Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial

Low rectal resection for low rectal endometriosis and rectal adenocarcinoma: Are we discussing the same risks?

OBJECTIVE

To evaluate the rate and risk factors for anastomosis leakage in patients undergoing colorectal resection with low anastomosis for rectal endometriosis and rectal adenocarcinoma.

METHODS

A retrospective cohort study evaluating prospectively collected data was conducted. Patients undergoing colorectal resection for rectal endometriosis and rectal adenocarcinoma with low anastomosis (<7 cm from the anal verge [AV]) from September 2018 to January 2023 were included in the analysis. The main outcome was the rate of anastomosis leakage. A multivariate logistic regression was conducted to evaluate risk factors for anastomosis leakage in both groups.

RESULTS

A total of 159 patients underwent colorectal resection with low anastomosis due to rectal endometriosis (n = 99) and rectal adenocarcinoma (n = 60). Patients with endometriosis were significantly younger than those with adenocarcinoma (35.7 ± 5.1 vs 63.7 ± 12.6; P = 0.001). The leakage rate was similar between the endometriosis (n = 12, 12.1%) and adenocarcinoma (n = 9, 15.0%) patients (P = 0.621). The anastomosis height less than 5 cm from the AV (adjusted odds ratio [aOR] 12.12, 95% confidence interval [CI] 2.24-23.54) was significantly associated with the anastomosis leakage. Protective stoma was associated with the decrease of the leakage risk (aOR 0.12, 95% CI 0.01-0.72). The type of disease (rectal endometriosis or adenocarcinoma) was not associated with the anastomosis leakage (aOR 2.87, 95% CI 0.34-21.23).

CONCLUSIONS

Despite the different pathogenesis, the risk of anastomotic leakage was found to be similar between patients with low rectal endometriosis and those with rectal adenocarcinoma. These results must be considered by the gynecologist and colorectal surgeon to deliver proper information before rectal surgery for endometriosis.

Gastrointestinal function and pain outcomes following segmental resection or discoid resection for low rectal endometriosis

INTRODUCTION

This study aims to examine the effect of full thickness discoid resection (FTDR) and modified, limited nerve-vessel sparing segmental bowel resection (NVSSR) in symptomatic patients with low rectal deep endometriosis (DE) within 7 cm from the anal verge.  Presurgical and postsurgical evaluation of gastrointestinal (GI) function reflected by low anterior resection syndrome (LARS) and gastrointestinal function-related quality of life index (GIQLI) scores, complication rates, pain scores/visual analog scale (VAS) and endometriosis health profile (EHP-30) was performed.

METHODS

In this prospective multicenter cohort study, 63 premenopausal patients with symptomatic low (within 7 cm from the anal verge) colorectal endometriosis, undergoing low modified limited nerve vessel sparing rectal segmental bowel resection (NVSSR) and full thickness discoid resection (FTDR) were evaluated. Presurgery and postsurgery lower anterior resection syndrome (LARS) scores, gastrointestinal function-related quality of life index (GIQLI), pain symptoms, endometriosis health profile (EHP-30) parameters compared between two groups.

RESULTS

Out of 63 women, 49 (77.8%) underwent NVSSR while 14 (22.2%) underwent FTDR. LARS-like symptoms were observed presurgically in 24/63 (38.1%) patients. Postsurgical LARS was observed in 14/63 (22.2%) of the patients (10/49, 20.4% in NVSSR vs. 4/14, 28.5% in the FTDR group). The LARS-like symptoms significantly decreased following surgery in the FTDR group (p = 0.049) and showed a trend for decrease in the NVSSR group (p = 0.077). Postsurgical de novo LARS was only observed in 5/63 (8%) of the patients (NVSSR 4/49, 8.1%, FTDR 1/14, 7.1%). Postsurgical GIQLI scores improved in both groups (p < 0.001) with comparable changes in the NVSSR and FTDR cohorts (p = 0.490). Postoperative grade III complication rates between NVSSR and FTDR did not vary significantly (6/49, 12.2% vs. 3/14, 21.4% p = 0.26). Pain/VAS scores and EHP-30 scores significantly decreased after a mean follow-up of 29.6 ± 11 months and 30.6 ± 11 months in the NVSSR and FTDR groups, respectively (EHP-30; p < 0.001; dysmenorrhea, dyspareunia, dyschezia all p < 0.05 for both cohorts).

DISCUSSION

When comparing low colorectal surgery by either NVSSR or FTDR in a high-risk group for surgical complications, both techniques confer improvement of GI function reflected by LARS and GIQLI with non-significant differences in major complication rates, reduced pain and EHP-30 scores.

Surgical treatment of colorectal endometriosis: an updated review

PURPOSE OF REVIEW

This review aims to summarize recent literature on the surgical treatment of colorectal endometriosis.

RECENT FINDINGS

The last decade has seen a surge in the number of studies on bowel endometriosis, with a focus on preoperative evaluation, perioperative management, surgical approach, and surgical outcomes. Many of these studies have originated from large-volume referral centers with varying surgical approaches and philosophies. Colorectal surgery for endometriosis seems to have a positive impact on patient symptoms, quality of life, and fertility. However, these benefits must be weighed against a significant risk of postoperative complications and the potential for long-term bowel or bladder dysfunction, especially for more radical procedures involving the lower rectum. Importantly, most studies regarding surgical technique and outcomes have been limited by their observational design.

SUMMARY

The surgical management of bowel endometriosis is complex and should be approached by a multidisciplinary team. Methodical preoperative evaluation, including appropriate imaging, is vital for surgical planning and patient counseling. The decision to perform a more conservative or radical excision is nuanced and remains an area of controversy. High quality studies in the form of multicenter randomized controlled trials are needed before clear recommendations can be made.

Endometriosis and Adenomyosis: Modern Concepts of Their Clinical Outcomes, Treatment, and Management

Endometriosis and adenomyosis are complex gynecological conditions characterized by diverse clinical presentations, including superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The hallmark features of these pathologies involve the manifestation of pain symptoms and infertility, and approximately 30% of patients are asymptomatic. Despite ongoing research, definitive treatments for these conditions remain elusive, and clinical management primarily revolves around medical or surgical interventions. Recent advancements in our understanding of the efficacy of various treatment modalities, including medical therapy and surgical interventions, have provided clinicians with valuable insights into pain relief and fertility preservation. This review aims to provide an updated overview of the latest literature on clinical outcomes, treatment options, and management strategies for different types of endometriosis. By synthesizing the newest available data, this review seeks to inform clinicians and guide decision making based on factors such as patients' symptom severity, childbearing desire, and overall health.

Comparing Surgical, Acupuncture, and Exercise Interventions for Improving the Quality of Life in Women With Endometriosis: A Systematic Review

Endometriosis is a chronic inflammatory condition that significantly impacts the quality of life (QoL) of affected women. This systematic review aimed to compare the effects of surgical interventions, acupuncture, and exercise programs on the QoL in women with endometriosis. A comprehensive search was conducted in databases such as PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). Randomized controlled trials (RCTs) and observational studies evaluating the impact of these interventions on the QoL were included. The review identified 10 studies (six RCTs and four observational studies) involving a total of 493 participants. Surgical interventions, particularly the laparoscopic excision of endometriotic lesions, demonstrated substantial reductions in pain and improvements in the QoL. Acupuncture effectively alleviated pain and enhanced overall well-being. Exercise programs improved the QoL, physical function, and pain reduction. The findings suggest that surgical-, acupuncture-, and exercise-based approaches can significantly improve the QoL for women with endometriosis. However, more personalized treatment approaches and further research are needed to understand the long-term benefits, optimal protocols, and underlying mechanisms of these interventions.

Bowel endometriosis: Surgical customization is demanding

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection

OBJECTIVE

To describe the management of recurrent bowel endometriosis after previous colorectal resection.

DESIGN

Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained.

SETTING

A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment.

INTERVENTION

Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed.

CONCLUSION

Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

Surgical treatment of deep endometriosis: Impact on spontaneous conception

Deep endometriosis (DE) is the most severe form of endometriosis and is commonly associated with infertility. Surgical treatment of DE appears to increase chances of spontaneous conception in appropriately selected patients wishing to conceive. Identifying, however, the exact impact of DE, and its surgical removal, on natural conception is highly challenging. The surgical approach should be favoured in symptomatic patients with pregnancy intention. Limited data from infertile patients suggest that outcomes may not differ from patients without known infertility. Complex DE surgery carries a risk of serious complications, therefore, it should be performed in centers of expertise. Such complications may, however, not have a significant negative impact on fertility outcomes, according to limited available data. Data on obstetric outcomes of spontaneous conceptions after DE surgery are too scarce. In asymptomatic, infertile patients the debate between primary surgery or Artifial Reproductive Technology is ongoing, until randomized studies report their results.

Robotic assisted laparoscopy for deep infiltrating endometriosis

Deep infiltrative endometriosis is a condition affecting up to 15 % of women of childbearing age, defined by extra uterine location of endometrial like tissues. The symptoms of endometriosis range from severe dysmenorrhea to infertility, chronic pelvic pain, bowel dysfunction and urinary tract involvement to name the most common. Endometriosis has an impact on the quality of life of patients, with personal and social consequences. Although medical treatment is indicated in the first instance, surgery may be necessary. Standard laparoscopy has become the gold standard for this surgery. However, surgery for deep infiltrative endometriosis is known to be highly complex, and the significant development of robotic assistance in recent years has had an impact on the evolution of surgical practice. This comprehensive review of the literature provides an overview of the contributions of robotic surgery in the field of endometriosis and gives an insight into the next steps in its development.

Discoid excision for colorectal endometriosis associated infertility: A balance between fertility outcomes and complication rates

OBJECTIVE

The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes.

METHODS

49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed.

RESULTS

Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16).

CONCLUSION

Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.

Patient-Reported Outcome Measures Used in Randomized Controlled Trials Following Surgical Intervention for Endometriosis: A Structured Review from the AAGL Practice Guidelines Group

OBJECTIVE

No consensus currently exists regarding patient-reported outcome measure (PROM) instruments. This structured review was conducted to identify the PROMs used by randomized controlled trials (RCTs) that evaluated surgical treatment in patients with endometriosis.

DATA SOURCES

Two parallel searches were conducted by a medical librarian using Ovid MEDLINE, Ovid Embase, and Cochrane Library for RCTs published from 2000 to July 2022. One search focused on studies reporting quality of life (QoL), and the second search focused on studies reporting pain and sexual, bowel, and bladder function.

METHOD OF STUDY SELECTION

During the title and abstract screening and reference check, 600 results were identified on PROMs relating to QoL and 465 studies on PROMs relating to pain and sexual, bowel, and/or bladder function and an evaluation of 17 and 12 studies conducted, respectively. The inclusion criteria involved selecting RCTs that focused on surgical intervention and assessing QoL, pain, and sexual, bowel, and/or bladder function using PROMs.

TABULATION, INTEGRATION, AND RESULTS

Covidence software was used to organize and identify duplicate articles through screening. We developed a data extraction form to collect key information about each included study, as well as the pertinent PROMs used in the study. Assessment of the risk of bias of each study was also performed. A total of 19 studies were identified involving 2089 participants and a total of 16 PROMs used across the studies; 9 of 19 studies (47%) were rated as having a low risk of bias. There were no high-risk studies identified in this review.

CONCLUSION

This study identified a large number of RCTs in surgical treatment of endometriosis that used various PROMs to assess QoL, pain, and bladder, bowel, and sexual function. The PROMs used by high-quality RCTs for QoL include Endometriosis Health Profile-30, Endometriosis Health Profile-5, Short-Form 36, Short-Form 12, and EQ-5D; for bowel-related symptoms Knowles-Eccersley-Scott-Symptom Questionnaire, Gastrointestinal Quality of Life Index, and Cleveland Clinic Fecal Incontinence Severity Scoring System/Wexner; for bladder-related function Bristol Female Lower Urinary Tract Symptoms, International Prostate Symptom Score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and Urinary Symptom Profile; and finally for sexual function Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and Sexual Activity Questionnaire. Unlike other domains, only one tool (visual analog scale) was the dominant PROM used for the assessment of pain. In addition, the use of more than one PROM in each study to assess different aspects of patient's health and pain symptoms did not become prevalent until after 2015.

Vascular- and nerve-sparing bowel resection for deep endometriosis: A retrospective single-center study

OBJECTIVE

Surgical management of bowel endometriosis is still controversial. Recently, many authors have pointed out the potential benefits of preserving the superior rectal artery, thus ensuring better perfusion of the anastomosis. The aim of this study was to evaluate the complication rate and functional outcomes of a bowel resection technique for deep endometriosis (DE) involving a nerve- and vascular-sparing approach.

METHODS

A single-center retrospective study was conducted by enrolling patients who underwent segmental resection of the rectus sigmoid for DE in our department between September 2019 and April 2022. Intraoperative and postoperative complications were recorded for each woman, and functional outcomes relating to the pelvic organs were assessed using validated questionnaires (Knowles-Eccersley-Scott-Symptom [KESS] questionnaire and Gastro-Intestinal Quality of Life Index [GIQLI] for bowel function, Bristol Female Lower Urinary Tract Symptoms [BFLUTS] for urinary function, and Female Sexual Function Index [FSFI] for sexual function). These were evaluated preoperatively and postoperatively after 6 months from surgery.

RESULTS

Sixty-one patients were enrolled. No patients had Clavien-Dindo grade 3 or 4 complications, there were no rectovaginal fistulas or ureteral lesions, and in no cases was it necessary to reoperate. Temporary bladder voiding deficits were reported in 8.2% of patients, which were treated with self-catheterizations, always resolving within 45 days of surgery. Gastrointestinal function evaluated by KESS and GIQLI improved significantly after surgery, whereas sexual function appeared to worsen, although without reaching the level of statistically significant validity.

CONCLUSION

Our vascular- and nerve-sparing segmental bowel resection technique for DE had a low intraoperative and postoperative complication rate and produced an improvement in gastrointestinal function after surgery.

Minimally invasive surgery for deep endometriosis

Deep endometriosis (DE) is endometriotic tissue that invades the peritoneum by >5 mm. Surgery is the treatment of choice for symptomatic DE, and laparoscopic surgery is preferred over laparotomy due to better vision and postoperative pain. In this review, we aimed to collect and summarize recent literature on DE surgery and share laparoscopic procedures for rectovaginal and bowel endometriosis.

Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial

BACKGROUND

The conventional laparoscopic approach for the surgical management of deep endometriosis (DE) infiltrating the rectum appears to ensure improved digestive functional outcomes. The natural orifice specimen extraction (NOSE) technique for the treatment of colorectal DE can significantly accelerate postoperative recovery; however, data on gastrointestinal function following conventional laparoscopic segmental bowel resection (CLR) compared with NOSE colectomy (NC) for DE are sparse.

MATERIALS AND METHODS

Between 30 September 2019 and 31 December 2020, a randomized, open-label, two-arm, parallel-group controlled trial with women aged 18-45 years was conducted at University Hospital.Ninety-nine patients were randomized to CLR or NC, with DE infiltrating at least the muscular layer, at least 50% of the circumference of the bowel, up to 15 cm from the anal verge, exhibiting pain and bowel symptoms and/or infertility. The primary endpoint was bowel function, represented by low anterior resection syndrome (LARS). Secondary parameters included the Endometriosis Health Profile 30 (EHP30), Gastrointestinal Quality of Life Index (GIQLI), Visual Analog Scale (VAS) scores preoperatively and at set times (1 and 6 months, 1 year) following surgery.

RESULTS

No significant differences were observed in the postoperative LARS scores, VAS, EHP30, and GIQLI between the NC and CLR groups. LARS scores did not reveal significant differences 12 months postoperatively compared to the preoperative values in both groups (CLR group P =0.93 versus NC group, P =0.87). GIQLI scores were significantly improved 12 months after the operation compared with baseline values in the CLR group ( P =0.002) and NC group ( P =0.001). Pain symptoms and quality of life scores significantly improved 12 months postoperatively in both groups.

CONCLUSIONS

NC is a feasible surgical approach for treating patients with rectal DE. Our study did not show a statistically significant difference between CLR and NC techniques in mid-term digestive and pain outcomes.

Evaluation of Bowel Function of Women with Colorectal Endometriosis: a Cross-Sectional Study

The objective was to evaluate bowel function in women with colorectal endometriosis according to treatment type. Cross-sectional study, carried out with 141 women with endometriosis, followed by the University of Campinas from May 2020 to April 2021. Women were divided into 3 groups according to the kind of treatment: 16 women with conservative surgery, 35 women with radical surgery treatment, and 90 women with clinical treatment. The clinical and sociodemographic characteristics of these women were evaluated. To access bowel outcome, we used the following questionnaires: the Bristol Stool Scale, the Bowel Function in the Community, the Gastrointestinal Quality of Life Index (GIQLI), and the Pelvic Floor Distress Inventory (PFDI-20). The mean treatment time was 32.24 ± 29.37 months. The women of the three groups had similar gastrointestinal quality of life index scores (p = 0.27) and pelvic floor distress inventory scores (p = 0.23). Women in the radical surgery group had a higher frequency of evacuatory effort and change in posture to evacuate (p = 0.01 and 0.009, respectively) than did those in the other groups. Women with constipation had worse quality of life and more pain than those without constipation. In conclusion, women with endometriosis treated with radical surgery (segmental resection) had a higher frequency of constipation. In addition, women with endometriosis and constipation had a worse quality of life and higher pain scores compared to those without constipation.

Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series

OBJECTIVE

To assess the long-term risk of repeated surgery in women undergoing complete excision of endometriosis by an experienced surgeon and to identify circumstances leading up to repeat surgery.

DESIGN

Retrospective study based on data recorded in a large prospective database.

SETTING

University Hospital.

PATIENT(S)

A total of 1,092 patients managed for endometriosis, from June 2009 to June 2018, by one surgeon.

INTERVENTION(S)

Complete excision of endometriosis lesions.

MAIN OUTCOME MEASURE(S)

The recording of a repeated surgery linked to endometriosis performed during follow-up.

RESULT(S)

Endometriosis was exclusively superficial in 122 patients (11.2%) and 54 women (5%) had endometriomas without associated deep endometriosis nodules. Deep endometriosis was managed in 916 women (83.9%), leading to infiltration or not of the bowel in 688 (63%) and 228 (20.9%) patients, respectively. A majority of patients were managed for severe endometriosis infiltrating the rectum (58.4%). Mean and median follow-up was 60 months. A total of 155 patients underwent a repeated surgery relating to endometriosis; 108 procedures were required because of recurrences (9.9%), 39 surgeries were related to the management of infertility by assisted reproductive techniques (3.6%), and in 8 surgeries, a direct relationship between surgery and endometriosis was probable but not certain (0.8%). The majority of procedures involved hysterectomy for adenomyosis (n=45, 4.1%). The probability of requiring repeated surgery at 1, 3, 5, 7, and 10 years was 3%, 11%, 18%, 23%, and 28%, respectively. Cox's multivariate model identified postoperative pregnancy and hysterectomy as being statistically significant independent predictors for a reduction in the probability of having a repeated surgery, after adjustment on continuous postoperative amenorrhea, the main localization of the disease, and management for endometriosis infiltrating the rectum during the first surgery.

CONCLUSION(S)

Up to 28% of patients may require a repeated surgical procedure during the 10 years after complete excision of endometriosis. Conservation of the uterus is followed by an increased risk of repeated surgery. The study is based on outcomes resulting from a single surgeon, which limits the generalizability of results.

Pain, gastrointestinal function and fertility outcomes of modified nerve-vessel sparing segmental and full thickness discoid resection for deep colorectal endometriosis - A prospective cohort study

INTRODUCTION

There is an ongoing debate on surgical techniques for colorectal deep endometriosis (DE) and their effects on gastrointestinal (GI) function. The aim of this study was to prospectively investigate the differences in pre- and postsurgical GI function, health profiles and pain symptoms in women undergoing colorectal surgery for symptomatic DE either with a modified segmental resection technique, so-called nerve-vessel sparing segmental resection (NVSSR), or full thickness discoid resection (FTDR). Complication rates and fertility outcomes were also evaluated.

MATERIAL AND METHODS

A total of 162 consecutive patients, 125 (77.2%) of whom underwent NVSSR and 37 (22.8%) FTDR, were evaluated regarding complication rates. Furthermore a lower anterior resection syndrome (LARS) scores, gastrointestinal function-related quality of life index (GIQLI), pain symptoms, endometriosis health profile (EHP-30) parameters were analyzed pre- and post-surgery in a final cohort of 121 patients.

RESULTS

There was no difference between postsurgical prevalence of LARS in either surgery group (14/98, 14.1% NVSSR; 2/23, 8.6% FTDR), with significantly decreased LARS scores and increased GIQLI values before vs after surgery in both groups (P < 0.001). The overall grade III complication rate was 7/162 (4.3%) with no significant differences between NVSSR and FTDR groups. Overall, EHP-30 and pain scores significantly decreased after a median follow-up of 41 (± 17.6) months (EHP-30 51.1, SD 21.5 vs 12.7, SD 19.3, P < 0.001; dysmenorrhea, dyspareunia, dyschezia all P < 0.001 both cohorts, respectively). The overall life birth rate and postsurgical pregnancy in infertile patients undergoing NVSSR and FTDR was respectively 58.1% in 25/43 patients; 55.6% in 5/9 patients; 56.0% in 14/25 patients and 100% in 5/5 patients.

CONCLUSIONS

NVSSR and FTDR for symptomatic colorectal DE confer a significant amelioration of GI function reflected by decreased LARS symptoms and increased GIQLI scores with no differences in postsurgical function in between the two techniques. Both techniques confer similar complication rates and effects on pain reduction and health profiles.

Current endometriosis care and opportunities for improvement

Endometriosis is a chronic disease associated with debilitating pain that affects many people assigned female at birth, from menarche through menopause, not just causing pain and infertility, but also negatively impacting quality of life, participation in daily activities, productivity and income. It is associated with increased incidence of obstetric and neonatal complications, depression, other chronic diseases, and substantial healthcare costs. Despite the profound negative impact of endometriosis on quality of life, current treatment options remain sub-optimal and many patients express dissatisfaction with current care. The prevailing acute-care, single-provider model in which the provider works in relative isolation and thus with limited therapeutic strategies readily available, proves inadequate for treating endometriosis. Patients would benefit from earlier diagnosis and referral to a center capable of providing a comprehensive and multi-modal management plan that utilizes a chronic care model. Often this can only be achieved through multidisciplinary teams of providers with expertise in endometriosis. Researchers need to agree on standardized core outcome measures, relevant to patients with endometriosis and the healthcare system as a whole. Only through increased education and recognition of endometriosis as a chronic disease can we achieve better treatment outcomes.

Fertility Outcomes after Surgical Management of Colorectal Endometriosis: A Single-center Retrospective Study

STUDY OBJECTIVE

To assess the pregnancy rate after surgery for colorectal endometriosis.

DESIGN

A retrospective, single-center study performed from January 2014 to December 2019.

SETTING

A university tertiary referral center.

PATIENTS

Patients with the intention to get pregnant younger than the age of 43 years, with or without a history of infertility and who were surgically managed for colorectal endometriosis.

INTERVENTIONS

Complete excision of deeply infiltrating endometriosis.

MEASUREMENTS AND MAIN RESULTS

The postoperative pregnancy rate was assessed. Seventy-seven patients had surgery; their mean age was 32.5 ± 4.4 years. Preoperative documented infertility was present in 77.9% of patients (n = 60). The mean length of history of infertility was 36.2 ± 24.9 months. The procedure was performed by laparoscopic surgery in 92.2% of patients (n = 71). Nonconservative, conservative, and mixed treatment were performed in 66.2% (n = 51), 29.9% (n = 23), and 3.9% of patients (n = 3), respectively. According to the Clavien-Dindo classification, the 3B complication rate was 6.5% (n = 5). The mean follow-up was 46.7 ± 20.6 months. Clinical pregnancies were defined by the presence of intrauterine pregnancy with an embryo with cardiac activity. The postoperative pregnancy rate was 62.3% (n = 48), and 54.2% (n = 26) were spontaneous. The mean number of pregnancies was 1.2 ± 0.4 per patient. In addition, 18.7% of patients (n = 9) got pregnant twice. The mean time from surgery to pregnancy was 13.8 ± 13.1 months. The live birth rate was 89.1% (n = 41). There were no significant differences concerning the prognostic criteria reported in the literature (antimüllerian hormone level, age, presence of adenomyosis). There were no predictive criteria for live births.

CONCLUSION

According to this study, surgery for colorectal endometriosis results in a high postoperative pregnancy rate. Studies with a high level of evidence are needed to determine good candidates for this type of surgery.

Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes

PURPOSE

The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection.

METHODS

The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes.

RESULTS

Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable.

CONCLUSION

Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.

Prevalence of urinary dysfunction after minimally invasive surgery for deep rectosigmoid endometriosis

PURPOSE

This study aimed to assess the prevalence and progression of lower urinary tract symptoms following laparoscopic surgery for deep-infiltrating endometriosis of the rectosigmoid and identify preoperative factors associated with worse postoperative outcomes.

METHODS

Prospective, observational study.

SETTINGS

single-center, referral hospital for endometriosis. Patients undergoing laparoscopic surgery for deep-infiltrating endometriosis of the rectosigmoid colon between October 2016 and October 2018.

MAIN OUTCOME MEASURES

urinary function was assessed with the validated Portuguese language version of the International Prostate Symptom Score, which is also used in women. The score was collected before and after surgery. The Wilcoxon signed-rank test was used to compare pre and postoperative scores and the chi-square test compared symptoms categorized by severity.

RESULTS

Fifty-three patients were assessed and 44 were included. Concerning urinary symptoms after surgery, the irritative symptoms prevailed over the obstructive ones. Additionally, 58.8% and 54.5% of the women reported moderate or severe symptoms at pre and postoperative, respectively. In at least one questionnaire category, the postoperative questionnaire scores increased in ten (22.7%) participants. A statistically significant difference was found comparing the changes from absent/mild to moderate/severe IPSS categories (P = 0.039). No significant changes were identified in any of the International Prostate Symptom Score pre and postoperatively (P = 0.876).

CONCLUSIONS

There was a high prevalence of pre and postoperative urinary symptoms. Patients with preoperative moderate/severe International Prostate Symptom Score are at risk of persisting urinary dysfunction after surgery for rectosigmoid deep endometriosis.

Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned

OBJECTIVE

To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm.

DESIGN

Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data.

SETTING

A tertiary referral center.

PATIENTS

Patients undergoing excision of rectal endometriosis.

INTERVENTION(S)

Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach.

MAIN OUTCOME MEASURE(S)

Feasibility of the technique.

RESULT(S)

The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler's jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required.

CONCLUSION(S)

The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.

Disk Excision Using End-to-End Anastomosis Circular Stapler for Deep Endometriosis of the Rectum: A 492-Patient Continuous Prospective Series

STUDY OBJECTIVE

To report a large series including women managed by disk excision using end-to-end anastomosis (EEA) circular transanal stapler to assess the feasibility of the technique, the features of nodules suitable for removal by disk excision, and the rate of major early complications.

DESIGN

Retrospective study on data prospectively recorded in 2 databases.

SETTING

Two tertiary referral centers.

PATIENTS

A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022.

INTERVENTIONS

Rectal disk excision using the EEA stapler.

MEASUREMENT AND MAIN RESULTS

Disk excision using EEA was performed in 492 patients (24.2%) of 2,029 women receiving surgery for deep endometriosis infiltrating the rectum during the 11-year study period. Deep endometriosis involved low rectum in 11% and mid rectum in 55.3%. The diameter of rectal nodules exceeded 3 cm in 65.9%. Mean operative time was 2 hours, mean diameter of rectal patches removed was 41 ± 11 mm, and the mean rectal suture height was 9.2 ± 5.5 cm. The presence of microscopic foci on the edges of rectal patches was identified in 30.2% of cases. Rectal fistula was recorded in 20 patients (4%). The distance from the anal verge was significantly lower in patients with fistula than women with no fistula (5.9 ± 2 cm vs 9.2 ± 5.6 cm, p = .027). Follow-up ranged from 1 to 120 months, with a median value of 36 months. Magnetic resonance imaging in 3 patients during follow-up revealed a recurrent nodule infiltrating the previous stapled line (0.6%) after a postoperative delay of, respectively, 36, 48, and 84 months.

CONCLUSION

Disk excision using the EEA stapler is suitable in nodules >3 cm if surgeons ensure deep shaving of the rectum, to allow complete inclusion of the shaved area into the stapler jaws. Postoperative rectal recurrences seem incidental, whereas bowel leakage rate is comparable with that after colorectal resection. This technique is suitable in almost a quarter of patients managed for rectal endometriosis nodules and is therefore a valuable technique that warrants more widespread use.

Three Types of Endometriosis: Pathogenesis, Diagnosis and Treatment. State of the Art

At present, there is no curative treatment for endometriosis. Medical management and surgical treatment do not provide long-term relief. A detailed understanding of its pathophysiology is mandatory in order to facilitate both the diagnosis and treatment. The delay that typically precedes proper diagnosis (6 to 7 years) is probably one of the most challenging aspects of endometriosis management. In 2012, the total cost per woman due to endometriosis was estimated to be 9579€ per year in a multicenter study across the USA and Europe. According to their physiopathology and their localization, ectopic endometrial lesions, consisting of endometrial glands and stroma, can be divided into three different types: superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The following paper aims to review the available data in the literature on the pathogenesis, diagnosis, and treatment of different types of endometriosis.

Bowel Endometriosis Management by Colorectal Resection: Laparoscopic Surgical Technique & Outcome

Background and Objectives

Bowel deep infiltrating endometriosis (DIE) management by colorectal resection is a complex procedure. The purpose of the present study is to delineate a meticulous approach to the assessment of the patient, step-wise surgical technique, pre, and postoperative care, and its short-term and long-term outcomes.

Methods

This is a single-center retrospective study done on patients of bowel DIE managed by colorectal resection between January 1, 2019 to June 30, 2021.

Results

There was a significant improvement in the symptomatology of patients post-surgery. Our surgical technique is feasible with acceptable short-term and long-term outcomes.

Conclusion

Bowel DIE management can be proficiently executed with a proper diagnostic approach, appropriate surgical expertise with exhaustive pelvic anatomy knowledge especially concerning autonomic nerve plexus.

Impact of Laparoscopic Sclerotherapy for Ovarian Endometriomas on Ovarian Reserve

STUDY

Objective: To evaluate the impact of laparoscopic sclerotherapy on the management of endometrioma during surgery for deep infiltrative endometriosis (DIE).

DESIGN

Observational study.

SETTING

Tivoli-Ducos Clinic, Bordeaux.

PATIENTS

Sixty-nine patients underwent laparoscopic sclerotherapy for endometrioma during surgery for DIE.

INTERVENTIONS

Laparoscopic sclerotherapy with 95% ethanol solution and DIE surgery.

MEASUREMENTS AND MAIN RESULTS

Antimüllerian hormone (AMH) levels before and at least 6 months after surgery, recurrences, and pregnancies. Mean AMH (ng/mL) levels were 3.4 (2.3) before surgery and 2 (1.7) after surgery (p <.001). Mean difference was 1.29 ng/mL. Preoperative AMH level was the only variable independently associated with an additive decrease in AMH. Mean (standard deviation) follow-up period was 17.5 months (4.6) (range 9-26 months); 18 of 44 patients (40.1%) with pregnancy intent conceived. Of 51 patients who underwent postoperative pelvic ultrasound, 6 (6 of 51, 11.8%) had a recurrence of endometrioma.

CONCLUSION

Laparoscopic sclerotherapy for endometrioma >40 mm during surgery for DIE sclerotherapy has a low impact on AMH, preserves fertility, and prevents recurrence.

Impact of surgery on fertility among patients with deep infiltrating endometriosis

OBJECTIVE

The aim of the study was to investigate pregnancy and live birth rate after surgical resection of rectosigmoid deep infiltrating endometriosis (DIE), and study if complications affect these rates.

STUDY DESIGN

Historical case series. 193 patients with rectosigmoid DIE and pregnancy intention undergoing a rectosigmoid resection for DIE from January 2009 to May 2019. All operations were performed at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark. Surgical and fertility outcome data were obtained through patient files. Anonymized data was analyzed statistically. Normally distributed continuous variables are stated as means, categorical data as percentages and time to pregnancy as Kaplan-Meier failure function. Live birth rates stratified on complications were tested with chi2 test.

RESULTS

117 patients became pregnant postoperatively with a pregnancy and live birth rate of 60.6% and 53.9%, respectively. 39 patients (20.2%) became pregnant spontaneously and 78 patients (40.4%) by intrauterine insemination or assisted reproductive technologies. Median time to pregnancy after surgery was 12.4 months (range: 0.4-58). Clavien-Dindo complication grade III (none grade IV) was registered among 16.6%. These patients had pregnancy and live birth rates of 50%, not statistically significantly different from those without complications.

CONCLUSIONS

Postoperative pregnancy and live birth rates after resection of rectosigmoid endometriosis in this study are in line with conservative treatment, when comparing with the literature. Interestingly, complications (Clavien-Dindo grade III) did not affect live birth rate or time to pregnancy.

Surgical Treatment of Deep Endometriosis

In deep endometriosis (DE), clusters of endometrium-like cells penetrate more than 5 mm below the peritoneum: The affected organs and tissue structures can eventuate in an alteration of the anatomy with eliminated organ boundaries, which in some cases can pose a real surgical challenge, even for experienced surgeons. A comprehensive description of the different manifestations of the disease can be found in the #Enzian classification. Since the operation is usually the foundation for the successful treatment of DE, what is important are conclusive indications, appropriate preoperative preparation and, above all, appropriate experience on the part of the surgical team. This article aims to provide a review of the surgical options that are currently available.

Transvaginal Ultrasound in the Diagnosis and Assessment of Endometriosis-An Overview: How, Why, and When

Endometriosis is a common gynaecological disease, causing symptoms such as pelvic pain and infertility. Accurate diagnosis and assessment are often challenging. Transvaginal ultrasound (TVS), along with magnetic resonance imaging (MRI), are the most common imaging modalities. In this narrative review, we present the evidence behind the role of TVS in the diagnosis and assessment of endometriosis. We recognize three forms of endometriosis: Ovarian endometriomas (OMAs) can be adequately assessed by transvaginal ultrasound. Superficial peritoneal endometriosis (SUP) is challenging to diagnose by either imaging modality. TVS, in the hands of appropriately trained clinicians, appears to be non-inferior to MRI in the diagnosis and assessment of deep infiltrating endometriosis (DIE). The IDEA consensus standardized the terminology and offered a structured approach in the assessment of endometriosis by ultrasound. TVS can be used in the non-invasive staging of endometriosis using the available classification systems (rASRM, #ENZIAN). Given its satisfactory overall diagnostic accuracy, wide availability, and low cost, it should be considered as the first-line imaging modality in the diagnosis and assessment of endometriosis. Modifications to the original ultrasound technique can be employed on a case-by-case basis. Improved training and future advances in ultrasound technology are likely to further increase its diagnostic performance.

Colorectal infiltrating deep endometriosis: Laparoscopic treatment. A case report

Endometriosis is a disease affecting approximately 10% of women of fertile age. A particular presentation is deep infiltrating endometriosis of the rectosigmoid colon with symptoms that can mimic an intestinal obstruction or neoplasm. We report the case of a 39-year-old woman with pelvic pain during the menstrual cycle and significant anemia who presented an ectopic endometrial tissue in correspondence of the rectum. Because of the thickness of the lesion the patient underwent a segmental laparoscopic colorectal resection with end-to-end anastomosis.

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.

Improvement of Post-Operative Quality of Life in Patients 2 Years after Minimally Invasive Surgery for Pain and Deep Infiltrating Endometriosis

This study addressed the improvement in the quality of life of patients 2 years after minimally invasive surgery for painful deep infiltrating endometriosis (DIE), evaluated with EHP-5 (Endometriosis Health Profile-5) scores and the intensity of dysmenorrhea and dyspareunia. This was a retrospective study, performed in a referral centre for endometriosis, between January 2010 and January 2019. EHP-5 scores were complete for 54 patients, and two subgroups were analysed: classic laparoscopy (CL) vs. robotic laparoscopy (RL), and conservative surgery (ConservS) vs. total surgery (TS). There was an important decrease in 2-year post-operative EHP-5 scores in the global population (pre-op: 61.36 (42.18−68.75) and 2-year post-op: 20.45 (0−38.06); p < 0.001). The Visual Analogic Scale (VAS) was also lower for dysmenorrhea (pre-op: 8 (7−9.75) vs. 2-year post-op: 3 (2−5.25); p < 0.001) and dyspareunia (pre-op: 6 (3.1−8.9) vs. 2-year post-op: 3 (0−6); p < 0.001). In the subgroup analysis, EHP-5 scores were improved in the RL group (pre-op: 65.9 (59.09−71.02) vs. 2-year post-op: 11.4 (0−38.06); p < 0.001) and the CL group (pre-op: 50 (34.65−68.18) vs. 2-year post-op: 27.27 (14.20−40.90); p < 0.001), with a slight advantage for RL (p = 0.04), and the same improvements were found for ConservS (pre-op: 61.4 (38.06−71.59) vs. 2-year post-op: 22.7 (11.93−38.07); p < 0.001) and TS groups (pre-op: 61.59 (51.70−68.75) vs. 2-year post-op: 13.63 (0−44.30); p < 0.001). Minimally invasive surgery improved the quality of life for DIE patients 2 years after surgery, and conservative surgery showed comparable results to total surgery.

Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications

Objective

The present work aimed to investigate the feasibility, complications, recurrence rate, and infertility outcomes of the radical and conservative surgical methods for colorectal endometriosis in short- and long-term follow-ups.

Methods

In this prospective study, the patients with confirmed diagnosis of colorectal DIE were included from March 2015 to March 2021, who were referred to an Endometriosis Surgery Center affiliated with Shiraz University of Medical Sciences (SUMS). Information on demographics, surgical approaches, intra-operative, and post-operative findings as well as complications were collected and compared. Six- and 12-month interviews were conducted to evaluate the functional outcomes of all the procedures.

Results

Out of 3,111 patients who underwent endometriosis surgery, 837 (28.19%) with the average age of 34.2 ± 5.9 years and average ASRM score of 102.1 ± 36.8 had rectosigmoid endometriosis. Laparoscopic rectal shaving was performed in 263(30.0%) patients while 326 (37.2%) underwent segmental bowel resection, and 248 (28.30%) were treated with disc excision. Prophylactic ileostomy was performed in six (0.68%) patients and peritonitis was reported in four (0.45%). Five (0.58%) subjects developed rectovaginal fistula and one (0.11%) was diagnosed with bladder atonia. The recurrence rate was 3.8%, 1.2%, and 0.3% in rectal shaving, disc, and segmental bowel resection techniques, respectively. Dysmenorrhea, dyspareunia, and dyschezia were improved after surgery by 7.3, 9.4, and 12.5 times, respectively. We observed 25.2% of total pregnancy following the operation, the majority of which occurred in the first year after the surgery.

Conclusion

There were very few short-term or long-term complications in the three different techniques when the choice was correct.

Transvaginal ultrasound evaluation of the pelvis and symptoms after laparoscopic partial cystectomy for bladder endometriosis

Objective:

To evaluate transvaginal sonography (TVS) findings after laparoscopic partial cystectomy for bladder endometriosis and to correlate postsurgical ultrasound findings with symptoms.

Material and Methods:

A retrospective study including women who underwent laparoscopic partial cystectomy for bladder endometriosis. Within 12 months after surgery, TVS examination was conducted in all patients to evaluate the bladder morphology, and the presence of any postsurgical sonographic findings of the pelvis. Painful symptoms were assessed using a visual analogue scale.

Results:

A total of 40 women were included. At the follow-up visit, 25 patients were receiving medical treatment while 15 had declined post-surgical therapy and had tried to conceive. The presence of bladder deep-infiltrating endometriosis (DIE) was found in nine (22.5%), fibrotic thickening of the bladder wall was found in 15 (37.5%), and normal bladder morphology was observed in 16 (40%). There was a correlation between anterior adenomyosis and bladder DIE, and fibrotic thickening of the bladder. Patients with TVS signs of bladder DIE and anterior adenomyosis suffered more dysmenorrhea and dysuria than patients with normal bladder.

Conclusion:

Post-operative TVS can detect the alteration of pelvis and could explain the causes of the persistence of symptoms.

Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review

INTRODUCTION

The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis.

MATERIAL AND METHODS

Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed.

PROSPERO ID

CRD42021250974.

RESULTS

A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR.

CONCLUSIONS

Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

Surgery for deep infiltrating rectal endometriosis-Selecting the right approach

Endometriosis involving the bowel is a form of deep infiltrating endometriosis (DIE). The endometriotic lesions can infiltrate the bowel layers mimicking a malignancy. The majority of bowel involvement happens in the colon and rectum. We report our experience in surgically managing rectal endometriosis in two patients, one via a conservative approach and the other with a more radical approach and their associated short-term and long-term outcomes are observed. In principle, surgery remains the mainstay of treatment in managing rectal DIE with adjuvant hormonal therapy. The selection of surgical approach should be based on disease factors such as the size of the lesions and extent of the disease, patient factors including fitness for surgery and expectations as well as logistics and resource limitations.

Ultrasound prediction of segmental bowel resection in women with rectovaginal endometriosis: a single centre experience

STUDY OBJECTIVE

To retrospectively evaluate the ability of routinely collected pre-operative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis.

DESIGN AND SETTING

Patients at University College London Hospital (UCLH) who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (BSGE) database. Imaging data were collected and analysed to determine associations with the requirement for bowel resection.

PATIENTS

We evaluated 228 consecutive women undergoing bowel surgery (shave, disc or segmental resection) for rectovaginal endometriosis.

INTERVENTIONS

The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection and segmental resection of the bowel. All patients underwent a pre-operative transvaginal ultrasound to assess the extent of endometriosis.

MEASUREMENTS AND MAIN RESULTS

There were 206 (90.4%) rectal shaves, 2 (0.9%) disc resections, and 20 (8.8%) segmental bowel resections. A multivariable analysis demonstrated an association between bowel resection and two or more nodules located in the rectovaginal space (odds ratio 6.85, 95% CI 1.37, 34.2), nodules in the vesico-uterine pouch (odds ratio 5.87, 95% CI 1.03, 33.3), and increasing nodule size (odds ratio 2.39 per 1cm increase per 1cm diameter increase, 95% CI 1.56, 3.64).

CONCLUSION

Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counselling and surgical planning in the pre-operative setting for women with rectovaginal endometriosis.

Natural Orifice Specimen Extraction (NOSE) colorectal resection for deep endometriosis: A 50 case series: NOSE resection for DIE: 50 cases

STUDY OBJECTIVE

To describe our experience with the use of Natural Orifice Specimen Extraction (NOSE) technique for segmental bowel resection in patients with colorectal endometriosis.

DESIGN

Retrospective, observational study.

SETTING

Single tertiary referral centre PATIENTS: 50 consecutive patients undergoing NOSE colectomy for colorectal endometriosis in our centre, between March 2021 and November 2021.

INTERVENTIONS

NOSE colectomy for colorectal endometriosis with removal of the excised colorectal specimen through the vagina or the anus.

MEASUREMENT AND MAIN RESULTS

45 procedures were performed laparoscopically and 5 procedures were carried out robotically. All interventions were carried out by 3 endometriosis surgeons in a multi-disciplinary fashion, with involvement of a colorectal surgeon. There were no cases of conversion to laparotomy. Concomitant surgical procedures were performed in all cases. 11 patients had concomitant interventions on the digestive tract. 5 patients had concomitant interventions on the sacral plexus or sciatic nerve. All anastomoses were latero-terminal. The mean height of colorectal anastomosis was 12 centimetres (SD= +/- 4), and the mean length of the excised colorectal specimen was 9 centimetres (SD= +/- 4). In 29 cases, the specimen was extracted through the vagina and in 21 cases through the anus. 5 patients required a re-operation in the early post-operative period: We identified 1 case of anastomotic leak, 1 case of post-operative bowel obstruction, 1 case of haemorrhage and 2 cases of pelvic collection (no macroscopic evidence of pus). No patient received blood transfusion. The mean operative time was 158 minutes (SD=+/- 70) and mean hospital stay was 4 days (SD=+/- 1).

CONCLUSION

NOSE colectomy is a reproducible surgical technique for the management of colorectal endometriosis. The complication rate appears comparable with the conventional (mini-laparotomy) surgical approach. In experienced hands, this technique has a short learning curve, both in laparoscopy as well as in robotic surgery.

Surgery vs. hormone-based treatment for pain control in deep infiltrating endometriosis: a retrospective cohort study

OBJECTIVE

To evaluate the outcome of surgical or hormone-based pharmacological treatment for deep infiltrating endometriosis (DIE) in patients with pain symptoms.

STUDY DESIGN

A retrospective cohort study of 122 women with DIE of the bowel was conducted: 61 women underwent surgical treatment due to poor pain control and 61 received hormone-based treatment alone for at least six months. Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia and dysuria were evaluated by a visual analog scale (VAS) to measure pain on a scale from 0 to 10. Dyspareunia was further evaluated using the Deep Dyspareunia Scale (scores of 0-3).

RESULTS

Surgery (n = 61 women) was performed at a mean of 3.3 ± 1.6 years previously, while hormone-based treatment alone (n = 61 women) was used for a mean of 3.0 ± 1.41 years. After surgery, women without a desire to procreate received hormone-based treatment. Before treatment, the most intense endometriosis-related pain in the surgical treatment group and hormone-based treatment group alone were chronic pelvic pain (VAS = 9.48 ± 1.49; 8.57 ± 2.22), dysmenorrhea (VAS = 9.61 ± 1.45; 9.02 ± 1.35) and deep dyspareunia (VAS = 8.04 ± 2.82; 7.47 ± 3.21, respectively), all with mean pain scores of around 8 (0-10) in both groups. Both treatments were effective at reducing all symptoms (p < .001). The surgical treatment proved to be more effective and more enduring at improving chronic pelvic pain (p < .001), dyschezia (p = .003) and deep dyspareunia (p < .001). Regarding deep dyspareunia, using the deep dyspareunia scale, ∼70% of surgically treated women scored 0 or 1 (absent or mild deep dyspareunia) after treatment, compared to scores 2 or 3 (intense dyspareunia) in about 70% of the group using hormone-based treatment (p < .001).

CONCLUSION

Both types of treatment, surgical and pharmacological, effectively improved pain symptoms associated with DIE. However, improvement in chronic pelvic pain, dyschezia and deep dyspareunia was greater and longer-lasting after surgery.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases

Purpose

The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI).

Methods

A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections.

Results

The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy.

Conclusion

In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Effect of Surgical Treatment for Deep Infiltrating Endometriosis on Pelvic Floor Disorders: A Systematic Review with Meta-analysis

OBJECTIVES

 To evaluate the impact of surgical treatment of deep infiltrative endometriosis (DIE) on pelvic floor dysfunction (urinary incontinence [UI], pelvic organ prolapse [POP], fecal incontinence [FI)] or constipation, and sexual function [dyspareunia]).

DATA SOURCE

 The present systematic review was performed in the PubMed database. For the selection of studies, articles should be published by January 5, 2021, without language restriction.

STUDY SELECTION

 Six randomized controlled studies that evaluated surgical treatment for DIE and the comparison of different surgical techniques were included.

DATA COLLECTION

 The studies were selected independently by title and abstract by two authors. Disagreements were resolved by a third author. All included studies were also evaluated according to the Cochrane risk of bias tool and the quality of the evidence was analyzed using the GRADE criteria. Subgroup analysis by different treatments and follow-up periods was also performed.

RESULTS

 Six studies were included in the quantitative analysis. The risk of bias between studies showed an uncertain risk of bias for most studies, with concealment of allocation being the least reported category. The quality of the evidence was considered low. High heterogeneity was found between the studies. No study has evaluated UI or POP comparatively before and after surgery.

CONCLUSION

 Dyspareunia and FI have improved after the surgical procedure, but it was not possible to demonstrate which surgical technique was related to these outcomes as there was surgical heterogeneity. This diversity was found across data, with the recommendation of future prospective studies addressing pelvic floor disorders with DIE.

Long term outcomes following surgical management of rectal endometriosis: 7-year follow-up of patients enrolled in a randomized trial

STUDY OBJECTIVE

To compare functional outcomes, recurrence rate and pregnancy likelihood in patients undergoing conservative or radical surgery in patients with deep rectal endometriosis 7 years post-operatively.

DESIGN

Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013.

SETTING

A tertiary referral center.

PATIENTS

55 patients with deep endometriosis infiltrating the rectum.

INTERVENTIONS

Patients underwent either segmental resection or nodule excision by shaving or disc excision, depending on a randomization which was performed preoperatively using sequentially numbered, opaque sealed envelopes.

MEASUREMENT AND MAIN RESULTS

The primary endpoint was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence or bladder dysfunction 24 months postoperatively. Secondary endpoints were values of gastrointestinal and overall quality of life scores. The 7 year-recurrence rates (new deep endometriosis nodule infiltrating the rectum) in the excision vs. the segmental resection arms were 7.4 % vs. 0% (P=.24). One of more symptoms included in the definition of the primary outcomes were recorded in 55.6% vs. 60.7% of patients (P=0.79). However, 51.9% vs. 53.6% of patients considered their bowel movements as normal (P=.99). An intention-to-treat comparison of overall quality of life scores did not find differences between the two groups 7 years postoperatively. At the end of the 7-year study period, 31 of the 37 patients who tried to conceive were successful (83.8%) including: 27 (57.4%) natural conceptions and 20 (42.6%) pregnancies resulting from ART procedures. Pregnancy rate was 82.4% vs. 85% in the two arms (P=.99). A 75.7% live birth rate was recorded. At the end of the follow up there were 15 women with one child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow- up, the reoperation rate was respectively 37% and 35.7% in each arm, P=0.84). Among the 27 reoperation procedures during the follow up period, 11 were postoperative complications (40.7%), 7 were necessary prior to ART management (25.9%), 8 were for recurrent abdominal or pelvic pain (29.6%) and one for midline ventral hernia following pregnancy (3.7%).

CONCLUSIONS

Our study did not reveal a significant difference in terms of digestive functional outcomes, recurrence rate, reoperation risk and pregnancy likelihood when conservative and radical rectal surgery for deep endometriosis were compared 7 years postoperatively. Postoperative pregnancy rate observed in our series is high.

Challenges of and possible solutions for living with endometriosis: a qualitative study

Background

Endometriosis as a chronic gynecological disease has several negative effects on women’s life, thereby placing a huge burden on the patients and the health system. The negative impact of living with endometriosis (impaired quality of life, diverse medical experiences) is detailed in the literature, however, we know less about patients’ self-management, social support, the meaning of life with a chronic disease, and the needs of patients. To implement a proper multidisciplinary approach in practice, we need to have a comprehensive view of the complexity of endometriosis patients’ life and disease history.

Methods

Four focus group discussions were conducted between October 2014 and November 2015 by a team consisting of medical and psychological specialists. 21 women (age: 31.57; SD = 4.45) with surgical and histological confirmation of endometriosis were included in the study. Discussions were audiotaped and transcribed verbatim, and a 62,051-word corpus was analyzed using content analysis.

Results

Four main themes emerged from the analysis: (1) the impact of endometriosis on quality of life, (2) medical experiences, (3) complementary and alternative treatments, and (4) different coping strategies in disease management. All themes were interrelated and highly affected by a lack of information and uncertainty caused by endometriosis. A supporting doctor-patient relationship, active coping, and social support were identified as advantages over difficulties. Finding the positive meaning of life after accepting endometriosis increased the possibility of posttraumatic growth. Furthermore, women’s needs were identified at all levels of the ecological approach to health promotion.

Conclusions

Our results highlight the need for multidisciplinary healthcare programs and interventions to find solutions to the difficulties of women with endometriosis. To achieve this goal, a collaboration of professionals, psychologists, and support organizations is needed in the near future.

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.

Blood tests for prediction of deep endometriosis: A case-control study

BACKGROUND

Deep endometriosis (DE) is the most aggressive subtype of endometriosis. The diagnosis may be challenging, and no biomarkers that can discriminate women with DE from those without DE have been developed.

AIM

To evaluate the role of blood hemostatic parameters and inflammatory indices in the prediction of DE.

METHODS

This case-control study was performed at the Women’s Hospital, Zhejiang University School of Medicine between January 2015 and December 2016. Women with DE and women with benign gynecologic disease (control group) eligible for gynecological surgery were enrolled. Routine plasma hemostatic parameters and inflammatory indices were obtained before surgery. Univariate and multivariate analysis were performed. Receiver operating characteristic (ROC) curves were generated, and areas under the curve (AUC) were calculated to assess the predictive values of the selected parameters.

RESULTS

A total of 126 women were enrolled, including 31 with DE and 95 controls. Plasma fibrinogen (Fg, P < 0.01), international normalized ratio (P < 0.05), and C-reactive protein levels (P < 0.01) were significantly higher in women with DE compared with controls. Plasma hemoglobin (HB) levels (P < 0.05) and shortened thrombin time (P < 0.05) were significantly lower in women with DE than in controls. Plasma Fg levels [adjusted OR (aOR) 2.12, 95%confidence interval (CI): 1.31-3.75] and plasma HB levels (aOR 0.48, 95%CI: 0.29-0.78) were significantly associated with DE (both P < 0.05). ROC analysis showed that the diagnostic value of Fg or HB alone for DE was limited. The AUC of the combination of both markers as a dual marker index was 0.773 with improved sensitivity (67.7%) and specificity (78.9%) at cutoffs of 3.09 g/L and 126 g/L, respectively.

CONCLUSION

The combination of Fg and HB was a reliable predictor of DE. A larger study is needed to confirm the findings.