Nerve-sparing laparoscopic disc excision of deep endometriosis involving the bowel: a single-center experience on 371 consecutives cases.

Abstract

Bowel endometriosis is the most common pattern of Deep Endometriosis (DE).Arising from the posterior portion of the cervix and spreading to the recto-vaginal septum, utero-sacral and parametrial ligaments could lead to a distortion of normal pelvic anatomy, causing pain and infertility.Hormonal therapy is the first-line treatment in non-symptomatic patient.Conversely, laparoscopic surgical treatment has to be considered when symptoms relief are not optimal or with signs of bowel occlusion. Retrospective experience of consecutive series of patients who referred to a third-level referral center with suspected bowel DE and failure of multiple medical treatments.After an intraoperative evaluation of nodule size with a rectal shaving of its external portion, patients underwent radical DE eradication with concomitant disc excision in rectal nodules < 3cm with no signs of substantial full-thickness infiltration. A total of 371 patients were considered eligible for analysis, with a median age of 37years. The median operative time of was 180min, with an estimated blood loss of 100mL and amedian diameter of removed rectal noduleof 25mm. Early postoperative procedure-related complications were 47 cases of acute rectal bleeding (12.7%), that were managed by rectal endoscopy, 3 bowel anastomotic dehiscence (0.8%), 8 hemoperitoneum (2.2%) and 3 ureteral fistula (0.8%). 22 patients experienced postoperative hyperpyrexia (5.9%), while 17 women underwent transient bladder deficiency (4.6%). Median follow-up was 60monthswith a bowel recurrence rate of 2.2%. There was an improvement of all symptoms in the immediate postoperative follow-up (p < 0.0001). Among all patients with childbearing desire, the pregnancy rate found was 42.2% and was obtained by in vitro fertilization (IVF) techniques in 32% of cases. Laparoscopic disc excision for bowel endometriosis is an effective surgical treatment in selected residual rectal nodules < 3.0cm. The concomitant radical DE excision contributes to a significant improvement of symptoms with an acceptable complications' rate.