Deep Infiltrating Endometriosis Research Articles

Enhanced recovery after posterior deep infiltrating endometriosis surgery: a national study

To evaluate the impact of the implementation of a national enhanced recovery after surgery (ERAS) program for posterior deep infiltrating endometriosis (DIE) surgery on the length of hospital stay, the rate of postoperative complications, and readmission within 30 days. Comparative exposed/nonexposed observational study. Study based on the French national medicoeconomic database of the Program of Medicalization of Information System. Seven hundred and sixty-four women who underwent DIE surgery were involved and matched (1:3 ratio) into two groups: ERAS group for the year 2019 and non-ERAS group for the year2015. Surgical management for posterior DIE. The length of hospital stay, the rate of postoperative complications during the initial hospital stay, and readmission within 30 days. The ERAS group included 191 women, and the non-ERAS group included 573 women. The mean length of hospital stay was shorter in the ERAS group than in the non-ERAS group (4.28 ± 3.80 days vs. 5.42 ± 4.04 days, respectively). The rate of postoperative abdominal or pelvic pain syndromes was lower in the ERAS group than in the non-ERAS group (5/191 (2.62%) vs. 48/573 (8.38%), respectively; relative risk, 0.31 [0.125-0.7969]). The rate of postoperative complication and the rate of readmission within 30 days were not different between the two groups. The implementation of ERAS has a significant positive impact on patient outcomes after DIE surgery. The length of hospital stay and abdominal or pelvic pain syndromes were reduced without increasing complications or readmission within 30 days.

Proposal for adenomyosis classification based on the endometriosis phenotype

Adenomyosis and endometriosis are common gynecological disorders; however, their pathophysiology and classification are still under debate. This article proposes a disease classification based on the multiple phenotypes of adenomyosis and endometriosis. This is an opinion article and proposal based on an extensive search of recent literature. The invasion of the inner myometrium by basal endometrium can cause intrinsic adenomyosis, which develops diffusely over time. Intrinsic adenomyosis is also called inner adenomyosis or internal adenomyosis and can be thought of as classic adenomyosis. On the other hand, pelvic endometriosis, including superficial peritoneal disease (SUP), ovarian endometrioma (OMA) and deep infiltrating endometriosis (DIE), is likely caused by the implantation of regurgitated menstrual debris, including eutopic endometrium. DIE typically infiltrates structures such as the uterosacral ligament, rectum, bladder, ureter, and uterus, which indicates that endometriotic cells should also be able to invade the outer myometrium through the uterine serosa. Extrinsic adenomyosis is sometimes called external adenomyosis, outer adenomyosis, or focal adenomyosis located in the outer myometrium (FAOM). Researchers have inferred that extrinsic adenomyosis may be considered a part of the DIE phenotype, albeit prematurely. This classification is based on the idea that adenomyosis and endometriosis are different phenotypes of a single disease. To reach a consensus, the terms used for adenomyosis classification, such as intrinsic/extrinsic, internal/external, inner/outer, or diffuse/focal, need to be organized and then discussed. Finally, future directions are proposed to achieve the goal of classifying adenomyosis.

The role of mutations in the PI3K/AKT/mTOR signal pathway in decreasing ovarian reserve in reproductive patients with deep infiltrative endometriosis

Aim. To study the effect of deep infiltrative endometriosis on the state of the ovarian reserve in patients of reproductive age, as well as to evaluate the spectrum of mutations in the PIK3CA gene among patients with infiltrative form of external genital endometriosis.
 Materials and methods. The main group of the study included 50 patients of reproductive age with deep infiltrative endometriosis, in 18 of whom deep infiltrative endometriosis was combined with ovarian endometriomas. The comparison group included 25 patients of reproductive age who underwent laparoscopic metroplasty of an inconsistent uterine scar from a cesarean section. All patients underwent determination of the level of anti-Mllerian hormone, follicle-stimulating hormone and estradiol in the blood by enzyme immunoassay, as well as counting the number of antral follicles in the ovaries during transvaginal ultrasound examination. The search for activating mutations of the PIK3CA gene was carried out by sequencing a new generation of DNA in tissue samples of ovarian endometriomas in patients with a combination of infiltrative endometriosis and endometrioid ovarian cysts (n=18), as well as in biopsies of healthy ovarian tissue in all patients of the main group (n=50) and comparison groups (n=25).
 Results. When assessing the state of the ovarian reserve in the patients of the two groups, it was found that the anti-Mllerian hormone level in the patient with the infiltration form of external genital endometriosis was 2.62.2 ng/ml, while in the comparison group it was 3.63.5 ng/ml, however, the difference did not reach statistical significance, p0.05. The number of antral follicles according to transvaginal ultrasound was significantly lower in the main group (8.54.5) than in the comparison group (12.24.1), p=0.001. This difference was statistically significant both for patients with ovarian endometriomas (6.04.2, p0.001) and for patients without ovarian endometriomas (9.84.2, p=0.04). Our study did not reveal PIK3CA gene mutations in any of the ovarian endometrioma tissue samples from patients with a combination of infiltrative endometriosis and endometrioid ovarian cysts, as well as in none of the healthy ovarian tissue biopsies from patients of the main group and the comparison group using the new generation DNA sequencing method.
 Conclusion. The presence of deep infiltrative endometriosis is associated with a decrease in ovarian reserve in patients of reproductive age, regardless of the presence of endometrioid ovarian lesions. Population studies are needed to identify mutations of this gene in endometriosis, as well as to study mutations of other genes encoding proteins regulating the antiapoptotic signaling pathway PI3K/AKT/mTOR, to identify the mechanism of ovarian reserve depletion in infiltrative form of external genital endometriosis.

The deep infiltrating endometriosis tissue has lower T-cadherin, E-cadherin, progesterone receptor and oestrogen receptor than endometrioma tissue

ObjectiveTo compare the T-cadherin, E-cadherin, PR and ER staining levels of deep infiltrating endometriosis (DIE) tissue, ovarian endometriomas and normal endometrial tissues. Materials and methodsDIE tissue of 24 cases, endometrioma of 30 cases and normal endometrial tissues of 30 cases were examined. T-cadherin, E-cadherin, ER-α and PR-α staining levels of DIE, endometrioma tissues and endometrial tissues were compared immunohistochemically. H-score was calculated to compare the expression of T-cadherin, E-cadherin, ER-α, PR-α in IHC staining based on the percentage of cells stained at each intensity level. ResultsT-cadherin, E-cadherin, ER and PR H-score were found lowest in DIE tissue and the highest in endometrial tissue (p < 0.0001, <0.0001, <0.0001 and < 0.0001, respectively). In correlation analysis, a positive correlation was found between T-cadherin, E-cadherin, PR and ER H-score (p < 0.0001 for each). No correlation was found between age, body mass index (BMI), visual analog scale (VAS) score, CA125, endometrioma size and the severity of dysmenorrhea, dyspareunia and dystonia (p > 0.05). ConclusionT-cadherin, E-cadherin, ER and PR H-score were found lowest in DIE tissue, the highest in endometrium tissue. The finding of lower expression of PR-α in endometriotic nodule in our study may be related to decrease in progesterone effect which could not inhibit the decrease in the expression of T-cadherin and E-cadherin, thus the invasiveness of DIE tissue. These findings suggest that DIE tissue and ovarian endometrioma tissues have a different biology.

Preoperative ureteral stenting in women with deep posterior endometriosis and ureteral involvement: Is it useful?

Systematic placement of a ureteral stent before surgery for posterior deep infiltrating endometriosis (DIE) was previously recommended, but it could increase perioperative complications. We evaluate the role of preoperative ureteral stent in women requiring surgery for ureteral involvement (UI) with large posterior DIE nodules and/or grade I-II hydronephrosis. Women undergoing minimally invasive surgery for DIE with UI having posterior nodules >3cm and/or grade I-II hydronephrosis from 2014 to 2019 were retrospectively included. We progressively changed our strategy from a systematic pre-operative stent insertion (S-PS, up to 2016) to a non-systematic one (NS-PS, from 2016). Eighty-eight women in the S-PS group and 96 in the NS-PS were included. Low urinary tract infections (UTI) were higher in the S-PS group (13.6% vs 2.1%, P=0.003). Hospital stay was longer in women with S-PS (9.8±5.3days vs 6.7±2.5days, P<0.001). Logistic regression analysis confirmed a significant association between NS-PS and low UTI (adjusted OR 0.20, 95% CI 0.05-0.81, P=0.024). Systematic placement of a ureteral stent before surgery in women requiring surgery does not reduce overall perioperative complication rate, but it is associated with a longer duration of hospitalization and a higher low UTI rate.

Feasibility of two robotic single-site surgery techniques for adolescent endometriosis: Focal versus butterfly.

This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n=36). Additionally, we assessed a novel technique known as butterfly resection for severe cases. This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon. There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P=0.64). Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques. Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.

Does the Presence of Adenomyosis Affect the Results of DEEP Infiltrating Endometriosis Surgery?

<h3>Study Objective</h3> To evaluate the impact of adenomyosis on surgical outcomes in women with deep infiltrating endometriosis (DIE) undergoing laparoscopic surgery. <h3>Design</h3> Retrospective study including women undergoing DIE surgery during a 3-year period. <h3>Setting</h3> Referral tertiary university hospital. <h3>Patients or Participants</h3> 157 women with DIE undergoing surgery. <h3>Interventions</h3> Two expert sonographers preoperatively diagnosed DIE and adenomyosis. DIE was defined according to the criteria of the International Deep Endometriosis Analysis group, and adenomyosis was considered when 3 or more ultrasound criteria of the Morphological Uterus Sonographic Assessment group were present. Demographical variables, current medical treatment, symptoms, DIE location, surgical time, hospital stay and difference in pre and post hemoglobin levels were collected. The Clavien-Dindo classification was used to assess surgical complications, and multivariate analysis was performed to compare patients with and without adenomyosis. <h3>Measurements and Main Results</h3> 157 DIE patients were included into the study; 77 (49.05%) had adenomyosis according to transvaginal ultrasound (TVS) and were classified in the A group, and 80 (50.95%) had no adenomyosis and were classified in the noA group. There were no differences between groups regarding demographic characteristics, current treatment, symptoms, r-ASRM classification or type of surgery. The mean operating time was higher in the A group (237min±98.4) compared to noA group (188min±79.3) (p=0.017). The mean hospital stay was also higher in the A group compared to noA group (3.62±4.3 vs 2.55±1.79 days, p<0.05). Adenomyosis was associated with a higher rate of surgical complications: 33.76% (A group) vs. 12.5% (noA group) (p<0.001). There was a statistically significant association between the number of criteria of adenomyosis present in each patient and the proportion of patients presenting surgical complications (p<0.001). <h3>Conclusion</h3> Adenomyosis seems to play a detrimental role in DIE surgical procedures. It increases the risk of presenting complications in DIE surgery after controlling for demographic, clinical and surgical factors. Adenomyosis should be considered an independent preoperative risk factor of surgical complications.

How Ovarian Reserve Changes after Deep Infiltrative Endometriosis Surgery?

Study Objective To study the ovarian response to surgical treatment of deep infiltrative endometriosis (DIE) in women of reproductive age. Design Prospective cohort-controlled study. Setting Surgical treatment of patients was performed by laparoscopic access using a standard closed technique under conditions of endotracheal anesthesia. Patients or Participants The main cohort was 70 women of reproductive age who underwent surgery for DIE. The comparison group consisted of 50 fertile women who underwent plastic surgery on the uterus. Interventions Surgical treatment of the patients of the main group consisted in maximum excision of foci of DIE and enucleation of endometrioid ovarian cysts. Measurements and Main Results Before and 6 months after surgery underwent determination of the level of anti-Müllerian hormone (AMH), follicle-stimulating hormone and estradiol in the blood by enzyme immunoassay, as well as counting the number of antral follicles (AFC) in the ovaries by transvaginal ultrasound. The baseline AMH level was significantly lower in patients with DIE (2.4±2.1 ng/ml) than in the comparison group (3.8±3.2 ng/ml), p<0.05. Surgical treatment of DIE led to a significant decrease in the level of AMH, the average level of AMH in patients of the main group 6 months after surgery was 1.6±1.6 ng/ml compared with the initial level of 2.4 ng/ml, p<0,05. In the patients of the comparison group after surgery the AMH level remained at the initial level (3.8±3.2 ng/ml). The initial AFC according to transvaginal ultrasound was also significantly lower in the main group (8.3±4.5) than in the comparison group (11.8±4.1), p<0.001. After surgical treatment of DIE, there was a slight decrease in the AFC according to ultrasound (7.2±3.5), but the difference with the preoperative level did not reach statistical significance. Conclusion Surgical treatment of DIE leads to a decrease in the initially compromised ovarian reserve in patients of reproductive age. To study the ovarian response to surgical treatment of deep infiltrative endometriosis (DIE) in women of reproductive age. Prospective cohort-controlled study. Surgical treatment of patients was performed by laparoscopic access using a standard closed technique under conditions of endotracheal anesthesia. The main cohort was 70 women of reproductive age who underwent surgery for DIE. The comparison group consisted of 50 fertile women who underwent plastic surgery on the uterus. Surgical treatment of the patients of the main group consisted in maximum excision of foci of DIE and enucleation of endometrioid ovarian cysts. Before and 6 months after surgery underwent determination of the level of anti-Müllerian hormone (AMH), follicle-stimulating hormone and estradiol in the blood by enzyme immunoassay, as well as counting the number of antral follicles (AFC) in the ovaries by transvaginal ultrasound. The baseline AMH level was significantly lower in patients with DIE (2.4±2.1 ng/ml) than in the comparison group (3.8±3.2 ng/ml), p<0.05. Surgical treatment of DIE led to a significant decrease in the level of AMH, the average level of AMH in patients of the main group 6 months after surgery was 1.6±1.6 ng/ml compared with the initial level of 2.4 ng/ml, p<0,05. In the patients of the comparison group after surgery the AMH level remained at the initial level (3.8±3.2 ng/ml). The initial AFC according to transvaginal ultrasound was also significantly lower in the main group (8.3±4.5) than in the comparison group (11.8±4.1), p<0.001. After surgical treatment of DIE, there was a slight decrease in the AFC according to ultrasound (7.2±3.5), but the difference with the preoperative level did not reach statistical significance. Surgical treatment of DIE leads to a decrease in the initially compromised ovarian reserve in patients of reproductive age.

Laparoscopic Resection of Deep Infiltrative Endometriosis of the Bowel and Bladder

<h3>Study Objective</h3> To show a systematic approach to perform resection of deep infiltrating endometriosis of the bowel and bladder in the setting of posterior cul-de-sac obliteration and intentional cystotomy creation. <h3>Design</h3> Step-by-step video demonstration of the technique. <h3>Setting</h3> A university tertiary care hospital. <h3>Patients or Participants</h3> A 28-year-old gravida 0 with a history of several years of severe dysmenorrhea, pelvic pain, and dyspareunia. She had been managed with hormonal medical therapy and physical therapy with little improvement in her symptoms. Pelvic ultrasound and MRI was significant for 0.8 × 1 cm rectal nodule located between the posterior wall of the uterus and anterior wall of the rectum, suggestive of deep infiltrating endometriosis. <h3>Interventions</h3> Studies have shown that surgery can improve pain in the context of deep infiltrating endometriosis. Moreover, deep infiltrating endometriosis has been associated with infertility with retrospective and prospective nonrandomized studies showing that resection improves spontaneous conception rates. Laparoscopy with resection of deep infiltrating endometriosis is performed using a conservative fertility sparing endometriosis surgery with bowel discoid resection. Deep infiltrating endometriosis of the bladder is performed with repair of therapeutic cystotomy. <h3>Measurements and Main Results</h3> We describe three phases of deep endometriosis nodule excision. First, opening pelvic avascular spaces, restoring anatomy, and identifying important anatomical structures. Second, resection of deep infiltrative endometriosis lesions with relevant vital structures properly identified and lateralized. Third, ensure integrity of our repair and hemostasis. At postoperative follow up, the patient reported improvement in pain symptoms. She had no bowel or bladder dysfunction postoperatively. <h3>Conclusion</h3> Management of deep infiltrating endometriosis begins in the preoperative period and continues beyond the immediate postoperative period. Appropriate preoperative evaluation, systematic and skilled intra-operative surgical technique, and appropriate postoperative follow up are important steps necessary to perform safe and effective fertility sparing endometriosis surgery.

Treatment of Deep Infiltrative Endometriosis with Methotrexate Carried in Lipid Core Nanoparticles (LDE): A Pilot Study

Study Objective To assess the safety and efficacy of intravenous methotrexate carried in lipid core nanoparticles (LDE-ddMtx) in women with deep infiltrative endometriosis (DIE) for a 180-day period. Design Pilot, cohort study. Setting Tertiary, academic hospital. Patients or Participants Women over 18 years with bowel endometriosis with VAS pain score equal or higher than 7 (n=11), diagnosed by transvaginal ultrasound (TVUS). Interventions LDE-ddMtx with body surface dosage of 25 (n=3) or 50 (n=8) mg/m2. When two doses were applied, it was given one week interval between them. Measurements and Main Results Women presented 30-49 years, were primiparous (54.55%), and overweight (BMI=26.16±6.50). Eight women used hormonal medication, and nine, non-hormonal drugs. Most of women did not report any severe adverse effects during LDE-ddMtx infusion (54.54%); however, late effects such as nausea (n=7) and abdominal pain (n=6) were the most reported symptoms. Dyspareunia (p=0.001) and dyschaezia (p=0.021) VAS scores have significantly reduced between baseline/90/120/180 days; differences within dyspareunia were noticed between baseline and 120 (p=0.026) / 180 (p=0.027) days; about dyschaezia, between baseline and 180 days (p=0.027) or 90/180 days (p=0.041). Dysmenorrhea (p=0.075) and acyclic pain (p=0.067) presented a reduction on VAS scores, but it was not statistically significant. About the bowel endometriotic lesions seen by US, no significant differences about its size/diameter were found in all assessments. No hepatic or hormonal changes were noticed during drug administration. Anti-mullerian hormone reduced after 180 days, but this was not significant (p=0.059). Subgroup analysis about the dosage found differences in the dysmenorrhea(p=0.024) and dyspareunia(p=0.034) scores, but interaction between dosages and interval follow-up did not find any associated variable. Conclusion LDE-ddMtx significantly reduced dyspareunia and dyschaezia VAS scores in DIE women in a 180-day period. However, no differences were perceived in bowel lesions by TVUS. Further studies, with a control group and larger sample are needed to confirm these findings and provide external validity to use in clinical scenarios. To assess the safety and efficacy of intravenous methotrexate carried in lipid core nanoparticles (LDE-ddMtx) in women with deep infiltrative endometriosis (DIE) for a 180-day period. Pilot, cohort study. Tertiary, academic hospital. Women over 18 years with bowel endometriosis with VAS pain score equal or higher than 7 (n=11), diagnosed by transvaginal ultrasound (TVUS). LDE-ddMtx with body surface dosage of 25 (n=3) or 50 (n=8) mg/m2. When two doses were applied, it was given one week interval between them. Women presented 30-49 years, were primiparous (54.55%), and overweight (BMI=26.16±6.50). Eight women used hormonal medication, and nine, non-hormonal drugs. Most of women did not report any severe adverse effects during LDE-ddMtx infusion (54.54%); however, late effects such as nausea (n=7) and abdominal pain (n=6) were the most reported symptoms. Dyspareunia (p=0.001) and dyschaezia (p=0.021) VAS scores have significantly reduced between baseline/90/120/180 days; differences within dyspareunia were noticed between baseline and 120 (p=0.026) / 180 (p=0.027) days; about dyschaezia, between baseline and 180 days (p=0.027) or 90/180 days (p=0.041). Dysmenorrhea (p=0.075) and acyclic pain (p=0.067) presented a reduction on VAS scores, but it was not statistically significant. About the bowel endometriotic lesions seen by US, no significant differences about its size/diameter were found in all assessments. No hepatic or hormonal changes were noticed during drug administration. Anti-mullerian hormone reduced after 180 days, but this was not significant (p=0.059). Subgroup analysis about the dosage found differences in the dysmenorrhea(p=0.024) and dyspareunia(p=0.034) scores, but interaction between dosages and interval follow-up did not find any associated variable. LDE-ddMtx significantly reduced dyspareunia and dyschaezia VAS scores in DIE women in a 180-day period. However, no differences were perceived in bowel lesions by TVUS. Further studies, with a control group and larger sample are needed to confirm these findings and provide external validity to use in clinical scenarios.

Rectal Shaving in Stage IV Endometriosis

Study Objective To describe rectal shaving as a surgical approach to perform resection of deep infiltrating endometriosis of the bowel and to highlight available evidence for surgical management of colorectal deep infiltrative endometriosis. Design Video presentation. Setting University tertiary care hospital. Patients or Participants 42-yo nulliparous patient with abnormal uterine bleeding, leiomyomas, pelvic pain, 3 cm rectovaginal nodule, and a 12 cm endometrioma who underwent an uncomplicated total laparoscopic hysterectomy, right salpingo-oophorectomy, left salpingectomy, rectal shaving, endometriosis resection, enterolysis, and cystoscopy for Stage IV endometriosis. Interventions Studies have shown that laparoscopic surgery can improve pain in the context of deep infiltrating endometriosis. A complete resection of deep infiltrative endometriosis with definitive hysterectomy and salpingo-oophorectomy was undertaken with rectal shaving as a technique to address the colorectal endometriosis. Measurements and Main Results At the 6-week postoperative follow up, the patient reported resolution of pain symptoms. Conclusion In conclusion given its low bowel complication rate of 1 % and acceptable recurrence rate we perform conservative bowel shaving technique whenever possible. To describe rectal shaving as a surgical approach to perform resection of deep infiltrating endometriosis of the bowel and to highlight available evidence for surgical management of colorectal deep infiltrative endometriosis. Video presentation. University tertiary care hospital. 42-yo nulliparous patient with abnormal uterine bleeding, leiomyomas, pelvic pain, 3 cm rectovaginal nodule, and a 12 cm endometrioma who underwent an uncomplicated total laparoscopic hysterectomy, right salpingo-oophorectomy, left salpingectomy, rectal shaving, endometriosis resection, enterolysis, and cystoscopy for Stage IV endometriosis. Studies have shown that laparoscopic surgery can improve pain in the context of deep infiltrating endometriosis. A complete resection of deep infiltrative endometriosis with definitive hysterectomy and salpingo-oophorectomy was undertaken with rectal shaving as a technique to address the colorectal endometriosis. At the 6-week postoperative follow up, the patient reported resolution of pain symptoms. In conclusion given its low bowel complication rate of 1 % and acceptable recurrence rate we perform conservative bowel shaving technique whenever possible.

Perioperative Outcomes in a Nationwide Sample of Patients Undergoing Surgical Treatment of Ovarian Endometriomas

Study Objective Surgery for deep infiltrating and bowel endometriosis involves risks of organ injury, reoperation, and prolonged hospital stay. Surgical outcomes following surgery for ovarian endometriosis (endometrioma, OMA) are currently unknown. The objective of this study was to evaluate perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for OMAs compared to other benign ovarian neoplasms. Design Retrospective cohort study. Setting Vizient Clinical Database, which contains information from 580 participating hospitals across the United States. Patients or Participants Patients ages 18-50 who underwent ovarian cystectomy or oophorectomy for benign indications 2010-2020 were identified. OMAs included ICD-9/10 codes for ovarian endometriosis. We excluded patients who received concomitant hysterectomy or obstetric or oncologic care. Interventions We abstracted clinical data, including surgical route, length of stay, and 30-day postoperative complication rates. Procedures performed for OMA were compared to other surgical indications. Measurements and Main Results We identified 58,874 patients who underwent oophorectomies (10,464 OMAs vs. 48,410 for other indications) and 125,911 ovarian cystectomies (30,058 OMAs vs. 95,853 other). During oophorectomy, patients with OMAs were less likely to undergo minimally invasive surgery (63% vs. 67%, p<0.001) and more likely to require conversion to laparotomy (4.3% vs. 3.4%, p<0.001) and extended hospitalization 2+ days (40% vs. 37%, p<0.001). Among women undergoing cystectomy, conversion to laparotomy (5.3% vs. 3.3%, p<0.001) and readmission (8.5% vs. 7.2%, p<0.001) were more common with OMAs. In multivariable logistic regression, OMA predicted conversion to laparotomy during oophorectomy (aOR 1.3, 95% CI=1.1-1.4) and cystectomy (aOR 1.6, 95% CI=1.5-1.7). Urinary tract injury was infrequent and occurred more often during surgery for indications other than endometriosis (oophorectomy 1.7% vs. 0.95%, cystectomy 0.74% vs. 1.3%, all p<0.001). Bowel injury was exceedingly rare (0.01% of all procedures). Conclusion We present population-level data demonstrating that patients undergoing ovarian cystectomy or oophorectomy for endometriomas had higher rates of perioperative adverse events, including conversion to laparotomy, extended hospital stay, and readmission. Surgery for deep infiltrating and bowel endometriosis involves risks of organ injury, reoperation, and prolonged hospital stay. Surgical outcomes following surgery for ovarian endometriosis (endometrioma, OMA) are currently unknown. The objective of this study was to evaluate perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for OMAs compared to other benign ovarian neoplasms. Retrospective cohort study. Vizient Clinical Database, which contains information from 580 participating hospitals across the United States. Patients ages 18-50 who underwent ovarian cystectomy or oophorectomy for benign indications 2010-2020 were identified. OMAs included ICD-9/10 codes for ovarian endometriosis. We excluded patients who received concomitant hysterectomy or obstetric or oncologic care. We abstracted clinical data, including surgical route, length of stay, and 30-day postoperative complication rates. Procedures performed for OMA were compared to other surgical indications. We identified 58,874 patients who underwent oophorectomies (10,464 OMAs vs. 48,410 for other indications) and 125,911 ovarian cystectomies (30,058 OMAs vs. 95,853 other). During oophorectomy, patients with OMAs were less likely to undergo minimally invasive surgery (63% vs. 67%, p<0.001) and more likely to require conversion to laparotomy (4.3% vs. 3.4%, p<0.001) and extended hospitalization 2+ days (40% vs. 37%, p<0.001). Among women undergoing cystectomy, conversion to laparotomy (5.3% vs. 3.3%, p<0.001) and readmission (8.5% vs. 7.2%, p<0.001) were more common with OMAs. In multivariable logistic regression, OMA predicted conversion to laparotomy during oophorectomy (aOR 1.3, 95% CI=1.1-1.4) and cystectomy (aOR 1.6, 95% CI=1.5-1.7). Urinary tract injury was infrequent and occurred more often during surgery for indications other than endometriosis (oophorectomy 1.7% vs. 0.95%, cystectomy 0.74% vs. 1.3%, all p<0.001). Bowel injury was exceedingly rare (0.01% of all procedures). We present population-level data demonstrating that patients undergoing ovarian cystectomy or oophorectomy for endometriomas had higher rates of perioperative adverse events, including conversion to laparotomy, extended hospital stay, and readmission.

Frozen Pelvis

Study Objective To demonstrate that a pelvis is never really frozen in a case of a deep infiltrative endometriosis. Design Surgical video of a pelvis completed affected by deep endometriosis with significant anatomical distortion. Setting We describe a case of a 37 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and chronic pelvic pain. The patient had no relevant past medical. The pre-operative investigation involved a transvaginal magnetic resonance imaging that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, with involvement of the left ovary and a retossigmoid nodule with 4cm of diameter and 8cm from de anal verge. The patient was in clinical treatment with dienogest, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis. Patients or Participants One patient with a pelvis completed affected by deep endometriosis with significant anatomical distortion. Interventions A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating surgical landmarks and a proper technique. It emphasizes mainly the development of the avascular spaces, isolation of the ureteral course, identification of the parametrial ligaments, preservation of the cranial, middle and caudal parts of the hypogastric plexus, performance of retossigmoid resection. Measurements and Main Results full and complete excision of all endometriosis lesions and restore of the anatomy. Conclusion The main indication for surgical treatment in women with endometriosis is pain and impairment in quality of life and the radical eradication of deep endometriosis is related not only with the relieve of symptoms, but also with the minimization of recurrences. The nerve-sparing technique is considered a feasible, safety and reliability approach and clearly is associated with lower post-operative complication rate and better results in terms of debilitating impairments in neurological functions. To demonstrate that a pelvis is never really frozen in a case of a deep infiltrative endometriosis. Surgical video of a pelvis completed affected by deep endometriosis with significant anatomical distortion. We describe a case of a 37 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and chronic pelvic pain. The patient had no relevant past medical. The pre-operative investigation involved a transvaginal magnetic resonance imaging that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, with involvement of the left ovary and a retossigmoid nodule with 4cm of diameter and 8cm from de anal verge. The patient was in clinical treatment with dienogest, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis. One patient with a pelvis completed affected by deep endometriosis with significant anatomical distortion. A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating surgical landmarks and a proper technique. It emphasizes mainly the development of the avascular spaces, isolation of the ureteral course, identification of the parametrial ligaments, preservation of the cranial, middle and caudal parts of the hypogastric plexus, performance of retossigmoid resection. full and complete excision of all endometriosis lesions and restore of the anatomy. The main indication for surgical treatment in women with endometriosis is pain and impairment in quality of life and the radical eradication of deep endometriosis is related not only with the relieve of symptoms, but also with the minimization of recurrences. The nerve-sparing technique is considered a feasible, safety and reliability approach and clearly is associated with lower post-operative complication rate and better results in terms of debilitating impairments in neurological functions.

Assessment of Sexual Quality of Life and Satisfaction in Couple Relationships Among Women With Deep Infiltrating Endometriosis and Adenomyosis

Adenomyosis and endometriosis are similar gynecological diseases that decrease sexual quality of life and, in the case of endometriosis, satisfaction in couple relationships. This study aimed to assess sexual quality of life and couple satisfaction in women diagnosed with adenomyosis (AD) or deep infiltrating endometriosis (DIE). The study population included three groups of couples: one composed of 58 couples in which the woman was diagnosed with AD by transvaginal ultrasound (AD group), a second group comprising 55 couples in which the woman was diagnosed with isolated DIE by transvaginal ultrasound (DIE group), and a third group composed of 60 couples in which the women did not have AD or endometriosis (non-AD/DIE group). All women completed the Sexual Quality of Life-Female (SQOL-F) questionnaire, and all the couples completed the Dyadic Adjustment Scale (DAS). Sexual quality of life was significantly worse in women with AD or DIE compared with non-AD/DIE controls. Dyadic adjustment was significantly worse in the AD and DIE groups compared with the non-AD/DIE group. AD and DIE may impair quality of sexual life and couple relationships. Clinicians should be aware of this issue when treating women with AD or DIE.

Müllerian Duct Anomalies: Role in Fertility and Pregnancy.

Müllerian duct anomalies (MDAs) have important implications for the reproductive health of female patients. In patients with both infertility and recurrent pregnancy loss, the incidence of MDAs is as high as 25%. Congenital uterine anomalies are often only part of a complex set of congenital anomalies involving the cervix, vagina, and urinary tract. Multiple classification systems for MDAs exist, each with different criteria that vary most for the diagnosis of septate uterus. Recognizing the features that guide clinical management is essential for interpretation. Identification of an MDA should prompt evaluation for associated urinary tract anomalies. In patients with infertility who seek to use assisted reproductive technologies such as intrauterine insemination, recognition of MDAs may have an affect on reproductive success, particularly in patients who have an incomplete and clinically occult septum that divides the cervix. Two-dimensional US is the first-line modality for evaluating the uterus and adnexa. Three-dimensional (3D) US or MRI may help to visualize the external uterine fundal contour and internal indentation of the endometrial cavity, which are two morphologic characteristics that are keys to the diagnosis of congenital uterine anomalies. Hysterosalpingo contrast-enhanced US may be performed in conjunction with 3D US to evaluate uterine morphologic characteristics, the endometrial cavity, and tubal patency in a single examination. MRI helps to characterize rudimentary uteri in patients with müllerian hypoplasia and allows assessment for ectopic ureters, abnormally positioned ovaries, or associated deep infiltrative endometriosis. Online supplemental material is available for this article. ©RSNA, 2021.

VP05.24: Detection of deep infiltrative endometriosis by ultrasound

VP05.24: Detection of deep infiltrative endometriosis by ultrasound

Bowel resection performed by gynecologists - Outcomes and learning curves. Activity profile in a Gynecology Department: 7-year observational cohort

ObjectiveBowel resection is frequently used when performing oncological surgery to obtain complete cytoreduction or to remove endometriosis in case of intestinal invasion. Acquiring the surgical skills to perform this kind of procedure is crucial to offer to our patients an optimal management. The aim of this study is to describe a 7-years surgical experience in bowel resections of a gynecologic surgeon and to determine his learning curves. Study DesignThis is a monocentric retrospective cohort study reporting digestive resection performed between January 2013 and April 2020 in the Gynecology Department of Strasbourg University Hospital. Ninety-one consecutive patients were assigned in two groups: gynecological cancer (n = 44) and deep infiltrating endometriosis (DIE) (n = 47). The main outcome measure was the postoperative complications rate at 30 days, based on the modified Clavien-Dindo severity system. Learning curves were evaluated using cumulative sum (CUSUM) analysis of operative time and risk-adjusted cumulative sum (RA-CUSUM) analysis of severe perioperative complications. Identification of predictive factors for operation duration and severe perioperative complication occurrence was conducted using multivariate analysis. ResultsMinor complications were found in 25% of cases. Major complication rate (Clavien-Dindo ≥ IIIa) was 14% in total and only involved patients operated for cancer. The CUSUM curve for operative time peaked at the 35th case and showed a downward slope after the 45th case. Significant predictive factors of operating time were cytoreductive tumoral surgery, size of the bowel resection and laparoscopic surgery, while learning phase 3 significantly decreased it. The RA-CUSUM curve for severe perioperative complications (Clavien-Dindo ≥ IIIa) showed a progressive decrease in the complication rate as the number of interventions increases without showing clear inflection points. Only cardiopulmonary pathologies were found as significant predictive factor of severe complications. ConclusionProficiency in performing highly complex surgery was achieved after approximately 45 cases, cancer and DIE all together. Acceptable rates of severe perioperative complications were observed even during the initial learning period and are comparable with those found in the literature concerning bowel resection performed by gynecologic oncologists but also by general and digestive surgeons.

Clinical and diagnostic aspects of deep infiltrative endometriosis (diagnosis, treatment, recurrence)

Aim. To analyze the recurrence of endometriosis after surgical treatment of patients with deep endometriosis.&#x0D; Materials and methods. The case histories of 90 patients aged 19 to 45 years were retrospectively analyzed. The study group consisted of 70 endometriosis patients: 20 with peritoneal endometriosis and 50 with deep infiltrative endometriosis (DIЕ). The comparison group included 20 women without endometriosis. There was an in-depth study of anamnestic data in the cohort of patients under study. The results of preoperative laboratory tests, including serum levels of the CA-125 and CA 19-9 oncomarkers, were processed.&#x0D; Results. Analysis of the obtained data showed that about half of the DIE patients (54%) in the main group had a history of surgical interventions for endometriosis. The number of operations was significantly higher in patients compared to the peritoneal endometriosis group (68% vs 20%, respectively; р=0.0012). Two subgroups were formed from the group of women with DIE: patients who had no history of previous surgical treatment for endometriosis and those hospitalized for repeated surgical treatment of endometriosis (patients with recurrent endometriosis). Patients with recurrent endometriosis had a significantly higher incidence of heavy menstruation, pregnancy terminations (abortions), and a high proportion of gastrointestinal diseases. Analysis of the hormonal therapy received in patients with DIE showed that every second patient with relapses (18/53%) after surgical treatment and every third patient without a prior history of surgery (5/31%) received hormonal therapy. Examination of the preoperative serum levels of CA-125 and CA 19-9 serum markers in patients with DIE showed an increase in their serum levels and a correlation with the frequency of endometriosis recurrence and the size of DIE foci.&#x0D; Conclusion. Despite the conservative and surgical treatment of DIE patients, the recurrence rate is still high. At present, there is no satisfactory therapy for all endometriosis patients. Therefore, the development of therapy for the conservative treatment of the disease remains an urgent task.

Pregnancy Rates After Surgical Resection of Deep Infiltrating Endometriosis in Patients with Infertility: A Systematic Review and Meta-Analysis

Objective: The aim of this review and meta-analysis was to assess spontaneous pregnancy rates after excision of deep infiltrating endometriosis (DIE) in patients with infertility. Materials and Met...

Evaluation of the SF-36 questionnaire for assessment of the quality of life of endometriosis patients undergoing treatment: A systematic review and meta-analysis.

Endometriosis has a negative influence on the physical, psychological, and social aspects of a patient's life; therefore, it affects the health-related quality of life (HRQoL). The current review aimed to investigate the efficiency of a 36-item generic questionnaire survey (SF-36) for patients with endometriosis who were undergoing medical or surgical treatment. A search strategy including the key words ‘endometriosis’, ‘quality of life’ (QOL), and ‘questionnaire SF-36’ was applied using the PubMed/MEDLINE, EMBASE, and Cochrane databases in order to include articles that evaluated the QOL among women with endometriosis using the SF-36. Only articles that included interviews of patients both before and after surgical or medical endometriosis treatment or those articles that compared study groups were considered. The qualitative analysis was based on 37 articles, whereas the quantitative analysis utilized 14 articles. The research participants included 11,101 women, among whom 6,888 patients were diagnosed with endometriosis. The analysis recorded 17 studies dealing with all types of endometriosis, 9 studies dealing with deep infiltrative endometriosis (DIE), and 9 studies dealing with bowel endometriosis or DIE with bowel involvement. QOL was evaluated using only SF-36 in 12 studies that collectively included 1,912 women and using SF-36 in association with other questionnaires in 25 studies that collectively included 8,022 women. For patients with endometriosis, physical functioning [odds ratio (OR), 78.87; 95% confidence interval (CI), 68.97-88.77; I2=98.77%; P≤0.001] was the most affected life parameter. This parameter showed the highest improvement after surgical intervention (OR, 63.39; 95% CI, 48.71-78.07; I2=97.65%; P≤0.001) or hormonal treatment (OR, 38.65; 95% CI, 14.39-62.91; I2=38.65%; P≤0.001). The 36-item survey generic questionnaire seems to be an efficient tool for assessment of the QOL of life of women with endometriosis who are undergoing surgical or medical treatment. It can be applied before and after the procedure, and it can also be used for comparing study groups.