Deep Infiltrating Endometriosis: Imaging Features and Laparoscopic Correlation

Indirect and atypical imaging signals of endometriosis: A wide range of manifestations

Background

Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning.

Objective

To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI).

Methods

Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors.

Results

Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis.

MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants.

Conclusion

The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

Exploring the Relationship between Endometriomas and Infertility

Several clinical and epidemiological studies demonstrated an association between endometriosis and infertility. A role in the genesis of infertility may be played by endometriomas, which may interfere with ovulation or damage ovarian tissue. Unlike peritoneal implants, the availability of an accurate noninvasive sonographic diagnosis facilitates the investigation of endometrioma associated infertility. The laparoscopic excision of an endometrioma relieves the ovary from the damage caused by the cyst itself, which may be progressive over time, but at the same time is associated with a detrimental effect on ovarian reserve and with high rates of postoperative endometrioma recurrence. Therefore, the management of endometrioma-related infertility should not be based upon surgery alone, but upon a combination of surgery, with a refinement of the operating technique, long-term oral contraceptive, in vitro fertilization and oocyte cryopreservation.

Endometrioma-Associated Infertility: Is Surgery Still the Best Way to Go?

Purpose

Endometriomas are frequently associated with female infertility. In these cases, management options include surgery and IVF. The purpose of the present review is to evaluate current literature on the treatment of endometrioma-associated infertility and to compare the pros and cons of the different therapeutic approaches.

Methods

Literature search of published studies on the treatment of ovarian endometriomas in infertile patients. Studies were evaluated both on the efficacy of the surgical treatment on postoperative reproductive outcome and on the effect of surgery on the ovarian reserve.

Results

Pregnancy rates around 50% have been consistently reported after surgery, which compare favorably with those obtained with IVF. Surgery is effective also on associated pain, and the histological evaluation of the excised specimen rules out a possible unexpected ovarian malignancy. Thorough histological analysis of the excised specimen permits the evaluation of the appropriateness of surgery.

Conclusions

Laparoscopic excision of the ovarian endometrioma in infertile patients should still be considered the treatment of choice, particularly in case of associated pain. Surgery should be performed following appropriate techniques, and by dedicated surgeons, in order to decrease the possible damage to the ovarian reserve that has been recently reported postoperatively.

Fast-track surgery in intestinal deep infiltrating endometriosis

STUDY OBJECTIVE

To evaluate the length of hospital stay (LOS) and the readmission rate in patients undergoing laparoscopic surgery to treat intestinal deep infiltrating endometriosis (DIE) with application of the concepts of fast-track surgery.

DESIGN

Retrospective study of women undergoing laparoscopic treatment of intestinal DIE (Canadian Task Force classification II-3).

SETTING

Tertiary referral private hospital.

INTERVENTIONS

We evaluated 161 women who underwent laparoscopic surgery between January 2010 and April 2013 for complete treatment of intestinal DIE, via either conservative surgery (rectal shaving, mucosal skinning, or anterior disk resection) or radical surgery (segmental bowel resection). After surgery, all specimens were sent for pathologic examination to confirm the presence of endometriosis.

MEASUREMENTS AND MAIN RESULTS

Patients were divided into 2 groups according to type of surgery (conservative [n = 102] or radical [n = 59]), and LOS and readmission rate were measured in both groups. Median LOS was shorter in the conservative group compared with the segmental bowel resection group (19 vs 28 hours; p < .001). Ninety-two patients (90.2%) in the conservative surgery group were discharged to home on the first postoperative day, compared with only 38 patients (64.4%) in the segmental bowel resection group. Overall, the readmission rate was low (3.1%): 6.8% in the segmental bowel resection group and 1% in the conservative group (p = .04; odds ratio, 7.34; 95% confidence interval, 0.8-67.3); however, the need for repeat operation was similar in both groups (3.4% vs 1%; p = .28; odds ratio, 3.54; 95% confidence interval, 0.31-39.95).

CONCLUSION

Implementation of fast-track concepts in the laparoscopic treatment of intestinal DIE resulted in a short LOS and low readmission rate in both the segmental bowel resection and conservative surgery groups.

Retrocervical deep infiltrating endometriotic lesions larger than thirty millimeters are associated with an increased rate of ureteral involvement

STUDY OBJECTIVE

To estimate the presence of ureteral involvement in deep infiltrating endometriosis (DIE) affecting the retrocervical area.

DESIGN

Retrospective study of women undergoing laparoscopic treatment of DIE affecting the retrocervical area.

DESIGN CLASSIFICATION

Canadian Task Force classification II-3.

SETTING

Tertiary referral private hospital.

PATIENTS

We evaluated 118 women who underwent laparoscopy for the treatment of retrocervical DIE lesions between January 2010 and March 2012.

INTERVENTIONS

All women underwent laparoscopic surgery for the complete treatment of DIE. After surgery all specimens were sent for pathologic examination to confirm the presence of endometriosis.

MEASUREMENTS

Patients with pathologically-confirmed retrocervical DIE were divided into 2 groups according to the size of the lesion (group 1: lesions ≥ 30 mm; group 2: lesions < 30 mm) and the rate of ureteral endometriosis was compared between both groups.

MAIN RESULTS

Ureteral involvement was present in 17.9% (95% confidence interval [CI] 10%-29.9%) of women with retrocervical lesions ≥ 30 mm whereas in only 1.6% (95% CI 0.4%-8.5%) of those with lesions <30 mm (odds ratio = 13.3 [95% CI 1.6-107.3]).

CONCLUSION

Patients undergoing surgery for retrocervical DIE lesions ≥ 30 mm in diameter have a greater risk of having ureteral involvement (17.9%).

Spontaneous healing of a rectovaginal fistula developing after laparoscopic segmental bowel resection for intestinal deep infiltrating endometriosis

The surgical treatment of intestinal deep infiltrating endometriosis has an associated risk of major complications such as dehiscence of the intestinal anastomosis, pelvic abscess, and rectovaginal fistula. The management of postoperative rectovaginal fistula frequently requires a reoperation and the construction of a stoma for temporary fecal diversion. In this paper we describe a 27-year-old woman undergoing laparoscopic treatment of deep infiltrating endometriosis (extramucosal cystectomy, resection of the uterosacral ligaments, resection of the posterior vaginal fornix, and segmental bowel resection) complicated by a rectovaginal fistula, which healed spontaneously with nonsurgical conservative treatment.