Deep Infiltrating Endometriosis Research Articles

Risk factors for recurrence of deep infiltrating endometriosis after surgical treatment.

To evaluate the frequency of complications and factors associated with the recurrence of endometriosis in women with deep infiltrating endometriosis (DIE) undergoing surgical treatment. A retrospective observational cohort study with 72 women who underwent surgery and followed up by DIE at the University of Campinas from 2007 to 2017. The variables analyzed were clinical characteristics, use and type of drug treatment before and after surgery, operative time and complications inherent to the procedure, as well as the recurrence of lesions on imaging. The mean age of women was 39.7 ± 6.3 years and the mean follow-up was 4.56 ± 2.60 years. Complications were reported in 16.6% of surgeries and recurrence of lesions in 34.7%. The risk of intraoperative complications was higher in the presence of lesions of the bowel and in those who used intramuscular progestin before surgery. A higher risk of recurrence was observed among those who did not use hormonal treatment or used a levonorgestrel-releasing intrauterine device (LNG-IUD) in the postoperative period. Women with DIE have a high rate of complications during surgical treatment and a higher risk of recurrence when they did not receive hormonal treatment or when treated with LNG-IUD after surgery.

Long-term Follow-up of Sexual Quality of Life after Laparoscopic Surgery in Patients with Deep Infiltrating Endometriosis

We performed a long-term follow-up to quantify the impairment of sexual quality of life (SQL) and health-related QL (HRQL) in sexually active women after laparoscopic excision of deep infiltrating endometriosis (DIE). Prospective case-control study. Hospital Clinic of Barcelona. A total of 193 patients (after dropout and exclusions) were divided into 2 groups: one hundred twenty-nine premenopausal women with DIE (DIE group) and 64 healthy women who underwent tubal ligation (C group). All patients underwent laparoscopic surgery: laparoscopic endometriosis surgery in the DIE group and laparoscopic tubal ligation in the C group. All women were followed for at least 36 months, and they completed the Medical Outcomes Study 36-item short form questionnaire to assess their HRQL and 3 self-administered questionnaires that evaluate different aspects of SQL: the generic Sexual Quality of Life-Female questionnaire, the Female Sexual Distress Scale to evaluate "sexually related distress," and the Brief Profile of Female Sexual Function to screen hypoactive sexual desire disorder. The patients with DIE as well as the controls completed the 4 questionnaires before surgery, and the patients with DIE also completed the questionnaires at 6 and 36 months after surgery. A comparison of the patients and controls before surgery showed a statistically significant impairment in SQL and HRQL among the patients with DIE. A statistically significant improvement in SQL and HRQL was observed in the DIE group 6 months after surgery, with scores being similar to those of the C group. An evaluation 36 months after surgery showed that SQL and HRQL were better than presurgical SQL and HRQL in the DIE group, with a slight reduction compared with the 6-month evaluation. SQL and HRQL improved in patients with DIE undergoing complete laparoscopic endometriosis resection and were comparable to those of healthy women at 6 months after surgery, showing a slight reduction at 36 months of follow-up.

Ureteral endometriosis, the hidden enemy: multivariable fractional polynomial approach for evaluation of preoperative risk factors in the absence of ureteral dilation

To determine whether it is possible to predict the risk of ureteral endometriosis (UE) using a mathematical model based on preoperative findings. Prospective observational study conducted between January 2017 and April2020. Tertiary-level academic referral center. Three hundred consecutive women of reproductive age with a diagnosis of posterior deep infiltrating endometriosis (DIE) scheduled for laparoscopic surgery. Before surgery, anamnestic data and the severity of endometriosis-related symptoms were evaluated, and all patients underwent a complete gynecological examination. Transvaginal and transabdominal ultrasound were performed to map the endometriotic lesion. Ureteral involvement was surgically and histologically confirmed. To select important risk factors for UE and determine a suitable functional form for continuous predictors, we used the multivariable fractional polynomial. UE was surgically found in 145 women (48.3%). Based on our multivariable polynomial mathematical model, UE was significantly associated with adenomyosis, parametrial involvement, and previous surgery for endometriosis. A posterior DIE nodule with a transverse diameter >1.8 cm was associated with a higher probability of ureteral involvement. Posterior DIE nodule with a transverse diameter >1.8 cm, adenomyosis, parametrial involvement, and previous surgery for endometriosis appear to be good predictors of UE.

Role of surgical treatment in endometriosis.

Endometriosis can take one of three forms depending on its clinical presentation and management: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis and deep infiltrating endometriosis (DIE).1Among them, DIE is considered the most aggressive, and the patient is often affected by more than one type together. The therapeutic methodology should not be influenced by a combination of different types of endometriotic lesion. According to the clinical context and the patient's needs, the treatment of this pathology can be medical or surgical. Although medical therapy could improve endometriosis-associated symptoms, it never offers a definite treatment for symptomatic patients, who often require surgical treatment. The rationale behind endometriosis surgical treatment is to achieve the complete removal of all lesions through a one-step surgical procedure; to obtain promising long-term results for pelvic pain, recurrence rate, and fertility; and to protect the functionality of the involved organs. Achieving these results depends on the total removal of the pathology from the pelvis, in an attempt to preserve, as much as possible, the healthy tissues surrounding the site of the disease. The choice of a surgical approach rather than medical therapy is subject to the patient's expectations, such as pregnancy desire, the effectiveness of treatment compared to possible complications, the type of pain and its intensity, and the location and severity of the disease. In this context, surgical management using a multidisciplinary endometriosis team is an important factor for achieving good outcomes.

Imaging for evaluation of endometriosis and adenomyosis.

Endometriosis and adenomyosis are two frequent diseases that impair women's quality of life by causing pain and infertility. Both endometriosis and adenomyosis are heterogeneous diseases that manifest as different forms. Adenomyosis may be described as diffuse adenomyosis, focal adenomyosis especially of the outer myometrium and cystic adenomyoma. Endometriosis has three phenotypes: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). These two diseases are closely linked, and it is now clear that adenomyosis can either arise on its own or coexist with endometriosis. There is a strong clinical relationship between endometriosis and adenomyosis according to their respective phenotypes. Various classifications are available to describe both diseases. Transvaginal ultrasonography (TVUS) and/or pelvic magnetic resonance imaging (MRI) are the first examination performed when endometriosis or adenomyosis are suspected. These two imaging techniques, used in a combination manner, allow accurate description of both endometriosis and adenomyosis, to assess the diagnosis and to improve clinical and surgical care. In this review, we described the different imaging aspects of endometriosis and adenomyosis to help the less experienced radiologist or gynecologist in the diagnosis and evaluation of those diseases.

Correlation between surgical findings and magnetic resonance imaging of deep infiltrating endometriosis

In this review, images during surgical excision of Deep Infiltrating Endometriosis (DIE) were correlated to preoperative Magnetic Resonance Imaging (MRI) findings. MRI is known to be the best tool for mapping DIE, it displays a high accuracy in the diagnosis and the characterization of endometriosis lesions. Recent studies showed also that MRI findings can be correlated to the length of operating time, to the duration of hospital stay, and to the risk of voiding problems. In this article we emphasize on the importance of having an experienced radiologist that has the ability of detecting adhesions and superficial peritoneal lesions, a value that was underestimated in previous studies. DIE presents on MRI as an intermediate signal intensity on T1-weighted images, hypointense signal on T2-weighted images, and homo- or heterogeneous enhancement after intravenous gadolinium injection. Preoperative MRI findings help doctors to elaborate a tailored therapeutic plan for each patient depending on the clinical context (Fertility preservation, IVF, complete surgical excisions). Most importantly correct investigation and accurate description of small lesions enhance surgical planification and adequate information of the patients.

Relationship between magnetic resonance imaging-based classification of adenomyosis and disease severity.

The purpose of this study is to first investigate the correlation between image features and histological findings and the clinical severity of adenomyosis; second, search for imaging features to assess the type and locoregional extension of the disease; and finally, discuss the notation of image-based classification. This paper combines a review of the literature on adenomyosis with a series of cases who underwent surgery at Nara Medical University Hospital. Currently, there has been a lack of clear, clinically relevant, and internationally acceptable definition and histological classification due to its diverse phenotype. A number of researchers have attempted to standardize the magnetic resonance imaging (MRI) features of adenomyosis. Some researchers have begun studies that relate the subtype classification using MRI to disease severity. There is evidence suggesting that diffuse adenomyosis and intrinsic adenomyosis are correlated with menstrual bleeding, while extrinsic adenomyosis and coexistence of deep infiltrating endometriosis (DIE) are related to pelvic pain. MRI-based classifications that are simple for use in the clinical setting are beginning to be proposed. However, the reliability and validity of these classifications have not yet been verified. A simplified notation is required to discuss the association between the classification and severity of adenomyosis. We introduce case reports using the notation of four items necessary for classification of adenomyosis. There is an urgent need to determine the definitions of terms used in subtype classification and to create and validate a globally unified notation that can predict the severity of adenomyosis symptoms.

Hormonal profile of patients with deep infiltrative endometriosis

Introduction. About 30 to 50% of women with endometriosis complain of infertility. The incidence of infertility in all localizations of endometriosis is about 3-4 times higher than that in the general population.Objective of the study: estimate the hormonal profile of patients with deep infiltrative endometriosis (DIE) based on the study of the level of AMH, FSH, LH, progesterone, estradiol, prolactin in the serum of peripheral blood, conduct a comparative analysis of the level of these hormones between groups of patients with DIE and tuboperitoneal infertility.Materials and methods: the main study group consisted of 99 patients of reproductive age (from 18 to 40 years) with DIE, the comparison group consisted of 18 patients with tuboperitoneal infertility. The patients of the main group were divided into 2 subgroups: subgroup IA - DIE with colorectal endometriosis (n = 63), subgroup IB - DIE without colorectal endometriosis (n = 36). AH patients underwent determination of the level of AMH, LH, FSH, progesterone, estradiol, prolactin in the serum of peripheral blood before surgery.Results and discussion: a significant decrease in AMH level was revealed in patients with DIE. The level of AMH in the main and comparison groups was 1.80 and 3.28 ng/ml, respectively (p = 0.01). At the same time, subgroup IA has a more decreased AMH level (1.37 ng/ml) than in the comparison group (p = 0.003). In subgroup IB (the median AMH level - 2.50 ng/ml) were no significant differences with the comparison group (p = 0.14). It was also noted that in the group of patients with colorectal endometriosis (subgroup IA) the percentage of patients with reduced ovarian reserve (AMH 0.01 - 1.0 ng / ml) was significantly higher than in the comparison group (30.2% versus 5, 6%, p = 0.03), there were no significant differences between the subgroups. There were no significant differences in the level of LH, FSH, E2, prolactin in serum between the groups (p> 0.05).Assessment of the level of anti-mullerian hormone, as the most accurate marker of ovarian reserve, revealed a significant decrease in AMH levels in patients with DIE, more decreased in the group of patients with colorectal endometriosis. Every 3rd patient with DIE had an AMH level of less than 1, which is a risk factor for a “poor” response to ovarian stimulation according to the Bologna criteria.Conclusion.A significant decrease in the level of serum AMH, along with a high percentage of previous surgeries for endometriosis, including ovarian resections, may be one of the factors in a decrease in the reproductive potential of patients with DIE.

Uterine pseudoaneurysm on the basis of deep infiltrating endometriosis during pregnancy-a case report

BackgroundPseudoaneurysm of the uterine artery (UPA) is a rare cause of potentially life-threatening hemorrhage during pregnancy and puerperium. It is an uncommon condition that mainly occurs after traumatic injury to a vessel following pelvic surgical intervention, but also has been reported based on underlying endometriosis. There is an increased risk of developing UPA during pregnancy. Diagnosis includes clinical symptoms, with severe abdominal pain and is confirmed by sonographic or magnetic resonance imaging (MRI). Due to its potential risk of rupture, with a subsequent hypovolemic maternal shock and high fetal mortality, an interdisciplinary treatment should be considered expeditiously.Case presentationWe present the case of a 34-year old pregnant symptomatic patient, where a large UPA was detected at 26 weeks, based on deep infiltrating endometriosis (DIE). The UPA was successfully treated by selective arterial embolization. After embolization, the pain decreased but the woman still required intravenous analgesics during follow-up. At 37 weeks she developed a sepsis from the intravenous catheter which led to a cesarean section and delivery of a healthy boy. She was discharged 10 days postpartum.ConclusionsUPA should be considered in pregnant women with severe abdominal and pelvic pain, once other obstetrical factors have been excluded. DIE might be the underlying diagnosis. It is a rare but potentially life-threatening condition for mother and fetus.

Evaluation of Iterative Denoising 3-Dimensional T2-Weighted Turbo Spin Echo for the Diagnosis of Deep Infiltrating Endometriosis.

The primary end point of this study was to evaluate the image quality and reliability of a highly accelerated 3-dimensional T2 turbo spin echo (3D-T2-TSE) sequence with prototype iterative denoising (ID) reconstruction compared with conventional 2D T2 sequences for the diagnosis of deep infiltrating endometriosis (DIE). The secondary end point was to demonstrate the 3D-T2-TSE sequence image quality improvement using ID reconstruction. Patients were prospectively enrolled to our institution for pelvis magnetic resonance imaging because of a suspicion of endometriosis over a 4-month period. Both conventional 2D-T2 (sagittal, axial, coronal T2 oblique to the cervix) and 3D-T2-TSE sequences were performed with a scan time of 7 minutes 43 seconds and 4 minutes 58 seconds, respectively. Reconstructions with prototype ID (3D-T2-denoised) and without prototype ID (3D-T2) were generated inline at the end of the acquisition. Two radiologists independently evaluated the image quality of 3D-T2, 3D-T2-denoised, and 2D-T2 sequences. Diagnosis confidence of DIE was evaluated for both 3D-T2-denoised and 2D-T2 sequences. Intraobserver and interobserver agreements were calculated using Cohen κ coefficient. Ninety female patients were included. Both readers found that the ID algorithm significantly improved the image quality and decreased the artifacts of 3D-T2-denoised compared with 3D-T2 sequences (P < 0.001). A significant image quality improvement was found by 1 radiologist for 3D-T2-denoised compared with 2D-T2 sequences (P = 0.002), whereas the other reader evidenced no significant difference. The interobserver agreement of 3D-T2-denoised and 2D-T2 sequences was 0.84 (0.73-0.95) and 0.78 (0.65-0.9), respectively, for the diagnosis of DIE. Intraobserver agreement for readers 1 and 2 was 0.86 (0.79-1) and 0.83 (0.76-1), respectively. For all localization of DIE, interobserver and intraobserver agreements were either almost perfect or substantial for both 3D-T2-denoised and 2D-T2 sequences. Three-dimensional T2-denoised imaging is a promising tool to replace conventional 2D-T2 sequences, offering a significant scan time reduction without compromising image quality or diagnosis information for the assessment of DIE.

Magnetic Resonance Imaging in endometriosis-associated pain.

Endometriosis affects 10%-15% of women in reproductive age and may cause no-cyclic chronic pelvic pain, dysmenorrhea, dyspareunia, urinary tract symptoms, and it is frequently associated with infertility. The peak of incidence is between 24 and 29 years old and the clinical diagnosis of endometriosis is generally delayed by 6-7 years. Laparoscopy with surgical biopsies is the "gold standard" for the diagnosis of endometriosis, with histological verification of endometrial ectopic glands and/or stroma. However, nowadays two different non-invasive modalities are routinely used for a presumptive diagnosis: Transvaginal Ultrasound (TVUS) and Magnetic Resonance Imaging (MRI). A structured search using PubMed was performed starting from October 2020 and including all relevant original and review articles published since 2000. The search used the following key word combinations: "endometriosis MRI" AND "DIE and MRI" (45); "MRI endometriosis and pelvic pain" OR "endometriosis and MRI technical development" (296). Ultimately, 87 articles were deemed relevant and used as the literature basis of this review. TVUS represents the first imaging approach for endometriosis showing a good diagnostic performance, but it is highly operator dependent. MRI is a second level examination often used in complex cases indeterminate after TVUS and in preoperative planning. MRI is considered the best imaging technique for mapping endometriosis since it provides a more reliable map of deep infiltrating endometriosis than physical examination and transvaginal ultrasound. We have analyzed and described the main forms of endometriosis: adnexal endometriosis, adenomyosis, peritoneal implants and deep infiltrating endometriosis, showing their appearance in the two imaging modalities. Endometriosis is one of the most common gynecologic disorders correlated to chronic pelvic pain whose treatment is still today complex and controversial. In this context, MRI has become an important additional non-invasive tool to investigate cases of chronic pelvic pain related to deep infiltrating endometriosis (DIE) with or without neural involvement.

Endometriosis and its correlation with carcinoid tumor of the appendix: a systematic review

The prevalence of appendiceal endometriosis ranges from 0.4% to 22%. The carcinoid tumor is the most common neoplasm of the appendix, with incidence ranging from 0.3% to 0.9%. Appendix lesions develop in up to 22% of women with deep infiltrative endometriosis. Even though these are most likely endometriosis, carcinoid tumors should always be considered. The aim of this review was to assess the prevalence of appendiceal carcinoid tumors and appendiceal endometriosis in patients undergoing gynecologic surgery, its association with endometriosis, and related symptoms. We included retrospective and prospective studies that assessed women who underwent appendicectomy in the past 20 years for appendiceal endometriosis and/or appendix carcinoid tumor confirmed by histological analysis. Results were reported as relative and absolute frequencies. Due to the heterogeneity of included studies, a statistical analysis (meta-analysis) was not performed. The prevalence of appendiceal endometriosis was 15.2% in patients who underwent surgery for pelvic endometriosis and 11.4% in those who underwent benign gynecological surgery. Conversely, carcinoid tumors of the appendix were present in 2.4% of endometriosis patients and 1.3% of other benign gynecological surgeries. The rates of carcinoid tumors in patients with endometriosis are the same as in the general population. Given the risk of a malignant appendiceal tumor, in all gynecological surgeries, especially those for endometriosis, the appendix should be inspected and removed if it has an abnormal appearance.

Surgical Neuropelviology: Combined Sacral Plexus Neurolysis and Laparoscopic Laterally Extended Endopelvic Resection in Deep Lateral Pelvic Endometriosis

Surgical demonstration of combined sacral plexus neurolysis and laparoscopic laterally extended endopelvic resection for deep lateral infiltrating endometriosis. Video showing principles of neurolysis and laparoscopic laterally extended endopelvic resection applied to endometriotic surgery. University tertiary referral center. Deep infiltrating endometriosis is an underestimated disease with real medical and clinical issues, recently classified as central pelvic endometriosis and lateral pelvic endometriosis further divided into superficial and deep according to the structures' involvement [1]. The surgical removal of endometriotic foci remains the standard treatment. A wide knowledge of neuroanatomy and high skills in minimally invasive surgery are required to manage this challenging surgical scenario [2]. New surgical approach for deep lateral infiltrating endometriosis based on the principles of lateral extended endopelvic resection and neuropelviologic surgery [3,4]. The patient was a 35-year-old woman, para 1, with neuropathic pain radiating to the left leg and a cyclic menstrual disorder. A laparoscopically assisted neuronavigation and subsequent neurolysis allowed the identification of the lateral nodule without damage to the autonomic pelvic innervation [1]. Then, a complete resection of the internal vascular compartment was required to obtain a radical endometriotic eradication. Shaving and bladder resection were also performed to complete removal of the endometriotic foci. The association of neuroanatomic knowledge and surgical oncologic principles applied to minimally invasive surgery should be considered to ensure an adequate surgical radicality and clinical benefit in patients with deep infiltrating endometriosis.

Estradiol/nomegestrol acetate as a first-line and rescue therapy for the treatment of ovarian and deep infiltrating endometriosis

Purpose Estradiol valerate/nomegestrol acetate (E2V/NOMAC) is a new combined oral contraceptive with a good tolerability profile and low drop-out rates, which was shown to improve menstrual-related symptoms. This study aims to evaluate its effectiveness in the control of symptoms and progression of disease in women with ovarian endomestriomas and deep infiltrating endometriosis (DIE). Methods This was a retrospective cohort study on 39 women with pelvic endometriosis treated with E2V/NOMAC. We assessed for each patient, at the beginning of treatment and after 6 months, the painful symptoms, through a global VAS (Visual Analogue Scale) index and the size of the greatest ovarian and/or deep infiltrating endometriotic lesions. Results After 6 months of treatment, a significant reduction was observed for the global VAS score for pain symptoms and for the mean size of ovarian endometriomas, whereas DIE lesions did not present significant changes in mean size. Conclusions E2/NOMAC was effective in reducing pain symptoms associated with pelvic endometriosis and the size of ovarian endometriomas, whereas DIE lesions remained stable. This therapy could provide good results in the control of symptoms and disease progression in women with pelvic endometriosis.

Extragenital endometriosis with lesions of the small and large intestine, the formation of a pathological cavity draining to the anterior abdominal wall (case report)

Extragenital endometriosis is one of the most severe benign diseases of the female reproductive system, characterized by different site of target organs. This pathology is associated with the development of severe complications, the treatment of which requires a multidisciplinary approach. This case report is dedicated to the experience of treating a patient with a history of multiple surgical procedures and long-term undiagnosed deep infiltrative endometriosis, complicated by abdominocutaneus endometriotic fistula.

A Detailed Study in Adenomyosis and Endometriosis: Evaluation of the Rate of Coexistence Between Uterine Adenomyosis and DIE According to Imaging and Histopathology Findings

The current study was designed to evaluate the relationship between adenomyosis and its subtypes with endometriotic lesions (ovarian endometrioma (OMAs) and posterior deep infiltrative endometriosis (DIE)), to examine the probability of existence of a common cause of these mysterious diseases, and to evaluate the accuracy, sensitivity, and specificity of both transvaginal ultrasonography (TVS) and MRI in diagnosis of adenomyotic uterus. In this retrospective cross-sectional study, we selected 154 women with coexistence of endometriosis and adenomyosis according to their imaging, intraoperative, or pathological findings who were nominated for laparoscopic surgery. Eighty-six patients with just DIE resection without LH (laparoscopic hysterectomy) (group 1), and 68 patients with LH + DIE resection (group 2). The accuracy, sensitivity, and specificity of ultrasonographic and MRI findings for diagnosing adenomyosis were 72.1%, 77.6%, 40.0% and 49.2%, 41.5%, 90.0% respectively. So, TVS is a more sensitive diagnostic tool for diagnosing adenomyosis. However, MRI was more specific than TVS in the diagnosis of diffuse adenomyosis especially with simultaneous presence of uterine leiomyoma. Regarding the association of different types of adenomyosis (focal and diffuse) with different endometriosis lesions (OMA and posterior compartment DIE), we just found diffuse type of adenomyosis more frequent in the absence of rectal and rectovaginal septum (RVS) DIE (p ≤ 0.05). In addition to the questionable different nature of rectal and RVS DIE lesion, there is no relationship between adenomyosis subtypes and endometriotic lesions.

Comorbidities and Quality of Life in Women Undergoing First Surgery for Endometriosis: Differences Between Chinese and Italian Population

An observational cross-sectional study was conducted in a group (n = 371) of fertile age women with endometriosis, by administering a structured questionnaire, in order to evaluate the incidence of gynecological and systemic comorbidities and the impact on quality of life (QoL) in two different groups of Italian and Chinese patients affected by endometriosis. Chinese (n = 175) and Italian (n = 196) women were compared regarding systemic (inflammatory, autoimmune, and mental) and gynecological comorbidities, pain symptoms, and QoL, by using the Short Form 12 (SF-12). Italian patients resulted younger at the diagnosis and suffered more frequently from severe pain than Chinese ones. Deep infiltrating endometriosis (DIE) and mixed phenotypes were more frequent in Italian patients, whereas ovarian (OMA) and superficial endometriosis (SUP) were more common in the Chinese. The Italian group showed more systemic comorbidities, and those disorder were already present before the diagnosis of endometriosis. Furthermore, the Italian group showed lower SF-12 physical and mental scores, suggesting a worse health-related QoL in Italian endometriotic patients. A number of differences has been observed between Italian and Chinese women with endometriosis in terms of comorbidities and QoL, which may be related to the ethnicity, the different health system organization and the social and cultural background.

Surgical treatment of deep endometriosis with adenomyosis externa: a challenging case in an infertile woman

To describe the management and the fertility-enhancing potential of surgery in an infertile patient with deep-infiltrating endometriosis and adenomyosis externa. Video case report. Minimally invasive and robotic gynecologic surgery unit of a university hospital. A 31-year-old nulliparous patient with dysmenorrhea, dysuria, dyspareunia, and primary infertility. Bimanual examination, transvaginal ultrasound, and magnetic resonance imaging (MRI) were performed as a comprehensive preoperative workup. The findings were consistent with bladder endometriosis and a 4-cm right pararectal cystic mass suggestive of adenomyosis externa. Laparoscopic excision of all visible endometriosis was performed. A pararectal lesion was found, completely developing in the retroperitoneal spaces, from the right medial pararectal space to the rectovaginal space, reaching the pelvic floor fascia without infiltration of the levator ani muscle. According to Koninckx classification, this kind of lesion corresponds to type III endometriosis or adenomyosis externa. Nerve-sparing eradication of the nodule was performed. The decision to use these techniques was taken with the intention to treat the patient, and not with the aim of testing the procedures performed. Therefore, as a common clinical practice in our institution and for the above reasons, there was no need for consultation of the institutional review board for approval. Improvement of symptoms and spontaneous conception after surgical removal of all endometriotic implants. There were no intraoperative or postoperative complications, and the patient was discharged after 3 days. She discontinued postoperative hormone therapy with gonadotropin-releasing hormone analogue after 3 months because she desired fertility. She conceived spontaneously after 2 months of attempting. She delivered vaginally and had no complications during pregnancy and labor. Neither recurrence of pain symptoms nor voiding or rectal dysfunctions were reported by the patient. In the management of a case of deep endometriosis, the preoperative assessment should be carefully carried out to give the surgeon the most accurate information about the extent of the disease and the patient's main objectives. Imaging techniques such as ultrasound and MRI play a fundamental role along with the clinical evaluation in also detecting lesions that are not visible at first laparoscopic inspection. In this case of a young woman without any detectable fertility issues except for endometriosis, the laparoscopic excision of endometriosis was feasible, safe, and effective in improving the patient's fertility and pain symptoms. The fertility-enhancing potential of complete eradication of pelvic endometriosis, including removal of deep posterior localizations such those presented in this case, has been hypothesized by various investigators. It has been suggested that skilled surgical management for symptomatic deep endometriosis may be followed by a high pregnancy rate, with most pregnancies resulting from postoperative natural conception even in patients with primary infertility.

Dienogest versus continuous oral levonorgestrel/EE in patients with endometriosis: what’s the best choice?

Objective Combined oral contraceptives (COC) and progestogens are widely used for the treatment of endometriosis. The objective of the study is to compare the efficacy of dienogest 2 mg vs continuous oral levonorgestrel/EE (levonorgestrel 0.1 mg/ethinyl estradiol 0.02 mg) on ovarian endometriomas, deep infiltrating endometriosis (DIE), chronic pelvic pain (CPP), dyspareunia, analgesic use, quality of life (QoL), compliance and side effects. Methods Prospective cohort study. Two cohorts of patients with endometriosis, 50 taking dienogest (group A) and 50 taking continuous levonorgestrel/EE (group B), were evaluated at the beginning of therapy (t0), after 3 (t3) and 6 months (t6). Size of endometriomas, DIE, QoL, pain symptoms, and side effects were assessed. Results Dienogest was significantly effective on CPP (p = .002), dyspareunia (p = .021) ovarian endometriomas (p = .015) and DIE lesions reduction (p = .014). Levonorgestrel/EE was significantly effective on dyspareunia (p = .023). Analgesics consumption significantly decreased in both groups (p < .001). Both treatments significantly improved the QoL. Over 6 months a significant improvement was found, more frequently in patients taking dienogest. The only side effect that both groups complained about was vaginal bleeding, present in the first 3 months of treatment (p < .001). Conclusions Both treatments are effective and safe for patients with endometriosis. Patients compliance and side effects are similar in both groups, however, there was a significantly higher reduction in endometriotic lesions, pain symptoms, and improvement of the QoL in women taking dienogest than in women taking continuous COC.

Transvaginal ultrasound features of normal uterosacral ligaments

To show a step-by-step technique to assess normal uterosacral ligaments (USLs) during transvaginal ultrasound. Uterosacral ligaments represent the most common location of deep infiltrating endometriosis (DIE) in the posterior compartment and their involvement significantly increases the risk of ureteral lesions. The ultrasonographic diagnosis of DIE involving USLs is characterized by a wide range of accuracies described between studies, probably due to variations in the examination technique, quality of ultrasound equipment, and experience of the operators. Although described as a new classification system of DIE involving USLs, the technique for visualizing normal USLs has not yet been described. Stepwise demonstration of the technique with narrated video footage. Academic tertiary hospital. The video shows a 33-year-old nulliparous woman scheduled for laparoscopic removal of a para-ovarian cyst of approximately 6 cm. Procedural steps were repeated and confirmed in another four patients submitted to laparoscopy for benign diseases (Table1). Moreover, we here show the case of a 29-year-old woman with an isolated DIE nodule of the right USL with a comparison of laparoscopic and ultrasound findings. To better point out the technique applied in a clinical setting we show also cases of infiltrated USLs (Table2) during the ultrasound scan in women scheduled for endometriosis surgery. Informed consent was obtained from all of the patients. The study protocol was approved by the local institutional Ethics Committee (580/2018/Oss/AOUBo). To understand correctly the right position of USLs we performed an ultrasound during a surgical procedure; in this way it was possible to recognize the area of interest while the surgeon filled the pouch of Douglas with fluid and highlighted the anatomical area with pliers. Uterosacral ligaments can be seen in the mid-sagittal and transverse view of the uterus. Description of appearance of normal USLs during transvaginal ultrasound. Uterosacral ligaments, at transvaginal ultrasound, appear as hyperechoic stripes starting from the cervix and pointing laterally in a semi-horizontal direction. We provided a step-by-step technique (Table3) that may be a useful tool to see accurately both the USLs at transvaginal ultrasound.