Surgery For Deep Endometriosis Research Articles

Enhanced recovery after surgery (ERAS) for deep infiltrating endometriosis surgery: Experience of a French center

ObjectiveThe objective of the study was to evaluate the implementation of an ERAS programme for deep pelvic endometriosis (DPE) surgery in terms of length of stay (LOS), postoperative complications (POC) and rehospitalisation rate. MethodsThis was a comparative retrospective monocentric study in the Gynaecologic Department of the La Conception Hospital in Marseille, France. We compared a ‘conventional’ group, with classic perioperative management corresponding to patients undergoing DPE surgery between April 8, 2014 and January 23, 2018, and an ‘ERAS’ group after setting up the ERAS protocol from February 6, 2018 to March 6, 2020. ResultsA total of 101 patients with DPE surgery were included, with 39 in the conventional group and 53 in the ERAS group. The LOS decreased by 1.91 days (p < 0.001). During the 45 postoperative days, no difference was found in rehospitalised rate (p = 1). The POC rate was 15/39 (38.5 %) in the conventional group and 12/53 (22.6 %) in the ERAS group (p = 0.1). ConclusionThe implementation of an ERAS programme for DPE surgery is an effective strategy because it can reduce the LOS without increasing the POC rate.

Surgical Outcomes After Colorectal Surgery for Intestinal Deep Endometriosis: A Retrospective Cohort Study

Surgical Outcomes After Colorectal Surgery for Intestinal Deep Endometriosis: A Retrospective Cohort Study

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy.

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81min vs 240 ± 79min, p = 0.010, and 216 ± 78min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.

Intermittent Self-catheterization for Bladder Dysfunction After Deep Endometriosis Surgery: Duration and Factors that Might Affect the Recovery Process

ObjectiveTo assess the duration needed for regaining normal bladder voiding function in patients with postoperative bladder dysfunction requiring intermittent self-catheterization after deep endometriosis surgery, and identify risk factors that might affect the recovery process. DesignRetrospective study based on data recorded in a large prospective database. SettingEndometriosis referral center. PatientsFrom September 2018 to June 2022, 1,900 patients underwent excision of deep endometriosis in our center. 61 patients were discharged with recommendation for intermittent self-catheterization and were thus included in the study. InterventionsIntermittent self-catheterization after endometriosis surgery. Measurements and Main Results43 patients (70.5%) stopped self-catheterization during the follow up period. Median follow up was 25 weeks (range, 7 to 223 weeks). Surgery was performed laparoscopically in 48 patients (78.7%) and robotically in 13 (21.3%). 47 patients (77%) had nodules involving the digestive tract, 11 (18%) had urinary tract involvement, 29 had parametrial nodules (47.5%) and 13 (21.3%) had sacral plexus involvement. The probability of bladder voiding function recovery and arrest of self-catheterization was 24.5%, 54%, 59%, 72%, and 77% at 4, 8, 12, 52, and 78 weeks respectively. Cox's multivariate model identified preoperative bladder dysfunction as the only statistically significant independent predictor for arrest of self-catheterization (HR 0.36, 95%CI 0.15-0.83). ConclusionsPatients requiring intermittent self-catheterization for bladder dysfunction after deep endometriosis excision may spontaneously recover bladder function in 77% of cases. Symptoms suggesting preoperative bladder voiding dysfunction should be reviewed before planning surgery, and patients should be informed of the higher postoperative risk of long-term bladder voiding dysfunction.

Innovative Medical Treatments for Endometriosis

This presentation will focus on the following innovative areas in medical treatments for endometriosis. Where were we, say, a decade ago compared to where we are now? What diagnostic techniques should we employ to define the population we should treat? Does gold standard surgical treatment help patients avoid unwanted medical treatment - or should it now be the other way round? Do we still believe that medical treatment is not indicated for infertility related to endometriosis? What are the genuinely evidence-based innovative medical treatments for endometriosis? Consensus statements and guidelines represent a clear line in the sand of what may be considered gold standard practice of the time – the World Endometriosis Society’s consensus on current management of endometriosis (2013) 1 provides a good perspective on where we were around a decade ago; the ESHRE Guideline (2022) 2 reflects best practice today. There is growing consensus that a laparoscopic (+/- histological) diagnosis is no longer practical, or indeed needed, in most cases to implement the whole gamut of medical treatment, even though the entire evidence base for treating endometriosis hinges on laparoscopic diagnosis. Hence, “in 2023, there is a strong case for treatment of endometriosis to be based on a clinical diagnosis of ‘likely endometriosis’ supported by imaging findings, when appropriate, in lieu of a traditional diagnosis by laparoscopy +/- histology”. Following laparoscopic surgery, those not intending to conceive should consider the levonorgestrel intrauterine system or combined oral contraceptive pill for at least 18-24 months to reduce the recurrence of endometriosis-related pain symptoms; 2 following surgery for either endometriomas or deep endometriosis, long term hormone therapy should be considered to reduce the chance of recurrence.2 Given the respective evidence bases, progestin hormone therapy may be preferable to the combined oral contraceptive pill to turn the tide of increasing prevalence of endometriosis. 3 While medical treatment has not been recommended to improve fertility, indeed a delaying effect on fertility through medical treatment has traditionally been highlighted, innovative analysis methods, including network meta-analysis, have raised the question whether some medical treatments (dydrogesterone and GnRH agonists) might benefit fertility – and this is merit-worthy of further investigation. GnRH antagonists and aromatase inhibitors are the innovative medical treatments that have shifted from ‘showing potential’ to ‘recommended’, so we will delve into the data supporting this to discover that, for aromatase inhibitors, this remains far from convincing, but for GnRH antagonists, these present a genuine innovative medical treatment option for those suffering from endometriosis.

En-block butterfly excision of posterior compartment deep endometriosis: The first experience with the new surgical robot Hugo™ RAS.

Minimally invasive surgery is the gold standard treatment for deep endometriosis when medical management fails. In selected cases, such as when bowel or urinary tract are involved, robotic assisted surgery can be useful due to its characteristics of high dexterity and manoeuvrability. This is the first case of robotic en-bloc excision of posterior compartment deep endometriosis performed with the new HugoTM RAS system. The purpose of this video article is to show for the first time the feasibility of bowel surgery for deep endometriosis with this new robotic device. A 24-years-old woman affected by severe dysmenorrhea, chronic pelvic pain, dyschezia and dyspareunia underwent to deep endometriosis excision using the new robotic platform HugoTM RAS system at the Unit of Gynaecological Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Intraoperative data, docking set up, post-operative outcomes up to three months follow up were evaluated. The surgical procedure was carried out without intra-operative or post-operative complications, operative time (OT) was 200 minutes, while docking time was 8 minutes. No system errors or faults in the robotic arms were registered. Post-operative complete disease-related symptoms relief was reported. According to our results, the introduction of this new robotic platform in the surgical management of deep endometriosis seems to be feasible, especially in advanced cases. However, further studies are needed to demonstrate the benefits of this surgical system and the advantages of robotic surgery compared to laparoscopy in this subset of patients.

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.

Deep endometriosis muscular infiltration of the bowel wall: correlation between MRI and histopathology

To assess the correlation between magnetic resonance imaging (MRI) and histopathology for predicting muscular infiltration of endometriosis in the bowel wall in patients undergoing colorectal resection.All consecutive patients who underwent colorectal surgery for deep endometriosis (DE) with a preoperative MRI in a single tertiary care referral hospital between 2001 and 2019 were included in a prospective cohort. MRI images were revised by a single blinded radiologist. The MRI results regarding the infiltration depth (serosal, muscular, submucosal, or mucosal) and lesion expansion of DE were compared to histopathology.A total of 84 patients were eligible for evaluation. A sensitivity of 89% and positive predictive value of 97% was shown for predicting muscular involvement of the bowel wall.This study showed that MRI is valuable in predicting the involvement of the muscular layer of the colorectal wall. Therefore, in patients with symptomatic pelvic bowel endometriosis MRI is a useful tool in guiding the extent of colorectal surgery.

Clavien-Dindo, comprehensive complication index and classification of intraoperative adverse events: a uniform and holistic approach in adverse event registration for (deep) endometriosis surgery.

What is the additional value of the comprehensive complication index (CCI) and ClassIntra system (classification for intraoperative adverse events (ioAEs)) in adverse event (AE) reporting in (deep) endometriosis (DE) surgery compared to only using the Clavien-Dindo (CD) system? The CCI and ClassIntra are useful additional tools alongside the CD system for a complete and uniform overview of the total AE burden in patients with extensive surgery (such as DE), and with this uniform data registration, it is possible to provide greater insight into the quality of care. Uniform comparison of AEs reported in the literature is hampered by scattered registration. In endometriosis surgery, the usage of the CD complication system and the CCI is internationally recommended; however, the CCI is not routinely adapted in endometriosis care and research. Furthermore, a recommendation for ioAEs registration in endometriosis surgery is lacking, although this is vital information in surgical quality assessments. A prospective mono-center study was conducted with 870 surgical DE cases from a non-university DE expertise center between February 2019 and December 2021. Endometriosis cases were collected with the EQUSUM system, a publicly available web-based application for registration of surgical procedures for endometriosis. Postoperative adverse events (poAEs) were classified with the CD complication system and CCI. Differences in reporting and classifying AEs between the CCI and the CD were assessed. ioAEs were assessed with the ClassIntra. The primary outcome measure was to assess the additional value toward the CD classification with the introduction of the CCI and ClassIntra. In addition, we report a benchmark for the CCI in DE surgery. A total of 870 DE procedures were registered, of which 145 procedures with one or more poAEs, resulting in a poAE rate of 16.7% (145/870), of which in 36 cases (4.1%), the poAE was classified as severe (≥Grade 3b). The median CCI (interquartile range) of patients with poAEs was 20.9 (20.9-31.7) and 33.7 (33.7-39.7) in the group of patients with severe poAEs. In 20 patients (13.8%), the CCI was higher than the CD because of multiple poAEs. There were 11 ioAEs reported (11/870, 1.3%) in all procedures, mostly minor and directly repaired serosa injuries. This study was conducted at a single center; thus, trends in AE rates and type of AEs could differ from other centers. Furthermore, no conclusion could be drawn on ioAEs in relation to the postoperative course because the power of this database is not robust enough for that purpose. From our data, we would advise to use the Clavien-Dindo classification system together with the CCI and ClassIntra for a complete overview of AE registration. The CCI appeared to provide a more complete overview of the total burden of poAEs compared to only reporting the most severe poAEs (as with CD). If the use of the CD, CCI, and ClassIntra is widely adapted, uniform data comparison will be possible at (inter)national level, providing better insight into the quality of care. Our data could be used as a first benchmark for other DE centers to optimize information provision in the shared decision-making process. No funding was received for this study. The authors have no conflicts of interest to declare. N/A.

Management of a Large Endometriotic Nodule of the Right Parametrium Involving the Sacral Roots, Vagina, Rectum, and Sigmoid Colon, with Intraoperative Bleeding

Deep endometriotic lesions may involve the deep parametrium which is highly vascular and includes numerous somatic and autonomous nerves (1,2). Surgeons who dissect in this area, must always be prepared to deal with major bleeding, and to master the different techniques of hemostasis. The goal of this video is to show the steps of laparoscopic excision of deep endometriotic lesion of the parametrium and the steps taken to control the bleeding encountered from one of the venous branches. Surgical educational video. Endometriosis referral center. Excision of the endometriotic parametrial nodule and the release of the sacral plexus, with excision of the vaginal involvement, rectal disc excision, and segmental resection of the sigmoid colon. The video shows the excision of a deep endometriosis involving the right parametrium, the mid rectum, the sigmoid colon, and the vagina. The excision of deep endometriosis of the parametrium followed the 10 steps previously described (1). During this procedure, careful dissection of arteries and veins branching from the internal iliac vessels is a crucial step. However, injury of one or more of the vessels can still occur. The movie presents the different techniques used to control the bleeding from a venous injury faced during the dissection around the nodule in the parametrium, including energy use, clips, hem-o-loks, and direct continuous pressure. Of note, hemostatic agents are available, however we have not yet successfully employed them in these circumstances in which large veins were injured. The ultimate solution in our case was the clamping of the injured vessels, allowing meticulous dissection and sectioning of all the feeding vessels, while taking care not to injure the sacral roots which were just beneath these veins. Total operative time was 4 hours. Surgery of deep endometriosis involving the sacral plexus may be successfully done laparoscopically. Thorough knowledge of the deep pelvis anatomy is mandatory, and the surgeon should master various techniques of hemostasis, particularly on deep veins.

A 39-Year-Old Woman with Endometriosis Who Developed a Subcapsular Liver Hematoma Following Laparotomic Surgical Left Adnexectomy, Rectosigmoid Anastomosis, and Bilateral Ureteral Reimplantation.

BACKGROUND Endometriosis is a chronic inflammatory disease caused by endometrial tissue that grows outside the uterus. Deep endometriosis surgery is associated with considerable rates of complications, although such rates are lower in surgical procedures carried out by expert surgical teams. This report details a case of a rare but life-threatening complication in the postoperative period following 72 h of endometriosis surgery: a giant subcapsular hepatic hematoma, which was successfully managed conservatively. CASE REPORT Here we describe the case of a 39-year-old woman with deep endometriosis with ureteral, ovarian, and intestinal involvement requiring multidisciplinary surgery. She presented with severe anemia, respiratory distress, and oliguria 72 h postoperatively. A 3-phase computed tomography (CT) scan revealed a giant intrahepatic subcapsular hematoma (180×165×50 mm) lateral to the right hepatic lobe, which was managed conservatively. The patient evolved favorably and the hematoma was reduced (77×16 mm) in a follow-up CT scan performed 5 months later. CONCLUSIONS Giant liver hematoma is a rare, life-threatening complication. The current experience relating to its management remains largely limited owing to the rarity of the condition and paucity of published cases. Actually, we found no articles on hepatic hematoma in the context of endometriosis surgery. Early diagnosis and treatment are essential to reduce the patient's risk of death. Imaging diagnosis plays an essential role.

From Radical Hysterectomy to Radical Surgery for Deep Endometriosis.

From Radical Hysterectomy to Radical Surgery for Deep Endometriosis.

Clinical outcomes following surgical management of deep infiltrating endometriosis

The main aim of the study was to evaluate severe post-operative complications following deep endometriosis surgery in a tertiary referral centre. This is a retrospective cohort study that included women who had surgery for deep infiltrating endometriosis between 1st January 2013 and 31st December 2019. Endometriosis was diagnosed based on clinical, imaging and histological parameters. We evaluated the rates of post-operative complications, potential risk factors for such complications and postoperative pregnancy rates. A total of 165 patients were included in the final analysis. The median follow-up was 63 (25–106) months. Thirty-seven patients (22.42%) had hysterectomy, 60 (36.81%) had ureterolysis and 44 (26.67%) had colorectal surgery. The overall and severe rates of post-operative complications were 16.20% (n = 23) and 2.42% (n = 4) respectively. Of the variables assessed, operative time and age were the only statistically significant risk factor for complications on multivariate analysis. Among women operated on for infertility, 34.5% (n = 20/58) got pregnant following surgery with 30% of these spontaneously. This study demonstrates acceptable overall and severe post-operative complications and pregnancy rates after deep endometriosis surgery. This information should help clinicians when counselling women to enable them making an informed choice about their management.

Deep Endometriosis and Infertility: What Is the Impact of Surgery?

In women with deep endometriosis, the spontaneous fertility rate might range from 2 to 10%. The optimal management of these women is still an area of debate. Therefore, this review aims to explore the literature on the impact of deep endometriosis surgery on reproductive outcomes and pregnancy rates in women with and without prior infertility. A total of 392 articles were identified through database searching. Twenty-three studies were eligible to be included in the review. A total of 1548 women were identified, 814 of whom became pregnant, with a mean pregnancy rate of 52.6% (95% CI 49.7-63%). Our review suggests that surgery may improve fertility outcomes. Due to the variability in the studies, it is impossible to stratify fertility outcomes of surgery by the localization of deep endometriosis. More investigations are needed to determine whether surgical management should be first-intention or limited to the failure of medically assisted reproduction treatment.

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

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. Retrospective study on data prospectively recorded in 2 databases. Two tertiary referral centers. A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022. Rectal disk excision using the EEA stapler. 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. 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.

8741 Versius®, a Revolutionary Robotic Platform - First Endometriosis Surgical Trials in Brazil

<h3>Study Objective</h3> This study aims to assess a gynecological surgical team's early outcomes with the new Versius® platform in terms of safety and efficiency in minimally invasive gynecological operations. <h3>Design</h3> A prospective study that followed for 10 days endometriosis surgeries performed by the new robotic Versius® platform. <h3>Setting</h3> An operation room with space foi the surgeon console and of all base system units. All patients were positioned in the same way in dorsal decubitus. The trocar punctures followed the same techniques for the 4 robot arms. <h3>Patients or Participants</h3> 10 women with deep endometriosis. <h3>Interventions</h3> the first 10 cases of gynecological surgeries in the Americas using the platform Versius, performed by the same team in a private hospital in Sao Paulo, Brazil. <h3>Measurements and Main Results</h3> Ten robotic gynecological surgeries were conducted to treat endometriosis in individuals with an average age of 42 years and a BMI of 25.3. Six of the patients had severe endometriosis with an AAGL IV classification, whereas the other four had an AAGL II classification. Two of the instances were linked to hysterectomy, while one was linked to myomectomy. The average docking time was 24.7 minutes, while the average procedure duration was 93.7 minutes, and all procedures were without complications. Nine of the ten patients were discharged within 24 hours after the operation, and one was discharged within 48 hours. Collisions between the surgical arms were noticed throughout procedures, necessitating changes to the placement of the units or further "port-training" to establish a better fit and avoid collisions. All patients had the same standardization of trocar placement for the highest efficiency and best cosmetic result (pictures below). <h3>Conclusion</h3> CMR's Versius® system and the treatment of deep endometriosis surgery are encouraging, but additional cases should be monitored to measure learning curve time and improvements in the positioning of units to avoid collisions.

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.

Quality of life and low anterior resection syndrome before and after deep endometriosis surgery.

Deep endometriosis (DE) is defined by the presence of ectopic endometrial glands, with rectal involvement ranging from 5.3 to 12%. The prevalence of low anterior resection-like syndrome (LARS) in patients with DE, how it affects quality of life (QoL), and its evolution after surgery is unclear. The objective of this study was to assess the gastrointestinal functional outcomes and QoL in patients who underwent surgery for DE. A prospective study was conducted from 2017 to 2019, recruiting patients who underwent DE surgery with and without rectal resection. Patients completed LARS and SF-36 questionnaires before, at 6months and at 1year after surgery. Eighty-two patients were enrolled. Rectal segmental resection was required in 16 (19.5%) patients, shaving in 16 (19.5%) and discoid resection in 8 (9.8%). All 8 domains of the SF-36 questionnaire showed improvement during follow-up, reflecting improved QoL after surgery (p ≤ 0.05) in all patients. Mean LARS scores for patients without rectal surgery were 7.5 ± 10.4 before and 13.7 ± 14.2 1year after surgery; rectal surgery was 13.6 ± 13.6 and 14.6 ± 13.1, respectively (p = 0.17). No significant differences were found in the rectal surgery patients' postoperative LARS score among the 3 rectal DE surgical techniques (p = 0.97), and the SF-36 scores improved independent of the technique performed. Patients with DE present a LARS-like syndrome before surgery that does not appear to be negatively affected after rectal surgery, independent of the technique performed. Rectal surgery improves the QoL of patients with DE patients as measured by the SF-36 questionnaire at 1year of follow-up.

Impact of Laparoscopic Sclerotherapy for Ovarian Endometriomas on Ovarian Reserve

StudyObjective: To evaluate the impact of laparoscopic sclerotherapy on the management of endometrioma during surgery for deep infiltrative endometriosis (DIE). DesignObservational study. SettingTivoli-Ducos Clinic, Bordeaux. PatientsSixty-nine patients underwent laparoscopic sclerotherapy for endometrioma during surgery for DIE. InterventionsLaparoscopic sclerotherapy with 95% ethanol solution and DIE surgery. Measurements and Main ResultsAntimüllerian 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. ConclusionLaparoscopic sclerotherapy for endometrioma >40 mm during surgery for DIE sclerotherapy has a low impact on AMH, preserves fertility, and prevents recurrence.

Nerve-sparing surgery for deep lateral parametrial endometriosis

Although dLPE is not overly rare, isolation of the autonomic nerves from dLPE cannot always be guaranteed. In patients with endometriosis lesions that are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except for those with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to bladder dysfunction, which seriously affects the quality of life. Therefore, the objective is to demonstrate the anatomical and technical highlights of nerve-sparing laparoscopic surgery for deep lateral parametrial endometriosis (dLPE). Stepwise demonstration of this method with a narrated video footage. An urban general hospital. A 38-year-old woman, para 1, presented with a 5-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. The patient showed no neurological disorders, such as bladder dysfunction. Magnetic resonance imaging revealed right ovarian endometrioma and hydrosalpinx with dLPE reaching the lateral pelvic wall. Based on the dermatome involved, we suspected that the main lesion causing gluteal pain was located around the second and third sacral roots. Laparoscopic excision of dLPE with a pelvic autonomic nerve-sparing technique, decompression of somatic nerves and preservation of all branches of the internal iliac vessels. Assessment of preserved tissue perfusion using indocyanine green. The procedure was performed using 8 steps, as follows: step 1, adhesiolysis and adnexal surgery; step 2, complete ureterolysis; step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; step 4, dissection of the internal iliac vessels; step 5, identification and dissection of the sacral roots S2-S4 and the pelvic splanchnic nerves; step 6, complete removal of dLPE; step 7, hemostasis and assessment of tissue perfusion using indocyanine green; and step 8, application of barrier agents to prevent adhesion. Dissection of the pelvic nerves before dLPE excision revealed the relationship between the lesions and pelvic innervation, thereby reducing the risk of nerve injury, whether by minimizing the risk of neuropraxia or by allowing as many nerve fibers as possible to be spared in patients with some invasion of the pelvic nerve system. We considered even partial preservation of these nerves as beneficial to the resumption of pelvic organ functions. The step-by-step technique should help perform each stage of the surgery in a logical sequence, ensuring easy and safe completion of the procedure. Relief from severe pain, avoidance of postoperative morbidity (including intermittent self-catheterization). The patient developed no perioperative complications, including postoperative bladder, rectal, or sexual dysfunctions. Pain was completely resolved. Nerve-sparing surgery is technically safe and feasible for selected patients with dLPE. Suitably tailored treatment should be provided for each individual based on both latest scientific evidence and life planning for the patient.