Infiltrative Endometriosis Research Articles

Total Laparoscopic Rectosigmoidectomy without Bowel Exteriorization: A New Surgical Technique for Endometriosis.

Study Objective The purpose of this video is to demonstrate the technical bases of a new laparoscopic technique for segmental resection of the rectosigmoid without intestinal exteriorization. Design 19 patients with indication for segmental resection of the rectosigmoid, due to infiltrative endometriosis, underwent this less invasive technique compared to classic techniques, which involves the externalization of the bowel through minilaparotomy or vaginally for intestinal resection and anvil placement. Setting The insertion of the endoscopic linear stapler and anvil, as well as the removal of the surgical specimen, were carried out through the vaginal route using intentional colpotomy or opportunely during the hysterectomy or resection of endometriosis infiltrating the posterior vaginal fornix. Patients or Participants Between June 2019 and January 2020, 19 patients underwent total laparoscopic rectosigmoidectomy to treat deep endometriosis. Interventions A 0˚ optic was introduced in a 10mm trocar and 3 auxiliary 5mm punctures were used in the inferior abdomen. Lesions located in the rectosigmoid were identified. The segment was prepared and isolated. A linear endoscopic stapler vaginally inserted was used to section the bowel. The proximal stump had its suture line opened with scissors and a purse-string suture was used to fix the anvil vaginally inserted into the abdominal cavity. A transanal circular stapler was used together with the anvil for anastomosis. Measurements and Main Results There were no intraoperative complications. At postoperative, there was no evidence of leakage, need for transfusion nor readmissions for a period of up to 60 days. Conclusion The total laparoscopic technique prevents traction and externalization of the intestinal loop through minilaparotomy or the vagina. There was a decrease in surgical time, less traction of the mesentery, preserving of vascularization and innervation, thus improving the quality of the anastomosis and protecting the nerves of the intestinal segment.

Management of Vascular Entrapment with Coexisting Fibrosis on the Sacral Nerve Roots

Study Objective To demonstrate decompression of sacral nerves from aberrant vessels and fibrous tissue located on the plexus. Design Video presentation of two cases. Setting Tertiary center specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 43-year-old gravidity 1 parity 1 female patient presented with dysmenorrhea, dyspareunia and pudendal pain with dysuria. Gynecological examination revealed deep infiltrative endometriosis with rectovaginal nodule and partial obliteration of pouch of Douglas. She had a history of laparoscopic endometriosis surgery with left oophorectomy and was treated with intravascular coil embolization for pelvic congestion syndrome. Case 2: A 41-year-old gravidity 1 parity 1 female patient presented with chronic pelvic pain and left sided sciatic pain with chronic dysesthesia in the dermatome of sciatic nerve without any motor deficit of lower extremity. Gynecological examination revealed deep infiltrative endometriosis and full obliteration of pouch of Douglas. She had a history of multiple laparoscopic and laparotomic operations for endometriosis. Interventions Robot-assisted laparoscopic sacral nerve decompression and dissection of cul-de-sac with rectal nodule shaving (case1) and laparoscopic sacral nerve decompression and dissection of cul-de-sac (case 2). Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. Both patients report significant pain reduction with visual analog scale score. Conclusion Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by an abnormal structure (abnormal vessels, fibrous tissue, tumor, etc.) located on the plexus. Deep infiltrative endometriosis may affect retroperitoneal tissue by causing fibrosis. An abnormal vessel, which is located on the sacral plexus may entrap the roots much easier with coexisting fibrosis. On six moths follow up the visual analog scale score of case 1 and 2 decreased from 10 to 4 and 10 to 3, respectively. Patients are still under surveillance.

Hormonal treatment isolated versus hormonal treatment associated with electrotherapy for pelvic pain control in deep endometriosis: Randomized clinical trial

ObjectiveThe aim of the study was to evaluate the clinical effectiveness of complementary treatment using self-applied electrotherapy treatment for pain control over the standard hormonal treatment alone for deep infiltrative endometriosis (DIE). Study designMulticentre randomized clinical trial. We included a hundred-one participants with DIE in electrotherapy (n = 53) (hormonal treatment + electrotherapy) or control group (n = 48) (only hormonal treatment) by 8 weeks of follow-up. The primary measurement was chronic pelvic pain (CPP) using a visual analogue scale (VAS) and deep dyspareunia. The secondary outcomes were the quality of life by endometriosis health profile (EHP-30) and sexual function by female sexual function index (FSFI). ResultsCPP relief was observed only in the electrotherapy group (pre:7.11 ± 2.40, post:4.55 ± 3.08, p < 0.001). In terms of deep dyspareunia, improvements were observed for both groups (electrotherapy pre:2.02 ± 0.54–1.36 ± 0.96, p < 0.001; control pre:1.95 ± 0.86–1.68 ± 0.82, p = 0.006). Considering the secondary outcomes, a higher total score post-treatment for the EHP-30 was noted in both groups. Regarding sexual function, there was a statistically significant improvement in the FSFI score for the electrotherapy group (p < 0.001), with an increase in the scores for lubrication and pain domains (p = 0.013 and p < 0.001). ConclusionsElectrotherapy treatment using transcutaneous electrical nerve stimulation proved to be a good complementary option for pain control, showing benefits in the reduction of CPP and deep dyspareunia and improving patient’s quality of life and sexual function.

External validation of putative biomarkers in eutopic endometrium of women with endometriosis using NanoString technology.

To combine different independent endometrial markers to classify the presence of endometriosis. Endometrial biopsies were obtained from 109 women with endometriosis as well as 110 control women. Nine candidate biomarkers independent of cycle phase were selected from the literature and NanoString was performed. We compared differentially expressed genes between groups and generated generalized linear models to finda classifier for the disease. Generalized linear models correctly detected 68% of women with endometriosis (combining deep infiltrating and ovarian endometriosis). However, we were not able to distinguish between individual types of endometriosis compared to controls. From the 9 tested genes, FOS, MMP7, and MMP11 seem to be important for disease classification, and FOS was the most over-expressed gene in endometriosis. Although generalized linear models may allow identification of endometriosis, we did not obtain perfect classification with the selected gene candidates.

Value of Minimally Invasive Gynecologic Surgeon in Surgical Management of Endometriosis

The quality of endometriosis surgery performed by a Minimally Invasive Gynecologic Surgeon (MIGS) is significantly different from that of a general gynecologist. Their training offers them the experience to detect subtle endometriosis, excise deeply infiltrative endometriosis, manage extra pelvic endometriosis and restore normal anatomy in stage 4 endometriosis. They are able to preserve fertility in an endometriosis patient if patient desires fertility. They are also able to address or excise endometriosis when performing concurrent hysterectomy, instead of disregarding it.

STANDARDIZATION OF LAPAROSCOPIC TREATMENT PATIENTS WITH DEEP INFILTRATIVE ENDOMETRIOSIS

Despite the success of medical treatment of endometriosis, in cases of deep infiltrative endometriosis (DIE) accompanied by resistant pelvic pain and (or) infertility surgical treatment remains the method of choice.The aim of the study: standardization of methods and techniques of laparoscopic treatment of GIE using different surgical energies.Material and research methods. We conducted a retrospective analysis of cases of laparoscopic treatment of 126 patients with deep infiltrative endometriosis (DIE).The results and discussion: Standardized laparoscopic surgery for DIE included: laparoscopic revision of the pelvic and abdominal cavities; visceroadhesiolysis, DIE verification, identefication of ureteral; surgical treatment of endometriomas; lateral and (or) central resection of the peritoneum, resection of noduls of endometriosis, and, if necessary, sigmoid resection with the anastomosis. The use of the modern surgical energies in the standardized treatment of DIE helped to reduce the incidence of postoperative hyperthermia, intestinal paresis, prolonged drainage of the abdominal cavity, the length of stay in the hospital.Conclusions. Standardization of laparoscopic treatment of D IE using the latest surgical energies helps to improve the postoperative period, reduce the frequency of postoperative complications, length of hospital stay, which indicates the clinical and cost effectiveness of this surgical approach in the treatment of deep infiltrative endometriosis.

Suboptimal Bowel Function after (Recto) Sigmoid Resection in Patients with Deep Infiltrating Endometriosis

Purpose: To investigate the postoperative outcomes regarding bowel functions in women and the pattern of symptoms after surgical treatment for deep infiltrating endometriosis in comparison with healthy subjects. Methods: This cross-sectional study was designed as a single tertiary-level academic center. We included 130 female adult patients who had undergone (recto) sigmoid resection for deep infiltrating endometriosis between January 2005 and December 2015. Patients were randomly age-matched to two controls derived from the general population in the Netherlands. We measured the prevalence of constipation, fecal incontinence, Irritable Bowel Syndrome and the Low Anterior Resection Syndrome Score. Results: The prevalence of constipation, fecal incontinence, and irritable bowel syndrome in the patients was significantly higher than in the controls (50.8% versus 26.2% and 15.4% versus 5.4%, and 14.6% versus 5.4%, respectively, P &lt; 0.05 for each). The prevalence of constipation and fecal incontinence was lower in the patients who had undergone surgery longer than 24 months ago, in comparison with those who had undergone surgery less than 24 months ago (46.7% versus 69.9% and 15.0% versus 17.4%), which was still significantly higher in comparison to the control group. The low anterior resection syndrome score was significantly higher in the patients than in the controls. Conclusion: The postoperative outcomes in patients treated for deep infiltrated endometriosis regarding constipation, fecal incontinence, and irritable bowel syndrome are suboptimal and do not come close to outcomes in the general female population in the Netherlands. These patients should be screened postoperatively and if necessary, treated for bowel functions.

Deep infiltrative endometriosis with bilateral endometrioma with serous cyst adenocarcinoma in a postmenopausal woman

Deep infiltrative endometriosis with bilateral endometrioma with serous cyst adenocarcinoma in a postmenopausal woman

One-stage, radical laparoscopic endometriosis excision involving three different organ systems: A case report from tertiary referral center

Introduction: We present a case of an extensive endometriosis involving left paracolpium and left parametrium, rectovaginal septum, urinary bladder, left interiliac region between artery and vein, left ureter and rectum, presenting as dysmenorrhoea, alternating bouts of diarrhea and constipation and hydronephrosis. Methods: Laparoscopic surgery made by a multidisciplinary team consist of gynecologic, abdominal surgeon and urologist. Results: Successfully managed deep infiltrated endometriosis. Conclusion: The aim of this report is to demonstrate benefit of one-stage, minimally invasive radical surgical procedure performed in a tertiary referral center. To the best of our knowledge, this report presents an extremely complex case because we successfully managed deep infiltrating endometriosis in three different organ systems at the same time, using minimally invasive nerve-sparing technique. A case with the same constellation has not been published yet since reported cases of extrapelvic endometriosis chiefly address one organ system involvement.

Surgical technique for right ureteral DIE resection and ureteroneocystostomy by the Leadbetter-Politano technique: a step by step description. DIE, deep infiltrative endometriosis.

Surgical technique for right ureteral DIE resection and ureteroneocystostomy by the Leadbetter-Politano technique: a step by step description. DIE, deep infiltrative endometriosis.

Catamenial rectal bleeding due to invasive endometriosis: a case report

BackgroundAlthough gastrointestinal involvement is the most common site for extra-genital endometriosis, deep infiltrative endometriosis, which affects the mucosal layer, is very rare.Case presentationWe present a case of a 41-year-old white woman with cyclic rectal bleeding. Magnetic resonance imaging was done, together with colonoscopy and histologic staining of biopsied samples, which led to the final diagnosis of intestinal invasive endometriosis with recto-sigmoid stricture. Our patient was treated symptomatically with stool softeners.ConclusionThis case provides a rare example of catamenial bleeding. It is important to keep invasive endometriosis on the differential diagnosis whenever a premenopausal woman has cyclical rectal bleeding.

The relationship between C-reactive protein, carbohydrate antigen 125, and hematological parameters to endometriotic nodule localization in pelvis.

Endometriosis is a pelvic inflammatory process, and hormonal, environmental, and genetic factors play a role in its etiopathogenesis; especially, deep pelvic endometriosis exhibits an extensive anatomical distribution. In the present study, we evaluated the contribution of routinely measured hematological parameters to the diagnosis as the number of endometriotic nodule localization increases, when evaluated with C-reactive protein (CRP) and carbohydrate antigen (CA) 125. The present study included patients with histopathologically confirmed diagnosis of endometriosis who underwent surgery at our hospital between January 2007 and December 2018. Their medical records were examined retrospectively. In total, 205 patients were included in the study, of which 129 patients (62.9%) with ovarian endometrioma and 76 patients (37.1%) with deep infiltrative endometriosis were assigned to Group 1 and Group 2, respectively, and the two groups were compared. Endometriotic nodules were observed in several localizations in 71 patients (34.6%) of the 205 patients with endometriosis. Pelvic nodules were grouped as per their four different localizations: uterosacral, recto-vaginal, bladder, and ureteral. Because the anatomical localization of endometriotic nodules increased in the pelvis, the variability in the levels of CA 125 and CRP as well as hematological parameters was examined. There were significant differences in hemoglobin (p < 0.036), CA 125 (p < 0.000), and CRP (p < 0.007) levels between patients with nodules in ≤2 localizations and those with nodules in ≥3 localizations. Our study included a total of 205 patients. There was a significant difference in the CRP, CA 125, and hemoglobin levels between Group 1 and Group 2, but it was concluded that coexistence of the endometriotic nodule had no effect on the other hematological parameters. For this purpose, prospective studies with a larger number of patients are needed.

Endometriosis in pregnancy.

Endometriosis constitutes the presence of ectopic endometrial glands and stroma outside the uterine endometrium, which is hormonally responsive and responds to pregnancy hormones as well. Decidualization is a physiologic process, where the normal endometrium readies itself for optimal accommodation of apregnancy. A similar hormonal response can be seen with ectopic endometrium as well. As such, ovarian endometriomas and deep endometriosis implants can undergo decidualization. Overall, the progestational state of pregnancy favors an improvement in endometriosis, however, decidualization can lead to findings that can lead to increased size of endometriomas and deep infiltrative endometriosis implants, changes in imaging appearance and even complications, such as spontaneous hemoperitoneum in pregnancy. Awareness of this process can help prevent misdiagnosis of decidualized endometriomas as ovarian malignancy and recognize common imaging manifestations of hormonal effects of pregnancy on endometriosis.

Postoperative imaging findings after laparoscopic surgery for deeply infiltrating endometriosis.

Deeply infiltrative endometriosis (DIE) is a common gynecologic disease affecting women of reproductive age and often causing chronic pelvic pain and infertility. Clinical treatment options and preventive actions are ineffective due to the lack of knowledge about the etiology of DIE. Surgical treatment is currently the only alternative to eradicate the disease. Diagnostic imaging plays a crucial role for surgical planning and postoperative evaluation. Transvaginal sonography (TVS) with a dedicated protocol and magnetic resonance imaging (MRI) can be used to evaluate recurrent disease. Extensive pelvic surgery may cause anatomical changes and a variable spectrum of postoperative findings. Residual disease and complications can be also evaluated and are of great importance to estimate pain relief and fertility prognosis. The most common imaging findings following radical surgery for DIE are fibrotic scars in the retrocervical space and bowel anastomosis, absence of the posterior vaginal fornix and loculated fluid in the pararectal spaces. Ovaries are the most frequent site of early recurrence. Complications include infection, hemorrhage, urinary/evacuatory voiding dysfunctions as well as bowel and ureteral stenosis. The purpose of this article is to review the surgical techniques currently used to treat endometriosis in the retrocervical space, vagina, bladder, bowel, ureters, and ovaries and to describe the most common imaging findings including normal aspects, residual disease, complications, and recurrence.

Encyclopedia of endometriosis: a pictorial rad-path review.

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.

Reproductive outcomes of surgical treatment of colorectal infiltrative endometriosis: literature review

Reproductive outcomes of surgical treatment of colorectal infiltrative endometriosis: literature review

Laparoscopic management of deep infiltrating colorectal endometriosis

Laparoscopic management of deep infiltrating colorectal endometriosis

Shaving for Bowel Endometriosis

To demonstrate laparoscopic shaving of deeply infiltrative endometriosis affecting the rectosigmoid colon, with particular emphasis on the anatomic and technical aspects of the procedure. Stepwise demonstration of the technique with narrated video footage. Intestinal involvement in deep endometriosis is estimated to occur in 8% to 12% of patients, with 90% of occurrences being located in the colorectal segment. Deep endometriosis of the rectosigmoid is defined as endometriosis involving the muscular layer of the bowel wall, usually >5 mm deep, thus excluding superficial lesions that only affect the serosal layer. In cases in which medical therapy is unsatisfactory, rectosigmoid deep endometriosis can be surgically managed by 3 recognized surgical techniques: (1) rectal shaving, (2) disc excision, and (3) segmental resection. There are helpful recommendations for different approaches on the basis of the characteristics of the lesion, including the size, length, depth of invasion, involved rectal circumference, and number of lesions, among other factors [1]. Rectal shaving is well suited for smaller lesions, typically <3 cm, and involves "shaving" the lesion in the affected muscular layer of the bowel wall off the mucosa, ideally without entering the bowel lumen. It is associated with lower rates of perioperative complications and lower probability of long-term postoperative bladder and bowel dysfunctions [2]. This video demonstrates and highlights the anatomic and technical aspects of the following important steps of the rectal shaving procedure: (1) suspension of ovaries; (2) mobilization of the diseased segment of the rectum; (3) shaving of the lesions, with pertinent comments at different stages of nodule excision; (4) checking for the integrity of the bowel wall; and (5) suture of the muscularis defect after excision of the lesions from the muscularis layer of the bowel. Compared with other alternatives, shaving for bowel endometriosis is a more conservative procedure with lower rates of perioperative complications, and it is less likely to result in long-term bladder and bowel dysfunctions. Therefore, shaving is preferable and recommended for appropriate lesions.

Ultrasound evaluation of deeply infiltrative endometriosis: technique and interpretation.

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue located outside the uterus and frequently associated with chronic pelvic pain and infertility. It is a polymorphic disease that can be presented as superficial implants, endometriomas and deep lesions that infiltrate the peritoneal surface associated with fibrosis and inflammatory reaction. Diagnosis of deep endometriosis is difficult and delayed, frequently missed in a routine ultrasound. Transvaginal ultrasound is the first-line imaging modality to investigate endometriosis and when performed by an expert in female pelvic imaging can provide a reliable mapping of the affected sites. Bowel preparation can be used to improve the detection of bowel lesions as well as the other sites affected by eliminating artifacts. Surgery has been the mainstay to treat symptomatic endometriosis and preoperative imaging mapping is crucial for better results and to reduce residual disease. The goals of surgery include radical removal of all lesions and the restoration of normal pelvic anatomy. The author describes technical aspects and imaging interpretation of the transvaginal sonography to investigate deeply infiltrative endometriosis.

Diagnostic Performances of Tridimensional Rectosonography and Magnetic Resonance Imaging in Rectosigmoid Endometriosis: A Prospective Cohort Study on 101 Patients

Tridimensional rectosonography (3-D RSG) is a transvaginal ultrasonography procedure combining intrarectal contrast with tridimensional technology. The objectives of this study were to assess the diagnostic performances of 3-D RSG in deep infiltrating rectosigmoid endometriosis using surgery and pathology as the gold standard, and to compare its results with those of magnetic resonance imaging (MRI). Patients referred for endometriosis with symptoms suggesting deep infiltrating intestinal endometriosis (DIE) were included if they agreed to undergo a 3-D RSG and MRI and if there was a surgical indication related to endometriosis. The study was a non-randomized monocentric prospective cohort study (Canadian task force classification Level II-2). From May 2012 to May 2017, 101 patients were included. Sixty patients (59.4%) had bowel involvement of the rectum (n = 21, 20.8%) or of the sigmoid (n = 39, 38.6%) confirmed in surgery and/or in pathologic testing. In the diagnosis of rectosigmoid DIE, 3-D RSG sensitivity, specificity, positive predictive value, negative predictive value, accuracy and κ index were 93%, 95%, 97%, 91%, 94% and 0.88, respectively. For MRI they were 87%, 90%, 93%, 82%, 88% and 0.76, respectively. The accuracy was not significantly different between 3-D RSG and MRI (p = 0.181). In conclusion, 3-D RSG is an effective technique to diagnose rectosigmoid endometriosis and seems to have similar diagnostic performances to MRI for this indication.