Infiltrative Endometriosis Research Articles

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.

Excision of a Deeply Infiltrating Endometriosis Nodule and Neuroma Involving the Sacral Nerve Root Plexus Adjacent to the Ischial Spine

Study Objective Present a surgical video that demonstrates the use of anatomic landmarks and dissection techniques for the laparoscopic excision of deeply infiltrative endometriosis at the ischial spine. This video will highlight the anatomy relevant to performing a nerve sparing technique to minimize neurological sequelae when excising nodules adjacent to the sacral nerve plexus and inferior hypogastric nerve. Design Surgical Educational Video. Setting Tertiary Referral Center at an Academic Residency Program. Patients or Participants 30-yo G0P0 with cyclical dysmenorrhea, gluteal pain, & dyspareunia that presented with a 2cm deeply infiltrative endometriotic nodule at the level of the ischial spine. Interventions Laparoscopic excision of deeply infiltrative endometriotic nodule at the ischial spine utilizing a nerve sparing technique. Measurements and Main Results 3.5 × 1.7 × 1.8 cm endometriotic nodule was confirmed by pathology. Immunohistochemical findings of +CD-10 which is consistent with stroma surrounding endometriosis and +S-100 consistent with neuroma. Operative time 145 minutes. EBL 25mL. Conclusion Surgical excision of Deeply Infiltrative Endometriotic lesions at the level of the ischial spine present unique challenges. By employing knowledge of the anatomy of the sacral nerve root plexus in relation to the ischial spine, inferior hypogastric plexus, inferior hypogastric plexus, and avascular planes, safe nerve sparing excision can be accomplished. Present a surgical video that demonstrates the use of anatomic landmarks and dissection techniques for the laparoscopic excision of deeply infiltrative endometriosis at the ischial spine. This video will highlight the anatomy relevant to performing a nerve sparing technique to minimize neurological sequelae when excising nodules adjacent to the sacral nerve plexus and inferior hypogastric nerve. Surgical Educational Video. Tertiary Referral Center at an Academic Residency Program. 30-yo G0P0 with cyclical dysmenorrhea, gluteal pain, & dyspareunia that presented with a 2cm deeply infiltrative endometriotic nodule at the level of the ischial spine. Laparoscopic excision of deeply infiltrative endometriotic nodule at the ischial spine utilizing a nerve sparing technique. 3.5 × 1.7 × 1.8 cm endometriotic nodule was confirmed by pathology. Immunohistochemical findings of +CD-10 which is consistent with stroma surrounding endometriosis and +S-100 consistent with neuroma. Operative time 145 minutes. EBL 25mL. Surgical excision of Deeply Infiltrative Endometriotic lesions at the level of the ischial spine present unique challenges. By employing knowledge of the anatomy of the sacral nerve root plexus in relation to the ischial spine, inferior hypogastric plexus, inferior hypogastric plexus, and avascular planes, safe nerve sparing excision can be accomplished.

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.

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.

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.

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

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.

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.

Surgical Neuropelveology: Lateral Femoral Cutaneous Nerve Endometriosis. Laparoscopic Resection and Nerve Transplantation

To demonstrate the application of surgical neuroanatomic principles for the diagnosis and treatment of deep infiltrating endometriosis involving the lateral femoral cutaneous nerve. Video demonstration of laparoscopic lateral femoral cutaneous endometriosis resection with nerve transplant. Endometriosis infiltrating somatic nerves is a poorly known condition, which can cause severe neuropathic symptoms [1] and is often unrecognized with a subsequent treatment delay [1]. Intimate knowledge of pelvic neuroanatomy and expertise in minimally invasive surgery are essential to manage this challenging surgical scenario [2-4]. Thirty-six years old patient with primary infertility and chronic pelvic pain associated with dysmenorrhea, dyspareunia, dysuria, and dyschezia. Preoperative magnetic resonance imaging detected a 3-cm parauterine and a 2-cm retrocervical endometriosis nodule. Magnetic resonance imaging did not demonstrate pelvic nerve involvement. Preoperative neuropelveologic assessment demonstrated a significant hypoesthesia of the corresponding lateral femoral cutaneous nerve dermatome, representing the primary complaint. A swab test showed spotting areas of allodynia. These findings prompted us to investigate for a right lateral femoral cutaneous entrapment. Laparoscopy showed an endometriosis nodule infiltrating the right lateral femoral cutaneous nerve. A resection of the nerve was necessary, and a subsequent reconstruction with a collagen bovine neuro-guide was carried out. The operative time was 300 minutes, and the estimated blood loss was 150 mL. Hospital stay was 3 days. After 3 months, the patient showed a clinical improvement in the pain and hypoesthesia on the reconstructed nerve dermatome. Neuropelvic anatomic assessment should be considered during the preoperative evaluation for patients with endometriosis who have pelvic pain and neuropathy as part of the diagnostic process [5]. This unique case demonstrates that nerve resection and transplantation can be used in specific situations for neuropathy related to deep infiltrative endometriosis of pelvic nerves.

Imaging Diagnosis in Colorectal Endometriosis

Colorectal deep infiltrative endometriosis (DIE) can have a major impact on patient’s health and quality of life. Surgical treatment of colorectal DIE varies depending on the location and characteristics of the lesions, which is why the preoperative non-invasive diagnosis needs to be correct and complete. Multiple imaging methods are currently available, but their usefulness is still being studied, as none of them has proven itself perfect. In the present study we wanted to find out to what extent the combined use of magnetic resonance imaging (MRI), endorectal ultrasound (ERUS) and computed tomography-based virtual colonoscopy (CTC) helps perform the preoperative mapping of lesions. We conducted a retrospective study of prospectively collected data that included 49 patients operated for colorectal DIE. In identifying rectal nodules, MRI as a single diagnostic method was the most useful. When ERUS or CTC was added, the concordance between intraoperative and imaging results was very strong. CTC was the most useful in identifying sigmoid nodules. ERUS evaluates the depth of rectal nodules best. CTC assesses best the stenosis for both rectal and sigmoid nodules. Each method contributed to the completion of the diagnosis, so performing ERUS and CTC in addition to MRI seems to be preferable in patients with colorectal DIE.

High-intensity focused ultrasound: opportunities and prospects in the treatment of uterine fibroid and deep infiltrative endometriosis

This literature review is devoted to the use of focused ultrasound in gynecological practice as an alternative to the traditional surgical treatment of uterine fibroids and deep infiltrating endometriosis. According to available data, the effectiveness of the treatment of uterine fibroids with focused ultrasound varies widely, ranging from 16.4% to 93.0%. Due to the lack of prospective studies, it is not possible to draw reliable conclusions about the effect of ablation of uterine fibroid with focused ultrasound on fertility. However, unplanned pregnancies after such treatment occurred up to 19.5%, and in 66.3% of cases, pregnancies ended with the childbirth. Research results demonstrate that in 87% of cases, treatment of retrocervical infiltrative endometriosis using focused ultrasound is feasible. Further data accumulation is required to determine the range of patients with uterine fibroids and deep infiltrating endometriosis, to whom the treating technique could be most effective and safe.

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

The most common reason for patients with endometriosis seeking medical help is infertility, which affects 25-50% of patients with this disease. One of the essential factors of infertility in deep infiltrative endometriosis is the depletion of the ovarian reserve. To study the effect of deep infiltrative endometriosis on the state of the ovarian reserve in patients of reproductive age, as well as to assess the range of mutations in the PIK3CA gene among patients with infiltrative endometriosis. The main group consisted of 50 patients of reproductive age with deep infiltrative endometriosis, 18 of whom with ovarian endometriomas. The comparison group included 25 patients of reproductive age with inconsistency of the uterine scar after cesarean section. The level of anti-Mullerian hormone, follicle-stimulating hormone and estradiol in the blood was determined, as well as the number of antral follicles in the ovaries was counted during trans-vaginal ultrasound. The search for activating mutations of the PIK3CA gene was carried out by the method of new generation DNA sequencing in tissue samples of ovarian endometriomas and in biopsies of healthy ovarian tissue. The anti-Mullerian hormones level was lower in patients with infiltrative endometriosis than in patients in the comparison group by 1.0 ng/ml (2.6 ± 2.2 ng/ml in the main group, 3.6 ± 3.5 ng/ ml in the comparison group), however, the difference did not reach statistical significance, p&gt;0.05. The number of antral follicles according to ultrasound data was significantly lower in the main group (8.5 ± 4.5) than in the comparison group (12.2 ± 4.1), p=0.001. This difference was statistically significant both for patients with ovarian endometriomas (6.0 ± 4.2, p

Management of patients with urinary tract endometriosis by gynecologists

Objective: The aim was to report the postoperative outcomes of urinary tract endometriosis (UTE), which is a form of deep, infiltrative endometriosis, and to contribute to the literature by presenting our experience.Material and Methods: In the present study, patients who underwent surgery for endometriosis at our clinic between 2005 and 2019 and had a final pathological diagnosis of UTE were examined in detail. Patient information was retrospectively retrieved from the medical records. Data obtained pre-, peri-, and postoperatively were analyzed.Results: Mean age of the 70 patients included, according to the study criteria, was 32.73±7.09 years. Ureteral involvement alone was observed in 49% (n=34) of the patients, bladder involvement alone was observed in 24% (n=17) of the patients, and both bladder and ureteral involvement were observed in 27% (n=19) of the patients. Microscopic hematuria was detected in 16% (n=11) of the patients, whereas preoperative urinary tract findings, such as recurrent urinary tract infections, were detected in 19% patients (n=13). Of the patients, 56% (n=39) were identified with dyspareunia, 56% (n=39) with dysmenorrhea, and 30% (n=21) with pelvic pain. Visual analog scale score was significantly lower after the procedure (p<0.0001).Conclusion: Although postoperative results were typically considered positive, surgical method performed in deep infiltrative endometriosis should aim to preserve fertility, improve quality of life, and reduce the complication rate to a minimum.

Infiltrative endometriosis and adhesions: is there a cause-and-effect relationship?

Endometriosis is a chronic inflammation condition which is associated with adhesive processes in the small pelvis and pelvic pain syndrome. The pathogenesis of adhesions has similar components to the mechanism of endometrioid heterotopia. A comprehensive approach to the treatment of infiltrative endometriosis proves its effectiveness and is the most rational for this cohort of patients. The use of proteolytic enzymes, which has long been included in clinical practice, is a pathogenetically reasonable addition to the pharmacological strategy in obstetrician-gynecologist practice.

Facets of the problem of infiltrative endometriosis: from pathogenesis to effective therapy

Endometriosis remains an unresolved problem in gynecology. The urgency of the fight against this disease is due to its high prevalence among women of reproductive age. Endometriosis, especially its infiltration forms, affects all aspects of the patients life, its clinical manifestations pelvic pain, dyspareunia, dysmenorrhea, dyschezia, lead to social disadaptation, problems in personal life, depression and anxiety. The socio-economic burden of the disease motivates researchers to further study the pathogenesis of endometriosis and search for pathogenetically justified pharmacological solutions.

Modern views on endometriosis surgery. Literature review

Endometriosis is a disease associated with the presence of tissue morphologically similar to the endometrium outside the uterine cavity and it is an important medical and social problem. Statistical analysis of the endometriosis prevalence is complicated by polymorphism of manifestations a gradual increase of symptoms and a long period of time from the first symptoms to diagnosis. Manifestations of endometriosis are chronic pain, algodismenorea, dyspareunia, decreased fertility. All these manifestations worsen the quality of life and do not allow a woman to realize her reproductive potential. The most common forms of endometriosis are superficial peritoneal endometriosis, endometrioid ovarian cysts and deep infiltrative endometriosis. Treatment tactics depends on the form and stage of disease, woman's age, presence or absence of reproductive plans, previous treatment. It is possible to use both medical and surgical methods of treatment. Surgical methods can be organ-preserving and radical. The optimal surgical approach should weigh the risks of the surgery itself and the likelihood of recurrence in the radicalism absence. Modern techniques of surgical intervention are considered as one of the main methods of endometriosis treatment. Severe forms of endometriosis are a serious challenge for the surgical team, as chronic inflammation and adhesions alter the normal pelvis anatomy. Such operations often require the involvement of surgeons, urologists and other specialists, and the decision about final operation scope is made during the operation. Endometriosis surgery aims at the maximum possible in each case, the removal of pathological foci, which leads to relief of pain and increase the likelihood of reproductive plans. This article describes the rational scope of surgical interventions and optimal strategies for the management of patients with various forms of endometriosis. The data of international researches of efficiency of various methods of surgical interventions, influence of degree of radicalism on a disease course, probability of recurrence and quality of patient’s life are resulted.

18 Morbidity associated with cancellation of “elective” surgery during the COVID-19 pandemic: A case of deeply infiltrative endometriosis with colorectal involvement.

Describe a case of deeply infiltrative endometriosis with colorectal involvement requiring emergent surgical intervention as a result of failed medical management and cancellation of scheduled “elective” surgery during the COVID-19 pandemic.