Endometriosis Nodules Research Articles

Douglas Pouch Fluid Improves the Accuracy of Transvaginal Ultrasound in the Diagnosis of Uterosacral Ligaments Deep Infiltration Endometriosis: A Prospective Study.

To compare the accuracy of transvaginal ultrasound (TVUS) with laparoscopy in detecting and characterizing uterosacral ligament (USL) nodules of deep infiltrative endometriosis (DIE) between patients with and without pouch of Douglas (POD) fluid. This prospective study was conducted between June 2021 and July 2023. We included patients from the Second People's Hospital of Shenzhen with two TVUS tests: no POD fluid on the first TVUS test and POD fluid on the second TVUS test. POD fluid was obtained in two ways: naturally occurring fluid during the luteal phase of the menstrual cycle and SonoPODography. Laparoscopic results are the gold standard. To compare the diagnostic performance of TVUS in the diagnosis of DIE on USLs with and without POD fluid. We included 42 patients with a mean age of 36.4 ± 5.4 years. The maximum length diameter for DIE nodules on USLs with and without POD fluid was 13.3 ± 3.3 mm and 10.2 ± 2.5 mm (P < .001), respectively, while the depth of infiltration was 8.1 ± 2.4 mm and 6.1 ± 1.4 mm (P < .001), respectively. When compared to laparoscopic findings, TVUS findings with and without POD fluid resulted in a sensitivity, specificity, accuracy, positive predictive value, negative predictive value area under the curve, and Cohen kappa of 92.3%, 93.8%, 92.9%, 96.0%, 88.2%, 0.930, and 0.850 and 61.5%, 93.8%, 73.8%, 94.1%, 50.0%, 0.766, and 0.499, respectively. Laparoscopy showed USL involvement in up to 59.5% of patients. With or without fluid, the most common ultrasound features of DIE lesions were USL thickening, irregular morphology, clear boundaries, low echo, and no blood flow signal. For patients with clinical suspicion of DIE, TVUS with POD fluid has a higher accuracy for diagnosing USL DIE than TVUS without POD fluid.

Evaluating the safety of high-intensity focused ultrasound treatment for rectal endometriosis: results from a French prospective multicentre study including 60 patients.

Is increasing the intensity of high-intensity focused ultrasound (HIFU) by 30% in the treatment of rectal endometriosis a safe procedure? This study demonstrates the safety of a 30% increase in the intensity of HIFU in the treatment of rectal endometriosis, with no Clavien-Dindo Grade III complications overall, and namely no rectovaginal fistulae. A feasibility study including 20 patients with rectal endometriosis demonstrated, with no severe complications, a significant improvement in digestive disorders, dysmenorrhoea, dyspareunia, and health status, although the volume of the endometriosis nodule did not appear to be reduced. A prospective multicentre cohort study was conducted between 2020 and 2022 with 60 patients with symptomatic rectal endometriosis. Following the failure of medical treatment, HIFU treatment was offered as an alternative to surgery. As the main objective of this study was to examine safety, all adverse events observed during the 6 months of follow-up were analysed and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) and Clavien-Dindo classifications. Secondary objectives included evaluating the evolution of symptoms using validated questionnaires: gynaecological and digestive pain symptoms with a visual analogue scale, health status with the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire, average post-operative daily pain level, and analgesic medication required in the 10 days following treatment. MRI was also performed at Day 1 to detect early complications. Finally, we performed a blinded MRI review of the evolution of the nodule at 6 months post-treatment. The procedure was performed under spinal anaesthesia for 30% of the patients. The median duration of treatment was 32 min. Fifty-five patients left the hospital on Day 1. MRI scans performed on Day 1 did not highlight any early-onset post-operative complication. Using the Clavien-Dindo classification, we listed 56.7% Grade I events, 3.4% Grade II events, and no events Grade III or higher. At 1, 3, and 6 months, all gynaecologic, digestive and general symptoms, as well as health status, had significantly improved. The evolution of the nodule was also significant (P < 0.001) with a 28% decrease in volume. The main objective was safety and not effectiveness. The study was not randomized and there was no control group. HIFU treatment for rectal endometriosis results in an improvement of symptoms with low morbidity; as such, for selected patients, it could be a valuable alternative to surgical approaches following the failure of medical treatment. The study was funded by the company EDAP TMS. Professors Dubernard and Rousset are consultants for EDAP TMS. Dubernard received travel support from EDAP-TMS. Dr F. Chavrier received industrial grants from EDAP-TMS. He has developed a device for generating focused ultrasonic waves with reduced treatment time. This device has been patented by EDAP-TMS. Dr Lafon received industrial grants from EDAP-TMS; he declares that EDAP-TMS provided funding directly to INSERM to support a young researcher chair in therapeutic ultrasound, which is unrelated to the current study. ClinicalTrials.gov identifier NCT04494568.

A 24-Months Follow-Up Study of Individuals With Endometriosis Using Transvaginal Ultrasound

Study ObjectiveTo investigate the progression of deep infiltrating endometriosis (DIE) using transvaginal ultrasound surveillance of patients undergoing conservative management. DesignRetrospective single cohort. SettingAustralian tertiary university hospital Patients122 women with endometriosis proven on transvaginal ultrasound who had not undergone surgical management. InterventionsThe progression of endometriosis lesions demonstrated on transvaginal ultrasound in women receiving conservative management over the course of 24 months. Measurements and Main Results122 patients fulfilled the inclusion criteria. All women had two ultrasounds that were performed at least 6 months apart. The median follow up time was 490.5 days (255.4 - 725.6). At second scan, 22% (95% CI: 15-30%) of cohort experienced an increase in the number of endometriosis nodules compared to first scan, with 51% (95% CI: 42-60%) remaining static while 27% (95% CI: 19-35%) experienced a decrease. While there was no statistically significant difference in the volumes of uterosacral ligament, retro cervical and bowel endometriosis, endometrioma volumes were significantly lower at second scan (Median = 3.24 mL, IQR = 0.6 - 16.87) as compared to the first scan (Median = 7.41 mL, IQR = 2.04 - 28.95), p<0.001. ConclusionIndividuals with deep infiltrating endometriosis are unlikely to see significant disease progression over time. Both surgical and non-surgical interventions are effective in managing endometriosis in terms of endometriotic nodule size and number, as measured by ultrasound.

Long-term outcomes after percutaneous cryoablation of abdominal wall endometriosis.

To retrospectively evaluate the long-term outcomes after percutaneous cryoablation of abdominal wall endometriosis (AWE). The Institutional Review Board approved this retrospective observational review of 40 consecutive patients, of a median age of 37years (interquartile range [IQR] 32-40years), presenting with a total of 52 symptomatic AWE nodules. All patients underwent cryoablation between January 2013 and May 2022 with a minimum follow-up period of 12months. Outcomes were assessed using a visual analog scale (VAS) that measured pain, as well as by magnetic resonance imaging (MRI). The pain-free survival rates were derived using the Kaplan-Meier estimator. Adverse events were analyzed and graded using the classification system of the Cardiovascular and Interventional Radiological Society of Europe. The median follow-up time was 40.5months (IQR 26.5-47.2months). The median VAS score before cryoablation was 8 (IQR 7-9). Complete relief of symptoms was documented in 80% (32/40) of patients at 3months after initial cryoablation and correlated with the absence of residual endometriosis nodules on MRI. The median pain-free survival rates were 89.2% [95% CI, 70.1-96.4%] at 36months and 76.8% [95% CI, 55.3-83.8%] after 60months. No patient or lesion characteristics were found to be prognostic of failure. No major adverse events or side effects were reported in long term. Cryoablation safely and effectively afforded long-term pain relief for patients with AWE nodules. AWE cryoablation was found to be safe and effective in the long-term. • Cryoablation is highly effective with 80% of patients experiencing complete relief of AWE symptoms after a single procedure. • Cryoablation is safe without long-term adverse events or side effects. • The median pain-free survival rates are 89.2% at 36months and 76.8% at 60months.

Dienogest in conjunction with GnRH-a for postoperative management of endometriosis.

Objective: The aim of this study is to assess the postoperative efficacy of the combined administration of dienogest (DNG) and gonadotropin-releasing hormone agonists (GnRH-a) in patients diagnosed with endometriosis (EMS), while acknowledging the extensive use of DNG in the extended therapeutic management of EMS. Methods: In this retrospective study, a cohort of 154 patients who underwent conservative surgical intervention for EMS were scrutinized. The cohort was stratified into two distinct groups based on their prescribed pharmacological regimens. Group A, 70 patients received postoperative oral administration of DNG at a dosage of 2mg/day, whereas Group B, 84 patients underwent treatment involving 3 to 4 injections of GnRH-a post-surgery, followed by DNG therapy. Parameters assessed included pelvic pain visual analog scale (VAS) scores, quality of life metrics (EHP-5), and the incidence of adverse reactions within both groups. Results: Both groups exhibited sustained low VAS scores following the prescribed treatments. The predominant occurrence of adverse bleeding patterns manifested predominantly within the initial 6months of the treatment. Notably, Group B demonstrated a significantly diminished of experiencing frequent and irregular bleeding in comparison to the DNG group (20.0% vs. 8.3%, 12.9% vs. 3.6%, p < 0.05). The administration of GnRH-a did not exacerbate the impact on bone health. Subsequent to health promotion interventions, the incidence of weight gain in both groups declined to 7.1% during the 6-month follow-up (p < 0.05). Group B exhibited a 100% satisfaction rate with the treatment, concomitant with a noteworthy reduction in EHP-5 scores (p < 0.05). Patients with deep infiltrating endometriosis (DIE) nodules displayed marginally higher postoperative VAS scores than their non-DIE counterparts (0.89 ± 0.96 vs. 0.49 ± 0.78). However, with sustained medication use, pain scores within the DIE group exhibited a continual decrease, maintaining a low level of 0.29 ± 0.67 at 12months and beyond. Conclusion: The short-term adjunctive use of GnRH-a prior to DNG treatment postoperatively in patients with EMS proves efficacious in mitigating early adverse bleeding, enhancing patient adherence, and improving overall quality of life. Notably, this therapeutic approach demonstrates favorable safety profiles and is equally effective in patients with DIE.

Ultrasonographic characterization of parametrial endometriosis: a prospective study

ObjectiveTo study the ultrasonographic diagnostic accuracy and characteristics of parametrial endometriosis comprehensively. DesignThis prospective study enrolled patients with suspected deep endometriosis scheduled for laparoscopic surgical treatment. Preoperative ultrasonographic examinations were performed following the International Deep Endometriosis Analysis criteria. The study aimed to evaluate the presence of parametrial endometriosis and its ultrasonographic characteristics, using surgical diagnosis as the reference standard. Additionally, indirect signs of deep endometriosis and concomitant deep endometriosis nodules associated with parametrial involvement were identified, assessing their predictive significance in anterior, lateral, and posterior parametrial areas. SubjectsPatients with suspected deep endometriosis scheduled for surgical treatment. Intervention/ExposureStandardized preoperative ultrasonographic examination. Main Outcome MeasuresThe diagnostic accuracy of transvaginal ultrasound in identifying parametrial endometriosis, including sensitivity and specificity. Ultrasonographic characteristics of parametrial nodules, prevalence in distinct parametrial areas, and associations with indirect deep endometriosis signs and concomitant nodules. ResultsSurgical confirmation of parametrial nodules was observed in 105 out of 545 patients (18.5% left, 17.0% right). Transvaginal ultrasound demonstrated a sensitivity of 77.1% (95% CI 68.0–84.8%) and specificity of 99.1% (95% CI 67.7–99.8%). Parametrial nodules typically exhibited characteristics such as a mild hypoechoic appearance (83.6%), starry morphology (74.7%), irregular margins (70.2%), and low vascularization. The posterior parametrium was the most common location (52.2%), followed by the lateral (41.0%) and anterior parametrium (6.8%). Concomitant deep nodules in the rectum (63.5%) and infiltrating the rectovaginal septum (56.5%) were significantly more prevalent in patients with parametrial involvement (both p<0.001). Indirect signs of deep endometriosis, such as ovaries fixed to the uterine wall (71.8%) and the absence of a posterior sliding sign (51.8%), were also more common in women with parametrial DE nodules (both p<0.001). Hydronephrosis, though relatively uncommon in patients with parametrial involvement (8.2%), was largely detected in lateral parametrial nodules (70.0%). ConclusionThis study represents a systematic ultrasonographic characterization of parametrial endometriosis, comprehensively assessing the diagnostic accuracy of transvaginal ultrasound in identifying parametrial involvement within a sizable cohort of patients with preoperative suspicion of deep endometriosis.

Adenomyosis and Endometriomas &amp; Assessing the Rectosigmoid Colon

Endometriosis is a common and often debilitating gynaecological disorder that affects 5-10% of women. The prevalence is even higher among women with symptoms of endometriosis. Approximately 80% of women suffering from endometriosis have superficial lesions while 20% have deep infiltrating endometriosis. Laparoscopy has always been considered the gold standard for diagnosing endometriosis as it allows diagnosis of both forms of endometriosis and often immediate removal of superficial endometriosis. The removal of deep infiltrating endometriosis is however significantly more complex, particularly when pouch of Douglas obliteration, bowel nodules or bladder nodules are present. Unless it was diagnosed preoperatively, the removal can usually not be completed because a multidisciplinary approach is often required with the involvement of a urologist or a colorectal surgeon. Over the last 15 years it has been well established in the literature that transvaginal ultrasound allows preoperative diagnosis of deep infiltrating endometriosis. The preoperative diagnosis of DIE with transvaginal ultrasound facilitates a more patient-centred approach to endometriosis management because an accurate preoperative documentation of the location and extent of the disease allows for referral to an endometriosis expert and/or bowel surgeon, better preoperative planning, less repetitive surgery, and better outcomes for women. The presentation on ‘Endometriomas and Adenomyosis’ will highlight the importance of these findings as red flags for the presence of deep endometriosis but also touch on how these conditions change over time with pregnancy and menopause. The presentation on ‘Assessing the rectosigmoid colon’ gives an overview on how to systematically assess the rectosigmoid for the presence of deep endometriosis nodules, and when this assessment must be included in the assessment of the pelvis.

Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series

To assess the long-term risk of repeated surgery in women undergoing complete excision of endometriosis by an experienced surgeon and to identify circumstances leading up to repeat surgery. Retrospective study based on data recorded in a large prospective database. University Hospital. A total of 1,092 patients managed for endometriosis, from June 2009 to June 2018, by one surgeon. Complete excision of endometriosis lesions. The recording of a repeated surgery linked to endometriosis performed during follow-up. Endometriosis was exclusively superficial in 122 patients (11.2%) and 54 women (5%) had endometriomas without associated deep endometriosis nodules. Deep endometriosis was managed in 916 women (83.9%), leading to infiltration or not of the bowel in 688 (63%) and 228 (20.9%) patients, respectively. A majority of patients were managed for severe endometriosis infiltrating the rectum (58.4%). Mean and median follow-up was 60 months. A total of 155 patients underwent a repeated surgery relating to endometriosis; 108 procedures were required because of recurrences (9.9%), 39 surgeries were related to the management of infertility by assisted reproductive techniques (3.6%), and in 8 surgeries, a direct relationship between surgery and endometriosis was probable but not certain (0.8%). The majority of procedures involved hysterectomy for adenomyosis (n=45, 4.1%). The probability of requiring repeated surgery at 1, 3, 5, 7, and 10 years was 3%, 11%, 18%, 23%, and 28%, respectively. Cox's multivariate model identified postoperative pregnancy and hysterectomy as being statistically significant independent predictors for a reduction in the probability of having a repeated surgery, after adjustment on continuous postoperative amenorrhea, the main localization of the disease, and management for endometriosis infiltrating the rectum during the first surgery. Up to 28% of patients may require a repeated surgical procedure during the 10 years after complete excision of endometriosis. Conservation of the uterus is followed by an increased risk of repeated surgery. The study is based on outcomes resulting from a single surgeon, which limits the generalizability of results.

Robotic assisted rectal disk excision: the 3-cm diameter cut off may be abandoned

To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm. Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data. A tertiary referral center. Patients undergoing excision of rectal endometriosis. Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach. Feasibility of the technique. The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler's jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required. The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion.

Anatomical Pitfalls of Excision of Deep Endometriosis Nodules of the Sciatic Nerve: A three-dimensional Reconstruction and Surgical Educational Video

To highlight the anatomical keys to safely performing an excision of deep endometriosis nodules of the sciatic nerve DESIGN: We present a didactic video combining an anatomical three-dimensional reconstruction of the pelvis using the Anatomage table and a surgical dissection video of the removal of deep endometriosis nodules of the left sciatic nerve [1]. The patient's approval was obtained. The patient consented that this surgical video be used for publication. Tertiary referral center. To reach this specific area, we must localize precise anatomical pitfalls [2,3]. Taking the external iliac vessels as an anatomical plane of reference, we can divide anatomical structures into lateral and medial. During the first step of the procedure, we open the latero-pelvic peritoneum covering the external iliac artery. This step allows the identification of the lateral anatomic keys. Lateral anatomic keys are represented by: (1) the genito-femoral nerve, an element which is superficially situated between the psoas muscle and external iliac artery, and (2) the obturator nerve (Video Still 1), which is deep and is located within the ilio-lumbar fossa. To enter it, a dissection between the psoas muscle and external iliac artery and vein must be performed. At this point, particular attention must be paid to the obturator artery that runs below the obturator nerve. In this fossa, the lumbosacral trunk is easily identified just below the obturator nerve; it lies at this level on the iliac bone. Then the opening of the posterior leaf of the broad ligament is realized. Therefore, we access the medial anatomic keys: (1) the ureter, and (2) the umbilico-artery trunk with the umbilical and uterine artery. In the opening of the posterior leaf, we can find the obturator nerve and lumbosacral trunk again. Finally, following the umbilical artery (that is the first branch of the internal iliac artery), we discover the internal iliac artery and vein. A very careful dissection of these vessels must be done to avoid big hemorrhages, which can be life-threatening [4-6]. In the plane below the internal iliac artery and vein, we access the sacral roots S1, S2, and S3 (Video Still 2), which join the lumbosacral trunk (lying on the piriformis muscle) to form the ischiatic nerve [7]. At this level, the ischiatic nerve exits through the infra-piriform foramen behind the ischiatic spine and sacrospinous ligament toward the gluteal area in an oblique way [8]. Two other elements may be seen: the pudendal nerve exiting the pelvis behind the sacrospinous ligament in a craniocaudal way and the posterior femoral cutaneous nerve. During this dissection, the autonomous system must be spared as usual to avoid functional sequelae. Removal of deep endometriosis nodules of sciatic nerves is a challenging procedure. Because few surgeries are specifically dedicated to the sciatic area, the specific anatomy of the region is poorly taught and known. However, pelvic anatomical knowledge is indispensable to the safe removal of nodules of sciatic nerves. The main advantage of this anatomical 3D reconstruction is the possibility of visualizing the deep pelvic anatomy in a laparoscopic position. Surgeons must be aware of both somatic and autonomous pelvic nerve anatomy within the retroperitoneal spaces and the great vessels surrounding them.

Laparoscopic Approach in Bladder Endometriosis, Intraoperative and Postoperative Outcomes.

Endometriosis is a benign condition affecting 10-20% of women at reproductive age. The urinary tract is affected in 0.3-12.0% of women with endometriosis and in 19.0-53.0% of women with deep infiltrating endometriosis. The bladder is the most commonly affected organ in the urinary tract with a prevalence of up to 80%. Bladder endometriosis is defined as the occurrence of endometrial glands and stroma in the detrusor muscle. The aim of the study was to present the detailed technique and intraoperative and postoperative outcomes of laparoscopic resection of bladder endometriosis. This was a retrospective study analyzing all surgical procedures, carried out at the Academic Hospital Cologne Weyertal between January 2014 and December 2022. In total 23,862 surgical reports were analyzed, and only patients (n=33 patients) with bladder endometriosis were included in the study. Follow-up was performed in 25 patients by phone contact. Twenty-three patients (92%) reported an improvement of symptoms, especially of dysuria, and an increase of quality of life. Only two patients (8%) reported no change in symptoms (dysmenorrhea and dyspareunia). Two patients (8%) reported bladder dysfunction. Mild postoperative pollakiuria was reported by two patients (8%). Four patients (with mild bladder dysfunction and pollakiuria) were satisfied with postoperative results owing significant improvement of symptoms and increasing the quality of life. Surgical treatment of bladder endometriosis can be performed by a gynecologist. In cases where a ureteroneocystostomy is required or the localization of endometriosis nodule is unfavorable, an intervention by a multidisciplinary team is recommended. Laparoscopic partial cystectomy and shaving seem to be an appropriate method for improving urinary symptoms. This surgical approach requires excellent laparoscopic skills.

Excision of Deep Rectovaginal Endometriosis Nodules with Large Infiltration of Both Rectum and Vagina: What Is a Reasonable Rate of Preventive Stoma? A Comparative Study

To compare postoperative complications and rectovaginal fistula rate in women undergoing excision of large rectovaginal endometriosis requiring concomitant excision of rectum and vagina during 2 time periods with differing policies for preventive stoma confection. Retrospective before-and-after comparative cohort study on data prospectively recorded in a database. Patients managed from September 2018 to March 2020 (first period) were compared with those managed from April 2020 to June 2022 (second period). Endometriosis Institute. One hundred sixty-eight patients presenting with deep endometriosis infiltrating the rectum and vagina, with lesions more than 3 cm in diameter during 2 consecutive time periods with differing policies regarding use of preventive stoma. Rectal disc excision or colorectal resection, concomitantly with large vaginal excision. A total of 87 and 81 women received surgery during the first and the second period, respectively, during which the rate of preventive stoma was, respectively, 32.2% and 8.6%. Deep rectovaginal nodule characteristics were comparable. The mean height (SD) of rectal sutures after disc excision and colorectal resection were, respectively, 6.5 cm (2.3 cm) and 7.2 cm (3.8 cm). Rectovaginal fistula was recorded in 17 patients, corresponding to an overall rate of 10.1%. The rates of rectovaginal fistula in the group of patients with and without preventive stoma, regardless of the period in which surgery was performed, were 11.4% and 9.8%, respectively (p=.76). The rates of fistula recorded during the first and the second period were, respectively, 9.2% and 11.1% (p=.80), and that of overall early main complications were 31% and 29.6% (p=.84). Regression logistic model identified an independent relationship between smoking and rectovaginal fistula (adjusted odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-14) after adjustment for the period (adjusted OR 1.4, 95% CI 0.4-4.9 related to the second period), stoma confection (adjusted OR 1.8, 95% CI 0.5-7.1 related to stoma confection), robotic surgery (adjusted OR 1.7, 95% CI 0.3-10.1 related to robotic assistance), and type of rectal surgery (adjusted OR 0.4, 95% CI 0.1-1.4 related to disc excision when compared with colorectal resection). No statistically significant differences were found concerning risk of rectovaginal fistula in women with rectovaginal endometriosis requiring large rectal and vaginal excision after a decision to no longer routinely perform preventive stoma.

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

To report a large series including women managed by disk excision using end-to-end anastomosis (EEA) circular transanal stapler to assess the feasibility of the technique, the features of nodules suitable for removal by disk excision, and the rate of major early complications. Retrospective study on data prospectively recorded in 2 databases. Two tertiary referral centers. A total of 492 patients undergoing surgery for rectal endometriosis from May 2011 to June 2022. Rectal disk excision using the EEA stapler. Disk excision using EEA was performed in 492 patients (24.2%) of 2,029 women receiving surgery for deep endometriosis infiltrating the rectum during the 11-year study period. Deep endometriosis involved low rectum in 11% and mid rectum in 55.3%. The diameter of rectal nodules exceeded 3 cm in 65.9%. Mean operative time was 2 hours, mean diameter of rectal patches removed was 41 ± 11 mm, and the mean rectal suture height was 9.2 ± 5.5 cm. The presence of microscopic foci on the edges of rectal patches was identified in 30.2% of cases. Rectal fistula was recorded in 20 patients (4%). The distance from the anal verge was significantly lower in patients with fistula than women with no fistula (5.9 ± 2 cm vs 9.2 ± 5.6 cm, p=.027). Follow-up ranged from 1 to 120 months, with a median value of 36 months. Magnetic resonance imaging in 3 patients during follow-up revealed a recurrent nodule infiltrating the previous stapled line (0.6%) after a postoperative delay of, respectively, 36, 48, and 84 months. Disk excision using the EEA stapler is suitable in nodules >3 cm if surgeons ensure deep shaving of the rectum, to allow complete inclusion of the shaved area into the stapler jaws. Postoperative rectal recurrences seem incidental, whereas bowel leakage rate is comparable with that after colorectal resection. This technique is suitable in almost a quarter of patients managed for rectal endometriosis nodules and is therefore a valuable technique that warrants more widespread use.

7489 Conjunction of Cystoscopy and Robotic-Assisted Bladder Trigone Endometriosis Nodule Removal with Ureteral Preservation

<h3>Study Objective</h3> Demonstrate tips for successful execution of robotic-assisted resection of large bladder trigone endometriosis nodule while preserving the ureters. <h3>Design</h3> Stepwise demonstration with narrated video footage. <h3>Setting</h3> An academic-tertiary-care hospital. <h3>Patients or Participants</h3> 36-year-old G0 with symptomatic full-thickness ill-defined nodule located in the posterior wall and trigone of the urinary bladder with anterior cul-de-sac endometriosis. <h3>Interventions</h3> Cystoscopy was first performed, and large mid-trigonal endometriosis nodule was noted to be extending within millimeters of the ureteral orifices. Bilateral ureteral orifices were identified, and double-J ureteral stents were sequentially guided up to the kidneys. The robotic instruments were docked, and inspection of the pelvic space conducted. The peritoneum lateral to the bladder bilaterally was incised to better define the edges of the bladder. Bilateral distal ureters were dissected out circumferentially and the dissection was carried distally. Flexible cystoscopy with Firefly technology was then utilized to define precise location and extent of the trigonal nodule in effort to minimize removal of uninvolved bladder tissue and preserve ureters. Using cystoscopic-guidance, the dissection was first carried through the serosal and muscular layers, and once the circumference of the nodule had been defined, we proceeded with the mucosal layer. The bladder lumen was entered, and the nodule meticulously excised to avoid injury to the intramural ureters as the dissection was carried distally. Bilateral ureters were preserved despite the close proximity to ureteral orifices and also maintain enough bladder tissue for bladder closure. Once resection was completed, running 3-0 V-loc sutures were utilized in 2-layer closure. <h3>Measurements and Main Results</h3> Patient was discharged in one-day with Foley catheter and ureteral stents with minimal pain. Cystogram at 10 days postop was negative for leak and Foley catheter was removed. <h3>Conclusion</h3> Robotic-assisted resection of bladder trigone endometriosis with cystoscopic guidance offers the most precise and delicate dissection of large bladder trigone endometriosis nodules, thus providing optimal bladder trigone and ureteral preservation.

Upper Vaginectomy for Rectovaginal Endometriosis: Manual Guidance for Deep Rectovaginal Dissection

<h3>Study Objective</h3> The objective of this video is to demonstrate a robotic-assisted excision of a rectovaginal endometriosis nodule. <h3>Design</h3> This case involves a 31-year-old nulligravid patient with dysmenorrhea, dyschezia, and dyspareunia. <h3>Setting</h3> This surgery was performed at an academic tertiary care center. The patient was in the dorsal lithotomy position and the robot was docked from the patient's left side. <h3>Patients or Participants</h3> The patient had a palpable rectovaginal nodule, which was confirmed with magnetic resonance imaging. <h3>Interventions</h3> The patient underwent diagnostic laparoscopy which showed bilateral pelvic sidewall endometriosis and cul-de-sac obliteration. The ovaries and fallopian tubes were normal. Pelvic sidewall dissection with extensive peritoneal stripping was required to remove all of the endometriosis implants. Bilateral uterosacral ligaments were excised. Within the posterior cul-de-sac, the rectocervical nodule was not visible due to tethering of the rectum. The rectovaginal space was carefully dissected with monopolar scissors. Despite opening the left para-rectal space, the nodule was still not visible. An assistant placed a single digit into the posterior fornix to mobilize the nodule to guide the surgeon. The surgeon dissected the rectovaginal space until the fibrosis was visualized abdominally. Chocolate cyst fluid was expelled, consistent with deep infiltrating endometriosis. Full-thickness entry into the vagina was required, and the colpotomy was closed with running barbed suture. After complete excision of endometriosis, a flat-tire test was performed to confirm rectal integrity. The surgery was then completed. <h3>Measurements and Main Results</h3> The patient did well and was discharged home from the recovery room. She had significant improvement in her pain, and her recovery proceeded without complications. <h3>Conclusion</h3> This surgical video demonstrates the importance of careful pre-operative planning and intra-operative use of resources to accomplish complete excision of endometriosis. Surgeons often need to be creative when tissue planes are obscured, and the target pathology is not clearly visible.

Ultrasound–integrated robotic identification of an isolated deep infiltrating endometriosis nodule of the sigmoid colon

In cases of isolated sigmoid colon deep infiltrating endometriosis (DIE), intraoperative inspection might not be enough for delineation of the lesion. Here, we present a novel approach where an intraoperative ultrasound–integrated robotic system is utilized to scan the sigmoid colon for identifying the affected segment to limit resection only to the involved area (Figure 1). Different surgical approaches including shaving, discoid excision, and segmental resection can be utilized to treat rectosigmoid DIE.

What is the accuracy of transvaginal ultrasound for endometriosis mapping prior to surgery when performed by a sonographer within an outpatient women's imaging centre?

This study aimed to assess the accuracy of transvaginal ultrasound (TVUS) for the mapping of endometriosis before surgery when performed by sonographers in an outpatient women's imaging centre. A prospective longitudinal cohort study was performed. The study group comprised of 201 women who underwent a comprehensive TVUS assessment, performed by a sonographer. Laparoscopy was performed as the reference standard. Complete TVUS and surgical data were available for 53 women who were included in the final analysis. Endometriosis was confirmed at a surgery in 50/53 (94.3%) participants, with 25/53 (47.2%) having deep endometriosis (DE) nodules and/or endometriomas present. TVUS for mapping of DE had an overall sensitivity of 84.0%, specificity of 89.3%, PPV of 87.5%, NPV of 86.2%, LR+ of 7.85, LR- of 0.18, and accuracy of 86.8% (P < 0.001). Ovarian immobility had poor sensitivity for detecting localised superficial endometriosis, DE, adhesions, and/or endometriomas (Left = 61.9% and right = 13.3%) but high specificities (left = 87.5% and right = 94.7%). Site-specific tenderness had low sensitivities and moderate specificities for the same. All soft markers of endometriosis failed to reach statistical significance except for left ovarian immobility (P = <0.001). Sonographers well experienced in obstetric and gynaecological imaging, working in an outpatient women's imaging setting can accurately map DE; however, the performance of soft markers for detection of SE was poor.

The Use of near Infra-Red Radiation Imaging after Injection of Indocyanine Green (NIR-ICG) during Laparoscopic Treatment of Benign Gynecologic Conditions: Towards Minimalized Surgery. A Systematic Review of Literature.

Background and Objectives: To assess the use of near infrared radiation imaging after injection of indocyanine green (NIR–ICG) during laparoscopic treatment of benign gynecologic conditions. Materials and Methods: A systematic review of the literature was performed searching 7 electronic databases from their inception to March 2022 for all studies which assessed the use of NIR–ICG during laparoscopic treatment of benign gynecological conditions. Results: 16 studies (1 randomized within subject clinical trial and 15 observational studies) with 416 women were included. Thirteen studies assessed patients with endometriosis, and 3 studies assessed non-endometriosis patients. In endometriosis patients, NIR–ICG use appeared to be a safe tool for improving the visualization of endometriotic lesions and ureters, the surgical decision-making process with the assessment of ureteral perfusion after conservative surgery and the intraoperative assessment of bowel perfusion during recto-sigmoid endometriosis nodule surgery. In non-endometriosis patients, NIR–ICG use appeared to be a safe tool for evaluating vascular perfusion of the vaginal cuff during total laparoscopic hysterectomy (TLH) and robotic-assisted total laparoscopic hysterectomy (RATLH), and intraoperative assessment of ovarian perfusion in adnexal torsion. Conclusions: NIR–ICG appeared to be a useful tool for enhancing laparoscopic treatment of some benign gynecologic conditions and for moving from minimally invasive surgery to minimalized surgery. In particular, it might improve treatment of endometriosis (with particular regard to deep infiltrating endometriosis), benign diseases requiring TLH and RATLH and adnexal torsion. However, although preliminary findings appear promising, further investigation with well-designed larger studies is needed.

Cystoscopic-guided Robotic Resection of Bladder Trigone Endometriosis Nodule with Ureteral Preservation

To demonstrate tips and tricks for the successful execution of robotic-assisted resection of a large bladder trigone endometriosis nodule while preserving the ureters. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 36-year-old G0P0 with a symptomatic full-thickness ill-defined nodule located in the posterior wall and trigone of the urinary bladder with anterior cul-de-sac endometriosis. Urinary tract endometriosis is a rare entity occurring in 1% of women with endometriosis and may involve the bladder and/or the ureters [1]. Bladder endometriosis (BE) frequently coexists with endometriosis in other locations such as the ovaries or peritoneum. Frequently seen lower urinary tract symptoms of BE include hematuria, frequency, and dysuria [2]. Previous literature has demonstrated the feasibility of a laparoscopic approach to BE in the trigone. However, there has yet to be any publications investigating the feasibility of robotic resection of bladder trigone endometriosis [3]. Cystoscopy was first performed, and the large mid-trigonal endometriosis nodule was noted to be extending within millimeters of the ureteral orifices. Bilateral ureteral orifices were identified, and double-J ureteral stents were sequentially guided up to the kidneys. The peritoneum lateral to the bladder bilaterally was incised to better define the edges of the bladder. Next, bilateral distal ureters were dissected out circumferentially, and the dissection was carried distally to the posterior bladder wall. Flexible cystoscopy with Firefly technology was then utilized to define the precise location and extent of the trigonal nodule to minimize removal of uninvolved bladder tissue and preserve the ureters. Using cystoscopic guidance, the dissection was first carried through the serosal and muscular layers, and once the circumference of the nodule had been clearly defined, we proceeded with the mucosal layer. The bladder lumen was entered, and the nodule was meticulously excised to avoid injury to the intramural ureters as the dissection was carried distally. We were able to preserve bilateral ureters despite the close proximity to ureteral orifices and also maintain enough bladder tissue for bladder closure. Once the resection of the trigonal nodule was completed, running 3-0 V-loc sutures were utilized in a 2-layer closure. The patient was discharged in 1 day with a Foley catheter and ureteral stents with reports of minimal pain. A cystogram at 10 days after the surgery was negative for leak, and the Foley catheter was removed. The ureteral stents were subsequently removed at 6 weeks after the surgery, and follow-up renal ultrasound demonstrated no hydronephrosis. Tips and tricks: (1) Utilizing robotic assistance in conjunction with cystoscopy aids the surgeon in precisely defining the boundaries of an endometriosis nodule and ureteral identification. (2) The precise dissection permitted by robotic-assisted surgery leads to greater tissue preservation of the bladder with complete endometriosis resection [4-6]. (3) Three-dimensional visualization provides depth of tissue analysis, which allows the surgeon to delicately dissect several centimeters of intramural ureter in the bladder wall and trigone. (4) Cystoscopy with Firefly technology guidance permits more precise localization compared with white light during dissection of the bladder nodule [7,8]. (5) The articulating instrumentation in the robotic surgical platform enables fine suturing technique [9,10]. Robotic-assisted resection of bladder trigone endometriosis with cystoscopic guidance may offer a precise and delicate dissection of large bladder trigone endometriomas, thus possibly providing optimal bladder trigone and ureteral preservation.

Long-term Outcomes Following Surgical Management of Rectal Endometriosis: Seven-year Follow-up of Patients Enrolled in a Randomized Trial

To compare functional outcomes, recurrence rate, and pregnancy likelihood in patients undergoing conservative or radical surgery for deep rectal endometriosis followed up for 7 years. Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013. A tertiary referral center. Fifty-five patients with deep endometriosis infiltrating the rectum. Patients underwent either segmental resection or nodule excision via shaving or disk excision, depending on randomization that was performed preoperatively using sequentially numbered, opaque sealed envelopes. The primary end point was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence, or bladder dysfunction 24 months after surgery. The secondary end points were values of gastrointestinal and overall quality of life scores. The 7-year recurrence rates (new deep endometriosis nodules infiltrating the rectum) in the excision vs segmental resection arms were 7.4 % vs 0% (p=.24). One of the symptoms included in the definition of the primary outcomes was recorded in 55.6% vs 60.7% of patients (p=.79). However, 51.9% vs 53.6% of patients considered their bowel movements as normal (p=.99). An intention-to-treat comparison of overall quality of life scores did not find a difference between the 2 groups 7 years after surgery. At the end of the 7-year study period, 31 of 37 patients who tried to conceive were successful (83.8%), including 27 pregnancies (57.4%) resulting from natural conception and 20 pregnancies (42.6%) resulting from assisted reproductive technology procedures. The pregnancy rate was 82.4% vs 85% in the 2 arms (p=.99). A 75.7% live birth rate was recorded. At the end of the follow-up, there were 15 women with 1 child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow-up, the reoperation rates were 37% and 35.7%, respectively, in each arm (p=.84). Among the 27 reoperation procedures during the follow-up period, 11 (40.7%) were for postoperative complications, 7 (25.9%) were necessary before assisted reproductive technology management, 8 (29.6%) were for recurrent abdominal or pelvic pain, and 1 (3.7%) was for midline ventral hernia after pregnancy. Our study did not reveal a considerable difference in terms of digestive functional outcomes, recurrence rate, reoperation risk, and pregnancy likelihood when conservative and radical rectal surgeries for deep endometriosis were compared 7 years after surgery. The postoperative pregnancy rate observed in our series was high.