Deep Endometriosis Research Articles

13666 Rectal Shaving in Deep Endometriosis

13789 Patient Characteristics and the Differences in Preoperative and Intraoperative Imaging Modalities for Deep Rectosigmoid Endometriosis

Targeted Excision of Deep Nerve Endometriosis (Sciatic–Pudendal–Presacral) with Ionm-Guided Surgical Precision

13747 Association between Intraoperative Ultrasound and Resection Type and Postoperative Outcomes in Deep Rectosigmoid Endometriosis Surgery

Robotic Assisted and Cystoscopic Partial Cystectomy for Deep Endometriosis: A Bladder Sparing Approach

14899 Conservative Treatment of Deep Endometriosis: Predicting Treatment Outcomes

13877 Excision of Residual Deep Endometriosis Following Hysterectomy

Deep Endometriosis Affecting the Rectosigmoid and Vagina: A Surgical Strategy to Preserve Functionality

Minimally Invasive, Maximally Effective: Nose and Advanced Ureteral Dissection in Deep Endometriosis Surgery with Hysterectomy

Painful Sexual poSiTions in endometriosis patients (the PSST! Study): a prospective cohort study.

The adhesive process after excision of the foci of endometriosis is the most common cause of chronic pelvic pain. The wide area of tissue dissection and the resection of the parietal peritoneum in many cases dictate the need to use anti-adhesive barriers at the final stage of surgical treatment. However, the use of these drugs in patients who have undergone colorectal resection is a controversial issue due to the difficulty in diagnosing possible postoperative complications. Objective. Assessment of clinical and laboratory indicators in the early postoperative period and quality of life in the long-term period in patients who underwent colorectal resection. Materials and methods. The study included 30 patients who underwent intestinal resection for deep infiltrative endometriosis using an anti-adhesive barrier (main group 1), and 30 patients after a similar operation without the introduction of an anti-adhesive gel intraoperatively (control group 2). In the postoperative period, clinical symptoms, laboratory and instrumental data were evaluated. Results. In the postoperative period, C-reactive protein was the most sensitive marker of inflammation that correlated with clinical data. On days 1, 2, 3, and 14, the content of C-reactive protein and the level of leukocytes in the blood were monitored in all patients who underwent surgery for infiltrative endometriosis. The severity of the pain syndrome had a positive correlation with the volume of the drug administered in group 1 patients. In the postoperative period, there was an increase in the level of C-reactive protein in patients of the main group compared with this indicator in patients of the control group with a peak in C-reactive protein content on day 2 in patients of the 1st group with a gradual decrease and normalization by day 14. In the late postoperative period, there was a decrease in the severity of pain syndrome in patients of the 1st group. Conclusion. Intraoperative use of anti-adhesive barriers is safe and reduces the likelihood of developing and severity of pain syndrome in the postoperative period.

Robotic excision of deep endometriosis involving the superior gluteal nerve.

Background: Despite recent progress in endometriosis treatments that modify the disease, pain continues to be the most significant symptom for many women suffering from endometriosis. Due to the role of inflammation and immune system abnormalities in the pathogenesis of endometriosis, this study aimed to determine the effectiveness of 10 mg prednisolone on pelvic pain management in women with Deep Infiltrative Endometriosis (DIE). Methods: This randomized, double blind, placebo-controlled clinical trial study was conducted with 60 women (ages 18–45 years) diagnosed with DIE. The intervention group received two tablets of prednisolone (10 mg) along with Dienogest (2 mg) daily starting from the 10th day of the first menstrual period after the baseline visit for 12 weeks. The control group received one Dienogest tablet (2 mg) daily along with two placebo tablets following the same regimen as the intervention group. Primary outcomes included changes in pain scores for dysmenorrhea, dyspareunia, and dyschezia after the intervention, as well as the change in the size of endometriosis. Results: Dysmenorrhea and dyspareunia and dyschezia scores significantly decreased in both groups. However, the frequency of patients in the prednisolone group who experienced a reduction in dysmenorrhea and dyspareunia scores ⩾30% was statistically higher compared to the control group. While the percentage of patients showing reduced endometrium size was higher in the prednisolone group (58.3% vs 36.4%), this difference was not statistically significant ( p = 0.15). No serious side effects were reported. Conclusion: This clinical trial demonstrated that low-dose prednisolone provides a significant decrease in pain associated with DIE. Further trials will be warranted to confirm these findings.

Deep infiltrative endometriosis (DIE) is characterized by the infiltration of endometrial tissue into the pelvic organs, such as the rectovaginal septum, utero-ovarian, and uterosacral ligaments. Bowel involvement occurs in approximately 3.8-37% of cases, whereas urinary tract involvement is less common (1-6%). The pathophysiology of DIE includes deep infiltration of endometrial tissue into the peritoneum, with the gastrointestinal system being a common site. The pathogenesis of endometriosis involves hormonal functional changes in estrogen and progesterone receptors and the influence of immune factors like peritoneal macrophages, natural killer cells, and lymphocytes. Diagnostic methods, including transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI), play crucial roles in identifying and assessing endometriosis. Medical treatment options include oral contraceptives, progesterone pills and devices, and gonadotropin-releasing hormone (GnRH) analogs or antagonists. Surgical treatment options are shave excision, disc excision, and colorectal resection. This review provides a comprehensive overview of DIE, its pathophysiology, diagnostic methods, treatment options, as well as implications for fertility and pregnancy outcomes.

ABSTRACTPatients with deep endometriosis of the posterior pelvic compartment might present various lower urinary tract symptoms, including urinary retention, without any prior pelvic surgery in their medical history. These symptoms, including urinary retention, pollakiuria or urge incontinence, urinary urgency, and decreased bladder sensitivity, imply an infiltration of the pelvic autonomic nerves by endometriosis lesions, in combination with inflammatory phenomena. Although there are numerous publications dealing with de novo urinary dysfunction after endometriosis surgery, significantly less scientific information is available on the effect of endometriosis surgery specifically tailored to improve preoperative voiding dysfunction in endometriosis. Therefore, in this case report, we analyze the effect of laparoscopic endometriosis surgery in a 28‐year‐old nulliparous woman with serious preoperative urinary retention mandating clean intermittent self‐catheterization three to four times daily. Patient history revealed neither prior pelvic nor abdominal operation, nor any neurological or other known disease. Uroflowmetry demonstrated significant voiding dysfunction. Filling cystometry showed signs of reduced bladder sensation (normal desire to void at 400 mL) along with preserved bladder compliance. During the pressure‐flow study, the patient was unable to initiate micturition, although abdominal straining and detrusor contraction were registered. The cause of voiding dysfunction was deemed to be pelvic floor dysfunction (dysfunctional voiding) rather than detrusor underactivity. Alpha blocker, muscle relaxant therapy, and pelvic floor relaxation training were introduced, achieving poor short‐term response. Transvaginal ultrasound examination showed hypoechogenic alterations on both uterosacral ligaments in the vicinity of their cervical attachment sites. These areas appeared to be painful while scanning with the probe. MRI examination confirmed the previous finding of transvaginal ultrasound with regard to bilateral alteration of the uterosacral ligaments characteristic of endometriosis. During laparoscopy, we confirmed the presence of endometriotic lesions of both uterosacral ligaments that were completely removed. The patient showed significantly improved emptying function following surgery. Uroflowmetry also demonstrated improved voiding parameters. We conclude that laparoscopic removal of endometriotic lesions of the uterosacral ligaments can significantly improve bladder function in patients suffering from preoperative voiding dysfunction.

To assess the impact of complex disease states, including pouch of Douglas (POD) obliteration and deep endometriosis (DE) of the bowel, on the diagnostic accuracy of transvaginal ultrasound (TVUS) for detecting endometriosis of the uterosacral ligaments (USLs) and torus uterinus (TU). This diagnostic accuracy study evaluated the performance of TVUS in diagnosing DE of the USLs and TU, using laparoscopic visualisation with histological confirmation as the reference standard among two previously reported prospectively collected cohorts. Complex disease states were defined as complete POD obliteration and/or DE of the bowel. Diagnostic accuracy metrics, including sensitivity, specificity, positive and negative predictive values (PPV) and likelihood ratios (LR), were calculated before and after the exclusion of complex disease cases. Among 177 participants, 18.6% (33/177) had POD obliteration, 18.6% (33/177) had DE of the bowel and 16.4% (29/177) had both. Accuracy ranged from 93.1% to 94.7% for USLs and 97.2%-98.5% for TU, with minimal change after exclusion (≤ 1.5%). Sensitivity declined following exclusion, by -6.4% (left USL), -3.5% (right USL) and -2.7% (TU) after POD obliteration exclusion and further decreases of -1.8%, -3.4% and -4.4%, respectively, after bowel DE exclusion. Specificity remained ≥ 97.8% across all sites and reached 100% at the USLs after POD obliteration exclusion. Contrary to the assumption that complex disease states hinder TVUS accuracy, their presence may enhance lesion recognition, likely due to increased sonographic attentiveness when severe disease is suspected. While TVUS remains highly specific, its sensitivity decreases in the absence of complex disease, emphasising the need for meticulous and systematic imaging approaches.

Endometriosis-associated pain has debilitating effects on the quality of life of patients. Despite its high prevalence in reproductive-aged women, the pathophysiology is still unknown, impeding the development of targeted treatment approaches. The prospective ExPAND study proposes the neurosteroids pregnenolone sulphate (PS) and dehydroepiandrosterone sulphate (DHEAS) as potential contributors to endometriosis-associated pain, due to their agonistic action at the pain-related ion channel TRPM3. To this end, endometrium, deep endometriosis lesions, and peritoneal fluid were prospectively collected in four demarcated patient groups, which were characterised based on their pain symptoms, as scored via the WERF-EPHect questionnaire, i.e., (1) control (n = 44), (2) endometriosis patients with no pain symptoms (n = 24), (3) with only severe dysmenorrhea (n = 54), or (4) with both severe dysmenorrhea and non-cyclic pelvic pain (n = 78). Tissue mRNA expression levels of steroidogenic enzymes were investigated and showed significantly increased levels of CYP17A1 in the endometrium of patients with severe pain symptoms compared to control tissue. In addition, liquid chromatography with tandem mass spectrometry (LC-MS/MS) was performed to investigate neurosteroid concentrations in the peritoneal fluid. Both neurosteroids PS and DHEAS were present in the peritoneal fluid at concentrations that are known to stimulate TRPM3 activity in vitro. Finally, using microfluorimetric Ca2+ imaging, we demonstrate that both DHEAS and PS stimulate human stem-cell-derived sensory neurons in a TRPM3-dependent manner. Taken together, these data indicate a potential contribution of steroidogenesis and TRPM3 in endometriosis-associated pain.

Does endometriosis and/or adenomyosis, diagnosed using the International Deep Endometriosis Analysis (IDEA) group and the Morphological Uterus Sonographic Assessment (MUSA) group revised definitions, impact cumulative live birth rates (CLBR) after three consecutive IVF or ICSI treatments? Women with endometriosis and/or adenomyosis, as diagnosed using transvaginal ultrasonography, had a 15% reduced chance of having a cumulative live birth after three consecutive IVF/ICSI treatments compared to women without these conditions. Women with endometriosis or adenomyosis reportedly have lower live birth rates after their first IVF/ICSI treatment. However, most women undergo multiple cycles, and given their shared pathophysiology, the combined impact of both conditions over consecutive treatments remains unclear. This was a prospective cohort study of 1035 women undergoing up to three consecutive IVF/ICSI treatments at a university hospital between January 2019 and April 2024. Swedish regulations entitle women to up to three subsidized treatment cycles, including fresh and/or frozen embryo transfers, until the birth of a living child is achieved. All 1035 included women underwent a transvaginal ultrasound examination prior to starting their first treatment. Using the IDEA and revised MUSA definitions, respectively, in total 293 (28.3%) women had endometriosis and/or direct features of adenomyosis on ultrasonography. All 1035 women underwent the first treatment cycle. In total, 818 (79.0%) women [595 (80.2%) of women without endometriosis and/or adenomyosis and 223 (76.1%) of women with either of the diseases] underwent all treatments they were eligible for. A total of 217 (21.0%) women dropped out after the first or second treatment even if they had not achieved a live birth. In total, 1725 fresh treatment cycles were initiated, leading to 1283 fresh and 622 frozen embryo transfers. Live births were recorded. The adjusted relative risk (aRR) for cumulative live birth after three consecutive IVF/ICSI treatment cycles was calculated on an intention-to-treat (ITT) as well as per-protocol (PP) basis, using a modified Poisson regression analysis, adjusting for age as a potential confounder. The CLBR over three consecutive IVF/ICSI treatment cycles was 666/818 (81.4%) in the total cohort. In an ITT and PP analyses, respectively, women with endometriosis and/or adenomyosis had a lower CLBR of 156/293 (53.2%) or 156/223 (70.0%) compared to women without, CLBR of 510/742 (68.7%) or 510/595 (85.7%), P < 0.001. The aRR for cumulative live birth for women with endometriosis and/or adenomyosis was aRR (ITT) 0.80 (95% CI, 0.71-0.90), P < 0.001, and aRR (PP) 0.85 (95% CI, 0.77-0.93), P < 0.001 compared to women without the diseases. After stratifying the results per treatment cycle, the LBR after the first treatment for women with endometriosis and/or adenomyosis was 90/293 (30.7%), aRR 0.69 (95% CI 0.57-0.84), P < 0.001, after the second 44/154 (28.6%), aRR 0.72 (95% CI 0.54-0.96), P = 0.023, and after the third treatment 22/84 (26.2%), aRR 0.83 (95% CI 0.54-1.28), P = 0.183. For women without the diseases, the LBR was 335/742 (45.1%) in the first cycle, 132/319 (41.4%) in the second, and 43/133 (32.3%) in the third cycle. The largest differences were seen after fresh compared to frozen embryo transfers. The ultrasound examinations were performed at a tertiary care hospital by an examiner with expertise in endometriosis and adenomyosis. According to the revised MUSA definitions, direct features of adenomyosis are pathognomonic, whereas indirect features are only indicative of the disease. It is possible that some women with only indirect features, who were considered healthy in this study, in fact had the disease and therefore were wrongly classified. Despite a lower CLBR over three IVF/ICSI cycles, women with endometriosis and/or adenomyosis still have a reasonable chance of achieving a live birth with consecutive treatments. Negative results after the first treatment should not be an argument to withhold further attempts. Future research should explore strategies to enhance treatment success in this population, including the role of long-term suppression protocols, exogenous progesterone dosing, and personalized embryo transfer approaches. This study was supported by regional research grants from Region Skåne, Sweden. N/A.

Endometriosis affects about 10% of reproductive-aged women, characterized by endometrial-like tissue outside the uterus, leading to chronic inflammation. The exact cause remains unknown, though genetic and epigenetic factors are increasingly recognized alongside traditional theories. The disease manifests in forms such as endometriomas, whether superficial or peritoneal, and deep infiltrating lesions, often causing chronic pain and infertility. Infertility affects nearly 50% of patients, requiring expensive treatments like in vitro fertilization. Oxidative stress plays a key role in endometriosis, with sirtuins, especially SIRT3, emerging as important regulators. SIRT3, located in mitochondria, helps manage oxidative stress and redox balance. Despite extensive research, no diagnostic biomarkers exist. This longitudinal study compares oxidative stress markers and SIRT3 levels in patients with different endometriosis types. While classic oxidative stress markers showed no significant differences, higher SIRT3 levels were observed in peripheral blood mononuclear cells of patients with deep endometriosis. Additionally, patients with prior surgeries had elevated SIRT3 levels, indicating a possible link between disease severity and SIRT3 expression. The findings suggest SIRT3 as a potential therapeutic target in endometriosis management.

Endometriosis is a chronic, hormone-dependent disease affecting up to 10% of women of reproductive age, often associated with chronic pelvic pain (CPP). Neuropathic pain has been increasingly recognized as a significant component in a subset of patients with CPP related to endometriosis. The study objective was to assess the prevalence of neuropathic-like pain in women with deep endometriosis (DE) and CPP, and to analyze its influence on pain perception and quality of life. Retrospective monocentric cohort study included 149 women with DE and CPP treated at a tertiary pain center between 2013 and 2017. Pain characteristics were assessed using validated tools, including the DN4 questionnaire for neuropathic pain, the abridged Saint-Antoine Pain Questionnaire (QDSA) for sensory and emotional dimensions of pain, and the EQ-VAS for quality of life. Psychological factors, including anxiety, depression, and catastrophizing, were also evaluated. Neuropathic-like pain was identified in 36% of patients. These patients reported significantly higher global and minimum pain intensity (p < 0.01, p < 0.01), greater emotional (QDSA affective subscore, p < 0.05) and sensory (QDSA sensory subscore, p < 0.001) pain impact, and higher catastrophizing scores (p < 0.001). Quality of life was notably impaired (p < 0.05). Neuropathic-like pain was not associated with the stage of endometriosis or surgical complexity. Anxiety and depression scores did not differ significantly between the two groups (p = 0.47 and p = 0.52, respectively). Neuropathic-like pain was retrieved in over one-third of patients with DE and CPP, contributing to greater pain intensity, emotional distress, and reduced quality of life. Systematic screening for neuropathic-like pain and tailored multidisciplinary care are essential to optimize pain management.