 8.2 ± 2.6 (resection group) to 3.3 ± 2.9 (p < 0.001) and 2.7 ± 2.7 (p < 0.001), respectively. Pregnancy rates were 73% for shaving and 69% for resection. Major complications occurred in 4% of patients in the shaving group and in 26% in the resection group (p = 0.001). Thirteen patients (7.6%) from the shaving group and none from the resection group were reoperated for suspicion of endometriosis recurrence (p = 0.37). Postoperative quality of life scores revealed no differences between the two groups.

CONCLUSION

Our study demonstrates that rectal shaving, when feasible for rectovaginal nodule (>2 cm) infiltrating the digestive serosa, has equal impact on pain and pregnancy rates compared with colorectal resection at long-term follow-up, with low complication and favorable pregnancy rates.

Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?

Deep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon.

Surgical outcomes of laparoscopic endometriosis surgery: a 6 year experience

OBJECTIVES

The aim of the present study was to review 6 year experience on the surgical outcomes of laparoscopic endometriosis surgery.

METHODS

A cohort study was performed in Shiraz University of Medical Sciences using data from medical records of 1315 cases of patients with endometriosis undergoing laparoscopic surgery with follow-up of 6 to 72 months.

RESULTS

This study concerned a cohort of 1315 patients diagnosed with endometriosis operated between April 2010 and April 2016, 1086 (82.5%) of whom were in stage III and IV; 968 (73.61%) had endometrioma (regardless of having deep infiltrative endometriosis [DIE] or peritoneal involvement) and 347 (26.39%) of patients had either DIE or peritoneal involvement without endometrioma. Regarding the patients, unilateral endometrioma was statistically significant in the left ovary (p = .002). One hundred and thirty-three (10.7%) rectal wall, 7 (0.32%) sigmoid colon, 4 (0.18%) vagina, 125 (5.6%) ureter and 33 (1.52) bladder involvements were detected. Prior to operation, the pain VAS score was 8.23 ± 2.03, which decreased to 4.46 ± 2.47 in 93.07% of patients. Fifty-three patients (6.56%) needed reoperation. Sixty-six (33.1%) infertile women had spontaneous pregnancy and 15 (25%) became pregnant using intrauterine insemination (IUI) or assisted reproductive technique (ART) post-operatively.

CONCLUSION

Surgical treatment of endometriosis seems to be an effective treatment. DIE can be present in the absence of endometrioma. The rate of left endometrioma is higher due to the pressure effect of the sigmoid colon. Nonetheless, if an expert surgeon performs this procedure, not only the rate of post-operative complications, but also the possibility of recurrence would decrease.

Management of deep infiltrating endometriosis of the rectum: Is a systematic temporary stoma relevant?

STUDY OBJECTIVE

To assess the value of performing a protective stoma in patients operated for rectal endometriosis.

MATERIAL AND METHODS

From June 2009 to December 2011, 47 patients were operated for rectal endometriosis by segmental or discoid resection in 4 different centers. Two groups were formed: one with protective stoma (group S), n=33 and one without protective stoma (group NS), n=14. Data were collected from the CIRENDO database.

MEASUREMENTS AND MAIN RESULTS

Postoperative complication rate of group NS was 57% against 48% in group S (P=0.75). There was an increasing trend of the rate of anastomotic leakage in group S as compared to group NS: 21% against 3% (P=0.073). All 3 patients of group NS with an anastomotic leakage were reoperated and the group S patient had medical treatment. In a center, digestive operative time was not necessarily performed in association with a gastrointestinal surgeon. All patients in group S had a restoration of continuity in about 3 months. Two of them had dilation of anastomotic stricture and 3 others showed a transient postoperative ileus during this recovery. Quality of life was assessed by the MOS SF-36 and significantly improved in both groups thanks to the intervention.

CONCLUSION

Temporary digestive stoma in patients operated for rectal endometriosis has to be considered because in our study, it seems reducing complications such as anastomotic leakage. This must be confirmed with studies with larger numbers.

Sexual Function and Quality of Life in Patients Affected by Deep Infiltrating Endometriosis: Current Evidence and Future Perspectives

Endometriosis is one of the most common gynecological diseases and has an incidence of approximately 6%-10% in women of reproductive age. Deep infiltrating endometriosis (DIE) is considered the most aggressive form of endometriosis and is defined as a lesion that penetrates for more than 5 mm under the peritoneal surface. It has been demonstrated that DIE is associated with pelvic pain symptoms, and the intensity of pain is correlated with the depth of infiltration. Other symptoms are dysmenorrhea, deep dyspareunia, and painful defecation and urination. These symptoms are strongly associated with a significant reduction of the quality of life and a marked impairment of sexual function in the affected women. Therefore, a multidisciplinary approach and psychological support for women affected by DIE appear mandatory in order to reduce the impact of the disease on quality of life and sexual function as much as possible.

Magnetic Resonance Colonography May Predict the Need for Bowel Resection in Colorectal Endometriosis

Purpose

To define if MRI findings in patients with deep pelvic endometriosis (DPE) may be predictive for the need of bowel resection.

Material and Methods

A retrospective survey of 196 pelvic MRIs of women who received laparoscopic procedures for DPE was carried out. A pelvic MRI was performed in all patients: it consisted in T2w-TSE sequences in axial, sagittal, and coronal planes and T1w and THRIVE sequences in the axial plane; the exam was completed by MR-Colonography. Intestinal lesions were measured in short and long axis and the degree of stenosis was established. A multivariate logistic regression was used to identify the predictors of intestinal resection.

Results

57/196 patients received an intestinal resection. Multivariate logistic regression demonstrated a predictive value of short axis (Odds-Ratio = 2.29, p = 0.011) and stenosis (Odds-Ratio = 1.20, p = 0.003). ROC analysis showed that a cut-off value of 11 mm for the short axis and 30% for the stenosis may correctly classify, respectively, 96,94% (sensitivity 92,9% and specificity 98,56%) and 97,96% (sensitivity 94,74% and specificity 99,3%) of the cases.

Conclusion

The presence of an endometriotic rectal nodule > 11 mm in short axis causing a stenosis > 30% in pelvic MRI reliably predicts the need of a rectal resection.

Magnetic Resonance Imaging Compared with Rectal Endoscopic Sonography for the Prediction of Infiltration Depth in Colorectal Endometriosis

STUDY OBJECTIVE

To compare the accuracies of magnetic resonance imaging (MRI) and rectal endoscopic sonography (RES) in the prediction of the infiltration depth of colorectal endometriosis.

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

A university teaching hospital.

PATIENTS

Forty patients with symptomatic deep infiltrating endometriosis (DIE) of the rectum who underwent colorectal resection were included.

INTERVENTIONS

All patients underwent abdominopelvic MRI and RES preoperatively to assess the infiltration depth of colorectal endometriosis, and segmental resection of the rectosigmoid by laparoscopy was performed if RES showed bowel invasion. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (LRs), and intermethod agreement were calculated for DIE muscularis and submucosal/mucosal infiltration confirmed by histopathological analysis.

MEASUREMENTS AND MAIN RESULTS

For MRI detection of DIE muscularis infiltration, the sensitivity, specificity, PPV, NPV, and negative LR were 68%, 100%, 100%, 20%, and 0.32, respectively. For the MRI detection of DIE submucosal/mucosal involvement, the sensitivity, specificity, PPV, NPV, and positive and negative LRs were 47%, 81%, 69%, 63%, 2.49, and 0.65, respectively. The PPV of RES detection of DIE muscularis infiltration was 93%. For the RES detection of DIE submucosal/mucosal layers, the sensitivity, specificity, PPV, NPV, and positive and negative LRs were 79%, 48%, 58%, 71%, 1.51, and 0.44, respectively.

CONCLUSION

In the current study, MRI is valuable for detecting endometriosis of the rectum but is less accurate in detecting submucosal/mucosal involvement than RES. Magnetic resonance imaging was not successful for preoperative determination of segmental resection versus a more conservative approach. When bowel involvement is detected by MRI, RES is not essential. When symptoms suggest DIE in patients without intestinal lesions detected by MRI, RES is necessary to exclude bowel invasion.