Center For Endometriosis Research Articles

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center

Assess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO2 laser. Retrospective cohort study. University gynecologic surgery unit, referral center for endometriosis. A total of 207 women having undergone laparoscopic BE excision between January 1998and January 2019. None. Intra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n=176) for "isolated" and "non-isolated" BE groups. Forty-three patients presented with isolated BE. Bladder "shaving" without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n=132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p=.406). Age at surgery (hazard ratio 0.91 [0.84-0.98], p=.016) and postoperative pregnancy (hazard ratio 0.07 [0.01-0.91], p=.042) showed influence on disease recurrence. The study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection.

Approach to ureteral endometriosis: A single-center experience and meta-analysis of the literature.

To report single-center outcomes of laparoscopic management of patients with ureteral endometriosis and perform a meta-analysis in order to select the best approach for these patients. The cross-sectional study was conducted during a 6-year period (2015-2021) in the referral endometriosis center on 353 patients with ureteral endometriosis. For the meta-analysis, 10 articles, including 505 patients, were found to be eligible. In our meta-analysis, as well as our study, all endometriosis-related pain symptoms and complications of surgery were evaluated, analyzed, and reported. Of the 326 patients whose ureteral involvement was confirmed in pathology, hydronephrosis and intrinsic ureteral lesions were detected in only 10.76% and 3.1% of the patients. Mean operating time and hospitalization were 3.25 ± 1.83 h and 86 ± 2.58 days, respectively. The most common site of concomitant involvement with endometriosis was uterosacral ligament (92.9%) and rectosigmoid (70.53%). Type II and III of Cliven-Dindo complications were seen in 5.66% and 1.13% of patients, respectively. During a follow-up period, no evidence of bladder or ureteral re-involvement was observed. Similar to our meta-analysis, all endometriosis-related pain decreased significantly following operation (p ≤ 0.001). In our meta-analysis, the rate of ureteral endometriosis recurrence, stenosis/stricture, bladder atonia, urinary tract infection, hematuria, and fistula formation after surgery were: 2.0% (I2 : 50.42%), 15.0% (I2 : 0.00%), 14.0% (I2 : 8.76%), 6.0% (I2 : 0.00%), 7.0% (I2 : 79.28%), and 2.0% (I2 : 0.0%), respectively. The laparoscopic resection of the UE could be suggested as a feasible and safe method associated with favorable functional outcomes.

Improvement of Post-Operative Quality of Life in Patients 2 Years after Minimally Invasive Surgery for Pain and Deep Infiltrating Endometriosis.

This study addressed the improvement in the quality of life of patients 2 years after minimally invasive surgery for painful deep infiltrating endometriosis (DIE), evaluated with EHP-5 (Endometriosis Health Profile-5) scores and the intensity of dysmenorrhea and dyspareunia. This was a retrospective study, performed in a referral centre for endometriosis, between January 2010 and January 2019. EHP-5 scores were complete for 54 patients, and two subgroups were analysed: classic laparoscopy (CL) vs. robotic laparoscopy (RL), and conservative surgery (ConservS) vs. total surgery (TS). There was an important decrease in 2-year post-operative EHP-5 scores in the global population (pre-op: 61.36 (42.18–68.75) and 2-year post-op: 20.45 (0–38.06); p < 0.001). The Visual Analogic Scale (VAS) was also lower for dysmenorrhea (pre-op: 8 (7–9.75) vs. 2-year post-op: 3 (2–5.25); p < 0.001) and dyspareunia (pre-op: 6 (3.1–8.9) vs. 2-year post-op: 3 (0–6); p < 0.001). In the subgroup analysis, EHP-5 scores were improved in the RL group (pre-op: 65.9 (59.09–71.02) vs. 2-year post-op: 11.4 (0–38.06); p < 0.001) and the CL group (pre-op: 50 (34.65–68.18) vs. 2-year post-op: 27.27 (14.20–40.90); p < 0.001), with a slight advantage for RL (p = 0.04), and the same improvements were found for ConservS (pre-op: 61.4 (38.06–71.59) vs. 2-year post-op: 22.7 (11.93–38.07); p < 0.001) and TS groups (pre-op: 61.59 (51.70–68.75) vs. 2-year post-op: 13.63 (0–44.30); p < 0.001). Minimally invasive surgery improved the quality of life for DIE patients 2 years after surgery, and conservative surgery showed comparable results to total surgery.

Association Between Laparoscopic Appearance of Superficial Endometriosis, Positive Histology, and Systemic Hormone Use

To assess the association between laparoscopic appearance of superficial endometriosis (SE) lesions, histopathology, and systemic hormone use. Retrospective study SETTING: Tertiary care academic medical center PATIENTS: We identified 266 women who underwent laparoscopic surgery at an endometriosis center with excision of lesions consistent with possible superficial endometriosis between 09/2015 and 11/2018. Appearance of the peritoneal lesions was confirmed with review of surgical videos and correlated with each pathology specimen. Lesions were dichotomized on positive or negative pathology assessment. All pathology positive lesions were further dichotomized by hormone use within one month of surgery. A total of 841 lesions were biopsied from included subjects during the study period. Of those, 251 biopsies were negative and 590 were positive for endometriosis on pathology assessment. Lesions had significantly higher odds of positive histology when they were red (OR 1.70, 95%CI 1.17-2.48), white (OR 1.99, 95%CI 1.47-2.70), blue/black (OR 2.98, 95%CI 2.00-4.44), or puckering (OR 9.78, 95%CI 2.46-38.91) in appearance. The following combined characteristics had significantly higher odds of positive histology: white and blue (OR 5.98, 95%CI 2.97-12.02), red and white (OR 2.22, 95%CI 1.38-3.56), red and blue (OR 4.11, 95%CI 1.83-9.24), and clear and white (OR 8.77, 95%CI 1.17-66.02). Among positive biopsies, those with hormone exposure were more likely to have clear lesions than those without hormone use (OR 3.36, 95% CI 1.54-7.34), and were 2.89 times more likely to have clear and white lesions (95% CI 1.07-7.85). While lesions suspicious for endometriosis may have differing rates of positive pathology based on appearance, no lesion characteristic was able to exclude the possibility of endometriosis. Additionally, hormone use may influence lesion appearance at time of surgery, with clear lesions more prevalent. These data have implications for appropriate identification of endometriosis at the time of laparoscopy to ensure accurate diagnosis and complete treatment of disease.

Interleukin-1β and plasminogen activating system members in endometriotic stromal cell migration/invasion

To study the role of interleukin (IL)-1β and the plasminogen activating (PA) system members in endometriotic stromal cell (ESC) migration/invasion. Primary cultures of ESCs. Tertiary referral center for endometriosis and pelvic pain. Patients with surgically excised endometriosis. Interleukin-1β stimulation of primary cultures of ESCs and knockdown of the PA system members urokinase plasminogen activator (uPA), uPA receptor, and plasminogen activator inhibitor-1 (PAI-1). Invasion/migration assays. In primary cultures, IL-1β-stimulated ESC production of the PA system members uPA, uPA receptor, and PAI-1. Interleukin-1β also enhanced ESC migration and invasion, and these effects were inhibited by the IL-1 receptor-1 antagonist anakinra. Knockdown of each of the 3 PA system members also inhibited ESC migration and invasion. Knockdown of these PA system members further attenuated the impact of IL-1β on migration and invasion, suggesting that they mediated the promigration and proinvasion effects of IL-1β. To supplement the cell culture work, immunohistochemistry was performed on tissue sections of endometriotic epithelium/stroma: uPA, PAI-1, and IL-1β histoscores were not found to be correlated with each other. In primary cultures of ESCs, IL-1β induces migration and invasion, which is mediated by PA system members and inhibited by the drug anakinra. However, the immunohistochemistry expression of IL-1β, urokinase plasminogen inhibitor-1, and PAI-1 were not correlated, suggesting other regulatory mechanisms for PA system members. Inhibition of IL-1β (e.g., with anakinra) may have potential as a novel treatment approach for the migration/invasion of endometriosis.

Trends among patients with endometriosis over a 7-year period and the impact of the COVID-19 pandemic: experience from an academic high-level endometriosis centre in Germany

PurposeEndometriosis is known to be an underestimated disease. Lately the awareness of the disease seems to have improved. Aim of this analysis is to provide an overview of the development of treatment of patients diagnosed with endometriosis. This includes a special scope on implications of the COVID-19 pandemic since in multiple settings postponed treatments resulting in negative impact on prognosis were reported.Materials and methodsWe analysed the development of numbers of patients treated for endometriosis in an academic centre within a 7-year period, 01/2015–12/2021, performing a systematic analysis of ICD-10-Codes from our computer system used in clinical routine.ResultsTreatment numbers increased over the past 7 years, i.e., 239 treated cases in 2015 vs. 679 in 2021.Following restrictions for outpatient evaluation and surgical capacity at our centre, during COVID-19 pandemic the numbers of treated patients were reduced, especially in the first lockdown period (03/22/2020–05/05/2020 vs. same period in 2019: outpatient clinic (9 vs. 36; p < 0.001), patients surgically treated (27 vs. 52; p < 0,001)). The comparison of 2020 to 2019 showed a reduction in April 2020 of − 37% in outpatient department and up to − 90% for surgically treated patients. Comparing to 2019, we found a reduction of surgical interventions in 2020 by − 9% and an increase by 83% in 2021.ConclusionsRaising numbers of patients treated for endometriosis point to a new awareness for the disease. After the decline during the lockdown period numbers raised again, leading to a delay, but not an omission of treatment. A certified endometriosis centre with established and well-organized structures is required to improve not only treatment results but also quality of life of those affected.

A case of didelphys uterus: tackling the double trouble adenomyosis and infertility

To present a case of didelphys uterus with severe pelvic pain and primary infertility with focal adenomyosis of outer myometrium (FOAM) of the left hemiuterus and tips and tricks for hemihysterectomy as a fertility preserving surgery. Descriptive step-by-step video demonstration of a case of didelphys uterus with adenomyosis of the hemiuterus. Local institutional review board approval for publication was obtained. Endometriosis Centre, Apollo Hospitals, Hyderabad, India. Women with uterus didelphys with FOAM of the left hemiuterus with severe pelvic pain and infertility. A 30-year-old woman presented with chronic pelvic pain and severe progressive dysmenorrhea with primary infertility for 3 years. She was diagnosed with uterus didelphys and longitudinal vaginal septum 3 years back and underwent hysteroscopy for septal resection and diagnostic laparoscopy for pain in an outside setting; however, no laparoscopic intervention was performed. The patient was diagnosed with FOAM of the left hemiuterus involving 75% of the hemiuterus. After detailed discussion and counseling regarding different options, laparoscopic hemihysterectomy was performed as pelvic pain relief was a major expected outcome along with fertility preservation. Pain relief with improved quality of life and fertility preservation. The postoperative period was uneventful. The patient was discharged on the second postoperative day with no complaints. Her chronic pelvic pain and dysmenorrhea resolved. She was not prescribed any medication after the surgery. During the routine follow-up, she had a regular menstrual cycle with a visual analogue score of 0/10. The safe removal of a hemiuterus in case of a didelphys uterus with pathology of hemiuterus through a minimally invasive technique is possible, which cures the pain caused by adenomyosis and enables quick recovery while preserving future fertility.

Urinary Tract Endometriosis: How to Predict and Prevent Recurrence after Primary Surgical Excision

To investigate the clinical and surgical predictors of urinary tract endometriosis (UTE) relapse. Retrospective single institutional study. Italian multidisciplinary referral center for endometriosis. Consecutive patients affected by UTE and surgically treated between January 2016 and March 2020. Surgical excision for UTE. Uni- and multivariate logistic regression analyses were fitted to evaluate clinical and surgical predictors of recurrence. A total of 105 female age-reproductive patients were enrolled. Median age was 32 years (interquartile range, 24-37). Ureteral involvement was recorded in 53 patients (50.5%), being unilateral and bilateral in 46 patients (43.8%) and 7 patients (6.7%), respectively. Bladder involvement occurred in 52 patients (49.5%). Open surgical approach was performed in 24 cases (22.9%), whereas 30 patients (28.5%) and 51 patients (48.6%) were treated with laparoscopic and robot-assisted approach, respectively. Overall, 53 patients (50.5%) received adjuvant hormonal therapy. At a median follow-up of 39 months (interquartile range, 22-51), 30 patients (28.6%) experienced disease relapse, with 14 recurrences (13.3%) recorded at the level of the urinary tract. At multivariable analysis, age at first surgery <25 years (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.10-1.84; p=.02) and the presence of a concomitant autoimmune disease (OR, 1.45; 95% CI, 1.24-2.17; p=.02) were found as predictors of deep infiltrating endometriosis recurrence, whereas adjuvant postsurgical therapy showed a protective role (OR, 0.83; 95% CI, 0.53-0.98; p=.01). Young age (<25 years) and the presence of autoimmune diseases were significant predictors for the development of disease recurrence, whereas adjuvant hormonal therapy showed a protective role.

O-030 Disturbed homeostasis of regulatory T-cells and imbalanced signal transducer and activator of transcription 5 (STAT5) in women with ovarian endometriosis

Abstract Study question Do women with endometriosis have altered cytokine signalling and regulatory T-cell (Treg) homeostasis compared to controls? Summary answer Altered homeostasis of circulating Treg cells seems to be associated with STAT5 phosphorylation, which is significantly increased in women with ovarian endometriosis compared to controls. What is known already Cytokine signaling influences homeostasis of regulatory T-cells (Treg), which play a crucial role in cell-mediated immunity and are responsible for certain immune disorders. Endometriosis is a condition associated with altered immune response to endometrial cells. While some animal studies have shown that Treg deficiency facilitates ectopic implantation of endometriosis, a recent study performed in a small number of women with endometriosis has shown the decreased proportion of a specific-activated subset of Treg cells in the endometrioma compared to controls. There is no data characterising cytokine signalling in circulating Treg subsets, which could underlie their altered homeostasis in women with endometriosis. Study design, size, duration A prospective cohort study including 14 women with endometriosis and 10 controls at a university-based tertiary care centre for endometriosis. The data were collected from August 2020 to September 2021. Serum blood samples were collected in the early follicular phase of the menstrual cycle, in women not using any hormonal treatment. Early follicular steroid hormone levels were measured. A detailed expert ultrasound examination was performed to diagnose and accurately map endometriotic lesions. Participants/materials, setting, methods We investigated signal transducer and activator of transcription (STAT) signalling in peripheral blood Treg subsets, including CD45RA+FOXP3low+ naive Tregs (nTregs). Expression of proliferation marker Ki-67 and STAT activation also in FOXP3- conventional (Tcon) CD4+T-cells was monitored, hypothesising that defects in this pathway could be associated with altered Treg/Tcon homeostasis in endometriosis. Immunophenotyping and flow cytometry methods with phospho-specific antibodies that allow analysis of basal STAT activation/phosphorylation also in rare subsets of Treg cells were used. Main results and the role of chance Among women with endometriosis, 5 had evidence of ovarian and deep infiltrating endometriosis (DIE), 5 had only ovarian endometriosis and 4 had only evidence of DIE. Groups were comparable in their clinical characteristics, there was no difference in the median age of women with endometriosis and controls; 31 (range 23-45) vs. 34 (range 27-39). We demonstrated significantly higher levels of phosphorylated STAT5 (pSTAT5) in nTreg from women with ovarian endometriosis compared to controls (p = 0.026). To assess the homeostatic balance between the nTreg and Tcon, we compared pSTAT5 levels between these cell subsets in each patient. STAT5 phosphorylation was significantly higher in Tcon than in nTreg subset (p &amp;lt; 0.001). Considering STAT5 activation in nTreg subset, this was positively correlated with the proportion of nTreg among CD4+T-cells (rs=0.54, p = 0.027) in all women with endometriosis. We also found a significant positive correlation between pSTAT5 levels in Tcon from women with endometriosis and the percentage of Ki-67+ cells in the Tcon subset (rs=0.66, p = 0.005) as well a significant correlation between luteinizing hormone (LH) levels and pSTAT5 in Tcon subset of CD4 cells (rs=0.71, p = 0.02). This implies LH-dependent imbalanced STAT5 signalling that could be responsible for increased Tcon homeostatic proliferation. Limitations, reasons for caution Our sample size is relatively small and the findings should be validated in future prospective studies. Due to the sample size, there is a risk for Type I error, although the results are coherent in indicating disturbance of Treg homeostasis. Wider implications of the findings Our study suggests that altered STAT5 signalisation may be associated with disturbed nTreg/Tcon homeostasis, which seems to be mostly prominent in women with ovarian endometriosis. If confirmed by further studies in the future, targeted treatment options could be developed to supress progress of endometriosis in this group of women. Trial registration number not applicable

P-339 Fertility outcomes after laparoscopic bladder endometriosis excision using a CO2 laser: 20-year retrospective analysis in an expert center

Abstract Study question To evaluate fertility outcomes after laparoscopic bladder endometriosis (BE) excision in patients presenting with a post operative pregnancy wish or pre-operative infertility. Summary answer Surgical excision of BE is followed by high pregnancy rates, with a significant proportion of spontaneous conceptions, even in the infertile population prior to surgery. What is known already There are currently no guidelines/consensus concerning management of BE in case of infertility( ART? surgery?) and the impact of BE excision on fertility is still not known. Most publications reporting surgical management of BE include patients with different endometriosis types with a very small number of cases of isolated BE, making it difficult to draw conclusions. Study design, size, duration This is a retrospective, unicentric cohort study conducted at Saint Luc University Hospital Brussels, a tertiary referral center for endometriosis. A total number of 207 patients having undergone laparoscopic bladder endometriosis excision using a CO2 laser between January 1998 and December 2018 were included. Only patients having histologically confirmed endometriosis infiltration of the detrusor muscle were included. Patients with small nodular lesions &amp;lt; 5mm or superficial peritoneal endometrial lesions in the vesico-uterine fold were excluded. Participants/materials, setting, methods Laparoscopic BE excision was performed by 3 senior surgeons of the team, either with bladder mucosae opening (partial cystectomy) or partial thickness excision (“bladder shaving”) technique. Pregnancy and live birth rates according to prior infertility, conception mode and time to pregnancy were recorded. Primary outcome was postoperative pregnancy rate (PR). Secondary outcomes were conception mode and time to pregnancy. Patients with minimum 1-year follow up (FU) after surgery were included for fertility analysis. Main results and the role of chance Forty-three patients had isolated BE, while BE was associated with other forms of endometriosis in 164 cases, including 50.2% posterior DIE. Among the 176 patients having a minimum 1y FU, mean FU was 7.05 (±4.65)y. Overall, PR among the hundred patients with a postoperative pregnancy wish was 75.8% (100/132): 49 natural conceptions and 51 following ART. Indication for ART were failed natural conception (24/51, 47.1%) or assosiated other cause of infertility (severe male factor, hormonal or tubal) requiring immediate IVF (27/51, 52.9%). PR (81.0% vs 74.8%, p = 0.545) and need for IVF (41.2% vs 53%, p = 0.374) did not statistically differ between patients with isolated or assosiated BE. Total live birth rate was 69.7%. In patients presenting with preoperative infertility,overall PR was 74.5% with 50% natural pregnancies. In the isolated BE group (n = 11) PR was 81.8% with 55.5% (5/9) natural pregnancies and 44.5% needing ART. No statistical difference were found in PR and need for IVF between the isolated and associated BE group. Most pregnancies occured in the first 2 years following surgery. Overall cumulative PR was 42% at 1 year, 65% at 2 years and 75% at 5 years respectively with similar distributions in the isolated and associated BE groups. Limitations, reasons for caution The main limitation is the retrospective nature of the study, making it difficult to exclude biases. Sample size also remains limited due to the rare incidence of BE, particularly concerning the isolated forms. Wider implications of the findings This is the largest reported series of patients treated surgically for BE. Fertility results are excellent for an endometriotic population and BE excision seems to have a positive impact, at least in case of natural conception. First-line surgery may be considered in patients with bladder endometriosis having a pregnancy wish. Trial registration number not applicable

Ultrasound Evaluation of Retrocervical and Parametrial Deep Endometriosis on the Basis of Surgical Anatomic Landmarks

To assess the value of combined transvaginal/transabdominal ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas and summarize the features and anatomic criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments. Retrospective study. A specialized endometriosis center in Avellino, Italy. A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention. Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals. A total of 4983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97% to 98% and 98% to 100%, respectively, for both retrocervical (torus uterinus and uterosacral ligaments insertion) and parametrial lesions. Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.

Patients’ and relatives’ perspectives on best possible care in the context of developing a multidisciplinary center for endometriosis and adenomyosis: findings from a national survey

BackgroundEndometriosis and adenomyosis are common benign conditions compromising both physical and psychological health, with a negative impact on quality of life. This survey aimed to establish what the users’ perspectives are on best possible care in the context of developing a multidisciplinary center for endometriosis and adenomyosis in Norway.MethodsAn electronic questionnaire was developed in collaboration between the Norwegian Patient’s Endometriosis Society (NPES) and gynecologists with special interest in endometriosis and adenomyosis. The questionnaire was distributed digitally to the members of NPES in May 2021.Results938 participants answered the questionnaire. Better patient information, long term therapeutic plans and integration of their partners into their care were the main concerns. Multidisciplinary care was a key issue for the majority, with (n = 775) 89% stating a need for a consultation with a psychologist, (n = 744) 86% at least one consultation with a nutritionist, (n = 733) 85% a physiotherapist, and (n = 676) 78% needing a sex therapist and (n = 935) 99,7% consider research and (n = 934) 99,8% consider quality assurance initiated by the endometriosis center to be important. The qualitative analysis of free text answers revealed a great need for updated and easily accessible information, meeting competent health care professionals and being taken seriously/listened to.ConclusionsThis survey shows similar perceptions and a high level of agreement regarding their needs amongst people with endometriosis and/or adenomyosis. This survey supports recommendations by the experts that endometriosis/adenomyosis care should be centralized in specialized, multidisciplinary centers. The results of the present work will be valuable for the future planning and development of a multidisciplinary endometriosis center.

Preoperative application of the Enzian classification for endometriosis (The cEnzian Study): A prospective international multicenter study.

To assess the diagnostic performance of preoperative application of the Enzian classification (cEnzian) using surgical findings as reference standard. A prospective international non-interventional study. Twelve endometriosis centres in four European countries (Austria, Germany, Switzerland and Czech Republic). 1062 women with endometriosis surgery. Extent of endometriosis was preoperatively classified using the cEnzian classification based on gynaecological examination and/or transvaginal ultrasound (TVS) and/or magnetic resonance imaging (MRI). After subsequent surgery, the surgeon classified the intraoperative findings using the Enzian classification. Sensitivity, specificity, PPV, NPV, LR+ , LR- and accuracy were calculated. Conditional frequencies of intraoperative Enzian codings and the corresponding 95% confidence intervals were computed for each preoperative coding and visualised in plots. Although overall consistency of cEnzian and Enzian was poor (35.14%, 95% confidence interval 32.26-38.03), high specificities and negative predictive values (NPVs) of the cEnzian compartments could be demonstrated. Looking at the individual parts of the Enzian classification, the poorest diagnostic performance was detected for compartment B and the highest PPVs were found for category 3 lesions (>3cm), independent of the compartment. Using the Enzian classification in a non-invasive setting is a useful tool providing us with an 'at a glance' summary of the diagnostic workup regarding deep endometriosis with high specificities and NPVs. An attempt to merge the two new endometriosis classification systems (#Enzian and AAGL 2021) seems reasonable taking into consideration the respective advantages of each other.

Comparison Between Sonography-Based and Surgical Evaluation of Endometriotic Lesions Using the #Enzian Classification - A Retrospective Data Analysis.

To compare the location and sizes of deep endometriosis (DE) lesions evaluated by preoperative transvaginal sonography (TVS) in different #Enzian compartments with intraoperatively assessed DE location and size. Retrospective data analysis of 93 women undergoing TVS and surgery for DE in 2019 at a tertiary referral center for endometriosis. #Enzian compartment C (rectum) showed the highest rate of exact concordance with 74% of cases, which increased to 87% when a tolerance margin of a maximum of 3mm for TVS measurements was taken into account. For compartment B (uterosacral ligaments, parametria) and compartment A (vagina, rectovaginal space), the rates of exact concordance were slightly lower. In compartment O (ovary), high exact concordance rates similar to those observed for compartment C were observed. In compartment T (tubo-ovarian unit), most reliable estimations were seen for slight (TVS T1) and severe adhesions (TVS T3). There were only a few cases of missed lesions as well as false positives on TVS: Sensitivity was 100% for all compartments except for A and B left (97%) and FB (urinary bladder, 86%); specificity was 100% for FB, FI (other intestinal locations), FU (ureters) and O right, 86%-98% for A, B right, C, O left and FO (other extragenital lesions) and 70% for B left. The preoperative evaluation of the location and size of DE lesions by TVS in different #Enzian compartments is accurate, providing a detailed presurgical description of the extent of ovarian and deep endometriosis and associated minor or severe adhesions.

8 En-block resection of the [LDQUO]butterfly[RDQUO] area in deep infiltrative endometriosis

Introduction Aims of the study: In this video, we demonstrate our structured approach for excision of the “butterfly area” when endometriosis involves both pelvic sidewalls, uterosacral ligaments and torus uterinus. Methods: This is an edited video of a procedure performed at our unit in Chertsey, UK, CEMIG (Centre for Endometriosis and Minimal Invasive Gynaecology).Results: We follow a structured approach which we call by the mnemonic “SO SURE Resection”. Depending on the case there may be an adjustment on the above order but in general the acronym itself is a well structured approach that facilitates the procedure.

13 From chaos to order: restoring anatomy in a frozen pelvis & segmental bowel resection for full thickness rectovaginal nodule

Introduction Aims of the study: Frozen pelvis/deep infiltrating endometriosis is one of the most intimidating spectacles a gynaecologist can come across during a laparoscopy. In this video we demonstrate our structured approach used in our unit in order to restore anatomy in cases of frozen pelvis. In this specific case we perform a segmental bowel resection for a full thickness rectovaginal nodule as well as appendicectomy for endometriosis of the appendix. Methods: This is an edited video of a procedure performed at our unit in Chertsey, UK, CEMIG (Centre for Endometriosis and Minimal Invasive Gynaecology).

Hemosiderin is a marker for complex disease in patients undergoing surgery for endometriosis

The study was performed to evaluate the finding of hemosiderin at the time of laparoscopic surgery for endometriosis and determine its relationship to disease phenotype. Women undergoing laparoscopic surgery at an academic endometriosis center between 09/2015 and 11/2018 with pathology positive for endometriosis were retrospectively reviewed. All surgeries were video recorded, and video review used to identify the presence of hemosiderin (brown, gelatinous/sticky substance adherent to the peritoneum or other abdominal structures without infiltration). Surgical findings, patient demographics, and additional clinical data were collected from surgical video review and the electronic medical record. IRB approval was obtained. A total of 208 patients met inclusion criteria, and 10 were found to have hemosiderin present during surgery. Average age was similar between patients with and without hemosiderin (35.9 vs 36.3, p=0.901). Women with hemosiderin were more likely to be nulliparous (mean 0.2±0.6 vs 1.1±1.4, p=0.017). Patients with hemosiderin were significantly more likely to have markers of complex endometriosis, including presence of endometriomas (80% vs 21.2%, p<0.001), deep endometriosis of the rectum (30% vs 8.1%, p=0.019), and moderate or severe ASRM staging (90% vs 30.3%, p<0.001). Additionally, mean operative time was longer in the hemosiderin group (189 vs 288 minutes, p=0.003). In our cohort of patients undergoing surgery for endometriosis, hemosiderin is a marker for complex features of disease and associated with longer operative times. The pathophysiology and clinical significance of this surgical finding remain unclear, and should be the focus of further research.

Endometriosis, an Ongoing Pain-Step-by-Step Treatment.

Endometriosis is a disease that is becoming more and more challenging for the medical community. The current therapeutic concepts (surgical therapy and/or hormonal therapies) often do not lead to sufficient pain control, and late diagnosis and high recurrence rates mean that women affected by the disease can suffer for decades before receiving proper treatment. Although the introduction of certified endometriosis centers has created contact points for surgical therapies performed by endometriosis experts, these centers are not sufficient to offer the affected patients the all-encompassing long-term support they need. In recent years, new findings regarding the pathogenesis and correlations of the pain phenomena caused by endometriosis have shown that conventional therapy strategies are not adequate and individual long-term concepts must be developed. Not only can endometriosis cause nociceptive pain, but it can also lead to a nociplastic reaction with central sensitization. Hence, aside from the classic cyclic complaints, patients increasingly suffer from atypical pain. Due to the high number of affected patients who are treated inadequately, it is necessary for gynecologists in private practices to become familiar with multimodal treatment concepts since they are the central point of contact of their patients. The following article will provide an overview of treatment strategies for chronic symptomatic endometriosis.

Heat can treat: long-term follow-up results after uterine-sparing treatment of adenomyosis with radiofrequency thermal ablation in 60 hysterectomy candidate patients.

Adenomyosis may induce pelvic pain, abnormal uterine bleeding or bulk symptoms. If hormonal treatment proves ineffective or contraindicated, hysterectomy may be necessary. For patients who desire to conserve the uterus despite severe symptomatology, uterine-sparing techniques have been introduced. Radiofrequency thermal ablation (RFA) consists of the local application of high temperature to eliminate diseased tissue, applied recently for adenomyosis treatment. The objective of the study was to analyze the efficacy of RFA for avoiding hysterectomy in patients with adenomyosis-related symptoms. This is a single-center, retrospective cohort study performed in a referral center for endometriosis. The study population consisted of all consecutive patients who underwent Radiofrequency thermal ablation (RFA) treatment as an alternative to hysterectomy for adenomyosis between March 2011 and June 2019 in our institution. RFA was performed using laparoscopic access. To evaluate the impact of RFA treatment on symptoms, follow-up findings were compared to preoperative symptomatology using the ten-point visual analog scale (VAS) for pain assessment. Sixty patients were included in the study, 39 of them (65%), underwent a concomitant surgery for endometriosis in association to RFA. On a long-term follow-up (mean 56months (range 10-115, SD 29), hysterectomy was performed in 8 patients (13%). The mean VAS score before vs after surgery was 7.4 vs 3.3 for dysmenorrhea, 3.7 vs 0.3 for dyschezia, 4.7 vs 0.7 for dyspareunia, and 4.0 vs 1.4 for chronic pelvic pain, being significantly reduced after RFA for all these pain components (p < 0.0001 in every case). Thirty-one patients (52%) suffered from AUB before RFA, this symptom persisted in 10 patients (16%) during follow-up (p < 0.001). Bulk symptoms were present in 16 patients (27%) and disappeared after RFA in all cases. RFA allows for hysterectomy avoidance in most cases. It leads to marked improvements in pain symptomatology, uterine bleeding and bulk symptoms.

Are double-J stents in surgery for deep infiltrating endometriosis always necessary? A retrospective analysis.

IntroductionThe therapy of deep infiltrating endometriosis places the highest demands. Double-J (DJ) stent insertion is recommended preoperatively. However, we could not find any publication in PubMed that showed the relevant advantages of double-J stent insertion in surgery of deep infiltrating endometriosis (DIE).AimTo report the advantages and disadvantages of inserting double-J stents in surgery for deep infiltrating endometriosis.Material and methodsAll patients who underwent surgery for deep infiltrating endometriosis at Academic Hospital Cologne Weyertal (a level III endometriosis center with up to approximately 900 endometriosis laparoscopic procedures annually) between January 2017 and September 2021 were included in this retrospective analysis. A total of 197 cases were included. The urinary tract complications were analyzed and they were divided into infections, pyelonephritis, urosepsis, intraoperative and postoperative ureteral lesions. Patients were divided into three groups: 1) with DJ stents in whom DJ stents were left in place postoperatively for at least 2 weeks, 2) with DJ stents in whom DJ stents were removed directly at the end of the surgery, 3) without DJ stents.ResultsThere was a significant difference between all three groups in urinary tract complications: group 1 – 32%, group 2 – 11.6% and group 3 – 7%. The p-value of 0.01 shows statistical significance between group with DJ stents and the group without DJ stents. Urinary tract infection occurred in 25.5% in the first group, 11.6% in the second group and 3.6% in the third group. Here, too, the p-value shows statistical significance between the group with DJ stents and the group without DJ stents. Ureteral injury, on the other hand, occurred rarely and no statistically significant difference was found between group 3 and the total population, 3.6% versus 2.5%. In group 1, the injury rate was minimally higher, 6.4%. After comparing groups 1 and 2 with group 3, there was also no significant difference in ureter injury (6.4% vs. 3.6%, p = 0.42).ConclusionsThe authors of this study recommend that DJ stent insertion should not be part of the general preoperative preparation.