Rectovaginal Endometriosis Research Articles

Accuracy of Physical Examination, Transvaginal Sonography, Magnetic Resonance Imaging, and Rectal Endoscopic Sonography for Preoperative Evaluation of Rectovaginal Endometriosis.

The aim of this study was to compare the effectiveness of physical examination, transvaginal sonography, magnetic resonance imaging, and rectal endoscopic sonography for the identification of rectovaginal endometriosis and potential rectal infiltration. Women with suspected rectovaginal endometriosis underwent physical examination, transvaginal sonography, magnetic resonance imaging, and rectal endoscopic sonography. Evaluation was performed for the presence of rectovaginal endometriotic foci and rectal infiltration. The findings obtained with these methods were compared with those of surgical and histopathological examination. Sensitivity, specificity, positive predictive values, and negative predictive values were evaluated for each method. Rectovaginal endometriosis was histologically confirmed in 21 (72.4%) of 29 women. With respect to diagnosis of rectovaginal endometriosis, the sensitivity, specificity, and accuracy of physical examination were 95.2%, 62.5%, and 86.2%; those of transvaginal sonography were 42.9%, 87.5%, and 55.2%; those of magnetic resonance imaging were 90.5%, 87.5%, and 89.7%; and those of rectal endoscopic sonography were 81.0%, 75.0%, and 79.3%, respectively. With respect to identification of rectal infiltration, the sensitivity, specificity, and accuracy of transvaginal sonography were 26.7%, 85.7%, and 55.2%; those of magnetic resonance imaging were 73.3%, 92.9%, and 82.8%; and those of rectal endoscopic sonography were 86.7%, 85.7%, and 86.2%, respectively. Magnetic resonance imaging combined with physical examination seem to be the main approach for the presurgical assessment of rectovaginal endometriosis. Rectal endoscopic sonography is a worthwhile method for the diagnosis of rectal infiltration.

40: Excision of rectovaginal endometriosis at the time of hysterectomy

40: Excision of rectovaginal endometriosis at the time of hysterectomy

Appyling Basic Principals to Difficult Situations: Uterine Sparing Vaginectomy for Rectovaginal Endometriosis

Appyling Basic Principals to Difficult Situations: Uterine Sparing Vaginectomy for Rectovaginal Endometriosis

Robotic Resection of Deep Infiltrating Rectovaginal Endometriosis with Bilateral Ureterolysis under Low Pressure Insufflation

Robotic Resection of Deep Infiltrating Rectovaginal Endometriosis with Bilateral Ureterolysis under Low Pressure Insufflation

Preserving Fertility by Treating the 3 Compartments: Laparoscopic Approach to Deep Infiltrating Endometriosis

Study ObjectiveTo describe a laparoscopic technique for the resection of deep endometriosis, treating the 3 compartments. DesignEducational video. SettingTertiary referral center in Strasbourg, France PatientA 37-year-old primiparous woman. InterventionAdenomyomectomy, partial cystectomy, and bowel resection. Fertility preservation was mandatory because of the patient's desire for future pregnancy. Measurements and Main ResultsA 37-year-old primiparous woman presented with main symptoms of dysmenorrhea and dyspareunia associated with pollakiuria and macroscopic menstrual hematuria (with emission of endometriotic tissue on analysis). She also complained of dyschezia. Magnetic resonance imaging revealed an endometriotic nodule in the vesicouterine space with an involvement of the anterior wall of the uterus and a suspicion of bladder adenomyosis. There were lateral spicules attracting the ovaries toward the midline and an infiltration of the round ligaments and nodules related to the rectovaginal space's endometriosis. A possible invasion was noted underneath the rectal mucosa. The patient expressed her desire preserve fertility. The local institutional review board has approved the video. Initially, an ultrasonography was performed showing the adenomyoma invading the bladder. The second step was a cystoscopic evaluation by means of a double J probe and a bladder catheter. After surgery the bladder catheter was left in place for 15 days and the double J stents for 6 weeks. The first step was the dissection of the vesicouterine space to dissect the anterior adenomyoma from the bladder. A partial cystectomy was then performed to remove the bladder nodule. The adenomyoma was resected at its uterine portion and the uterus sutured. Surgery was then performed in the posterior compartment. Ureterolysis was performed bilaterally, and the pararectal fossas were then opened. The rectovaginal space was dissected. A rectosigmoid resection was mandatory to remove the bowel nodule. Patient follow-up included regular consultations and a hysterosonography at 6 weeks after surgery. Hysterosonography demonstrated an adequate patency. No adhesions to the uterus were found. We recommended to wait for 6 months to allow pregnancy according to the department's protocols. A clinical improvement was observed. Today, at 8 months she has not attempted pregnancy. ConclusionsA complete surgery is feasible for severe and deep endometriosis with a multicompartmental disease, using a laparoscopic approach aiming to preserve fertility.

Laparoscopic excision of deep rectovaginal endometriosis in BSGE endometriosis centres: a multicentre prospective cohort study

ObjectiveTo estimate the effectiveness and safety of laparoscopic surgical excision of rectovaginal endometriosis.DesignA multicentre, prospective cohort study.Setting51 hospitals accredited as specialist endometriosis centres.Participants5162 women of reproductive age with rectovaginal endometriosis...

The outcomes of ureterolysis during complex rectovaginal endometriosis surgery in stented patients.

The outcomes of ureterolysis during complex rectovaginal endometriosis surgery in stented patients.

Sentinel lymph node labeling of patients with deep infiltrating rectovaginal endometriosis – does thismake sense?

PurposeDeep infiltrating endometriosis is a chronic disease of largely unresolved pathogenesis. Lymphatic dissemination of endometriotic cells has been shown in incidentally removed mesorectal lymp...

Postcoital bleeding in a case of recto-vaginal endometriosis

Introduction: Rectovaginal Endometriosis (RVE) is a severe form of endometriosis, less frequent than peritoneal or ovarian endometriosis. Recto-vaginal endometriosis has multiple diagnostic and management options with long-term outcomes varying according to the management strategy used. Case: A 40 years old woman complained of postcoital bleeding. Detailed history revealed that she suffered from persistent dysmenorrhea, dyschasia and constipation. Vaginal speculum examination revealed a large fleshy polypoidal mass in the posterior vaginal fornix, which was excised and biopsied. Histo-pathological examination revealed vaginal endometriosis. Four months later the mass recurred, in spite of, receiving hormonal treatment. Ultrasound and MRI revealed multiple uterine fibroids, with heterogenous lesion located in the rectovaginal area, and CA-125 was 80 u/ml. exploratory laparotomy was done after proper bowel preparation. Total abdominal hysterectomy with excision of the upper vaginal portion and a part of the anterior aspect of the recto-sigmoid was resected due to the invasion of its musculosa, short of the mucosa, with primary repair. Histo-pathological examination showed advanced endometriosis including the vaginal fornix and the rectal wall. The patient received two doses of Leuprolide Acetate 11.25 mg as an adjuvant treatment. Conclusion: All women with postcoital bleeding or pelvic pain should have a detailed history taken from them and thorough examination including speculum examination and visualization of posterior vaginal fornix to detect vaginal endometriosis. The primary line of management for recto-vaginal endometriosis is surgery, as hormonal therapy is less effective in such cases, which might be explained by difference in origin from the peritoneal disease.

Multidisciplinary Resection of Deeply Infiltrative Endometriosis

Study ObjectiveTo describe a multidisciplinary approach for the resection of deeply infiltrative endometriosis using the robotic platform. DesignA technical video showing a step-by-step approach for the resection of deeply infiltrative endometriosis (Canadian Task Force classification level III). Institutional review board approval was not required for this study. SettingThere is considerable involvement of the bowel and bladder with deeply infiltrative endometriosis [1–3]. The need for operative procedures involving multiple organs while performing a complete resection is common. The benefits of minimally invasive surgery for a gynecologic pathology have been documented in numerous studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis, and better quality of life [4–6]. We believe that deeply infiltrative endometriosis does not preclude patients from having a minimally invasive resection procedure. In this video, we describe how the robotic platform was used for a seamless transition between surgical specialties including gynecology, colorectal, and urology to ensure complete resection of endometriosis lesions involving multiple organs. PatientA 47-year-old woman with a 4-year history of severe pelvic pain, dysuria, dyspareunia, dyschezia, and dysmenorrhea failing multiple medical therapies presented to our clinic to discuss surgical options. After thorough counseling, the decision was made to proceed with definitive surgical management. Postoperatively, the patient was admitted for 2 days of postoperative inpatient care. After meeting all immediate postoperative milestones, she was discharged with an indwelling Foley catheter and instructed to follow up in the clinic with all 3 surgical specialties. At the 1-week interval, she was seen by the urology team; her indwelling catheter was removed after a cystoscopy was performed documenting adequate healing. Two weeks postoperatively, the patient was seen by the gynecology and colorectal teams and was noted to be healing adequately from the procedure. Her six-week visit was also unremarkable. She continued to follow up with the gynecology team for her yearly well-woman examinations and has been symptom free for 2 years after the surgery. She takes norethindrone daily to minimize recurrence. InterventionsPreoperative pelvic magnetic resonance imaging (MRI) showed bladder endometriosis and extensive rectovaginal endometriosis. We describe the multidisciplinary approach used for surgery and the procedures performed by each specialty. The urology team performed a cystoscopy preoperatively to assess for full-thickness erosions and the location of those lesions in that event. The urology team also reviewed the magnetic resonance images with the radiology team, and the endometriosis lesions were suspected to be close to the bladder trigone, keeping in mind that this finding could be overestimated given that the bladder was deflated at the time the imaging was obtained. Accordingly, at the time of surgery, the decision was made to proceed with cystoscopy and the placement of ureteral stents as a prophylactic measure. An intentional cystotomy and resection of the bladder section involved with endometriosis were performed followed by watertight closure. The trigone area of the bladder was not involved, and ureteral reimplantation was not needed in this case. The gynecology team operated second and performed an extensive dissection of the retroperitoneal space with the development of the pararectal and paravesical spaces. They also ligated the uterine artery at its origin followed by dissection of the uterovesical space, effectively reflecting the bladder off of the lower uterine segment. At this point, they proceeded with a total hysterectomy, and the specimen was removed from the pelvis through the vaginal cuff. Preoperatively, the colorectal surgeon ordered a colonoscopy to determine if full-thickness erosions were present and reviewed the magnetic resonance images with the radiology team. Based on the MRI and colonoscopy, all patients are counseled and consented for the possibility of a low anterior resection and loop ileostomy to protect the anastomosis. Based on the understanding that colorectal and gynecologic surgeries have a different approach when dissecting the pararectal space at our institution, a discussion between the 2 teams is initiated at the multidisciplinary session for surgery planning. In the case we present, the colorectal surgeon opted for the removal of the uterus before his dissection was initiated given that he dissects this space presacrally and not retroperitoneally like the gynecology counterpart. He would also benefit from the extra space for dissection with the uterus out of the pelvis. The colorectal part of the case was initiated by mobilization of the rectum and dissecting the obliterated rectovaginal space. The presacral space was then opened followed by mobilization of the rectosigmoid from its attachment. The case was concluded with full transection and reanastomosis of the rectum section involved with endometriosis. The specimen was also removed from the pelvis through the vaginal cuff. Measurements and Main ResultsComplete resection of deeply infiltrative endometriosis spanning beyond the scope of 1 surgical specialty. No immediate intraoperative, perioperative, or long-term complications from surgery. Complete resolution of endometriosis symptoms. ConclusionWe encourage collaborative care for planning and performing comprehensive and safe resection of deeply infiltrative endometriosis.

40 - Partial Vaginectomy for Excision of Rectovaginal Endometriosis

Rectovaginal endometriosis, a variant of deep infiltrating endometriosis, can cause dyspareunia and dyschezia when it involves the rectovaginal wall. It most commonly affects the posterior vaginal fornix and nodularity is often palpable in the posterior cul-de-sac on pelvic exam. Oftentimes, surgical excision is necessary to provide symptomatic relief. This video will demonstrate the excision of rectovaginal endometriosis through two examples – A) after completion of a total laparoscopic hysterectomy and B) performed conservatively when the uterus is left in-situ. We demonstrate advanced surgical techniques and tips in laparoscopic retroperitoneal dissection and laparoscopic suturing for reconstruction of the vagina to ensure complete excision in the definitive treatment of this lesion.

"Per vaginam" topical use of hormonal drugs in women with symptomatic deep endometriosis: a narrative literature review.

We aim to provide a comprehensive overview of the role of the vagina as a route for drug delivery and absorption, with a particular focus on the use of vaginal hormonal compounds for the treatment of deep infiltrating symptomatic endometriosis. A MEDLINE search through PubMed was performed to identify all published studies in English language on vaginal hormonal treatments for symptomatic endometriosis. Main advantages of the vaginal route include avoidance of the hepatic-first pass metabolic effect, the possibility of using lower therapeutic dosages, and the reduction of side effects compared with the oral administration. Studies on endometriosis treatment mainly focused on the use of vaginal danazol (n=6) and the contraceptive vaginal ring (n=2). One pilot study evaluated the efficacy of vaginal anastrozole in women with rectovaginal endometriosis. Most investigations evaluated the vaginal use of hormonal agents in women with deep infiltrating endometriosis/rectovaginal endometriosis. Overall, a substantial amelioration of pelvic pain symptoms associated with endometriosis was observed, particularly of dysmenorrhea. A significant reduction in rectovaginal endometriotic nodule dimensions measured at ultrasound examination was detected by some but not all authors. The vaginal route represents a scarcely explored modality for drug administration. High local hormonal concentrations might achieve a greater effect on endometriotic lesions compared with alternative routes. Future studies should focus on the use of the vagina for delivering target therapies particularly in patients with deeply infiltrating rectovaginal lesions.

Spontaneous fertility after expectant or surgical management of rectovaginal endometriosis in women with or without ovarian endometrioma: a retrospective analysis

To investigate spontaneous pregnancy rate (SPRs) of women with rectovaginal endometriosis (RV) with/without ovarian endometrioma (OMA) and treated with the use of expectant or surgical management. Retrospective study. University hospital. The study included patients with RV with or without OMA who tried to conceive spontaneously for 1year either without undergoing surgery (group E; n = 284) or after surgery (group S; n = 221). The study population was further divided into four subgroups: women with RV without OMA who directly tried to conceive (group eRV; n = 121) or tried to conceive after surgery (group sRV; n = 96), and women with RV with OMA who directly tried to conceive (group eOMA; n = 163) or tried to conceive after surgery (group sOMA; n = 125). Expectant or surgical management. Crude and cumulative SPRs. At 1year, crude and cumulative SPRs were lower in group E (17.3% and 23.8%, respectively) than in group S (35.7% and 39.5%). Similarly, crude and cumulative SPRs were lower in group eRV (24.8% and 30.6%) than in group sRV (42.7% and 45.7%, respectively) and in group eOMA (11.7% and 18.0%) than group sOMA (30.4% and 34.5%). At 1year, crude and cumulative SPRs were higher in group eRV (24.8% and 30.6%) than in group eOMA (11.7% and 18.0%), and in group sRV (42.7% and 45.7%) than in group sOMA (30.4% and 34.5%). Crude and cumulative SPRs are lower in women treated with the use of expectant rather than surgical management. The presence of OMAs decreases SPRs independently from the treatment modality adopted.

Efficacy and acceptability of long-term norethindrone acetate for the treatment of rectovaginal endometriosis

ObjectiveTo study the efficacy of long-term treatment with norethindrone acetate (NETA) in patients with rectovaginal endometriosis. Study designThis retrospective cohort study included 103 women with pain symptoms caused by rectovaginal endometriosis. Patients received NETA alone (2.5mg/day up to 5mg/day) for 5 years. Primary outcome was the degree of satisfaction with treatment after 5 years of progestin therapy. Secondary outcomes were the assessment of any variation in pain symptoms and the volumetric assessment of the disease by magnetic resonance imaging (MRI). ResultsSixty-one women completed the 5-year follow-up (61/103, 59.2%) with 16 women withdrawing because of adverse effects (38.1%). Overall, 68.8% (42/61) of the women who completed the study were satisfied or very satisfied of this long term NETA treatment. This represents a 40.8% (42/103) of the patients enrolled. Intensity of chronic pelvic pain and deep dyspareunia significantly decreased during treatment (p<0.001 versus baseline at 1 and 5year). Dyschezia improved after 1-year respect to baseline (p=0.008) but remained stable between first and second year (p=0.409). At the end of 5 years treatment, a radiological partial response was observed in 33 patients (55.9%, n 33/59); a stable disease in 19 patients (32.2%, n 19/59). Seven women (7/59, 11.9%) displayed a volumetric increase of rectovaginal endometriosis under NETA treatment. ConclusionFive-year therapy with NETA is safe and well tolerated by women with rectovaginal endometriosis. Due to its low cost and good pharmacological profile, it represents a good candidate for long-term treatment in this setting.

The benefit of adenomyomectomy on fertility outcomes in women with rectovaginal endometriosis with coexisting adenomyosis

Study Objective:To evaluate the effect of removal of coexisting adenomyosis on fertility outcomes in women with rectovaginal endometriosis.Design:A retrospective cohort study.Setting:A general hospital.Patients:A total of 190 women who underwent laparoscopic nodule excision surgery for rectovaginal endometriosis between April 2007 and December 2012.Interventions:Surgical excision of the rectovaginal endometriosis and coexisting uterine adenomyosis. Statistical analysis for fertility outcomes.Measurement and main results:A total of 119 women desired postoperative pregnancy. Coexisting adenomyosis was found in 21% of the women. The overall clinical pregnancy rate was 41.2%. The only determining factor associated with a successful pregnancy was “age at surgery”. Clinical pregnancy rates with or without adenomyosis were 36.0% and 42.6%, respectively. We found no significant difference in clinical pregnancy rates between the groups.Conclusion:There is a possibility that surgical removal of coexisting adenomyosis positively effects fertility outcomes in women with rectovaginal endometriosis. However, it is also important to note that the age at surgery was a critical factor for successful pregnancy.

P15.01: Meta‐analysis and systematic review to determine the optimum imaging modality for the detection of rectovaginal septum deep infiltrative endometriosis

P15.01: Meta‐analysis and systematic review to determine the optimum imaging modality for the detection of rectovaginal septum deep infiltrative endometriosis

Combination of the non-invasive tests for the diagnosis of endometriosis.

Combination of the non-invasive tests for the diagnosis of endometriosis.

Robotic Cerclage in Advanced-stage Endometriosis

Study ObjectiveTo show a stepwise surgical technique of robotic-assisted transabdominal cerclage placement in a patient with deeply infiltrative endometriosis. DesignA step-by-step surgical tutorial using narrated video. SettingThe George Washington University Hospital. Local institutional review board approval is not required for case reports (Canadian Task Force Classification III). PatientsA 38-year-old woman with cervical incompetence and a history of infertility with 5 pregnancies accomplished by in vitro fertilization. Pregnancies were as follows: 3 first trimester losses, 1 second trimester loss, and another second trimester loss despite McDonald cerclage placement. InterventionsIndications for transabdominal cerclage placement include a congenital short or amputated cervix, cervical scarring that would prevent a transvaginal approach, and failed prior vaginal cerclage [1]. Robotic-assisted abdominal cerclage placement was performed in a case of advanced rectovaginal endometriosis. Normal anatomy was restored; however, no excision of endometriosis was performed because the patient was asymptomatic and already undergoing in vitro fertilization for infertility. The procedure used a 12-mm camera port through the umbilicus, 2 ancillary 8-mm robotic ports, and a 5-mm assistant port; ¼-inch-width Mersilene tape (Ethicon, Somerville, NJ) was preloaded in the abdomen through the 12-mm port before docking. Survey of the pelvis revealed the presence of advanced rectovaginal endometriosis hindering visualization of the cervicouterine isthmi on the posterior side of the uterus. The preloaded needle was parked on the right parietal peritoneum. Before cerclage placement, retroperitoneal spaces dissection bilaterally was necessary to lateralize the ureters and mobilize the rectum away from the cervicovaginal junction where the cerclage would be placed. Anteriorly, the vesicouterine peritoneum was dissected transversely, and the bladder was dissected off the lower uterine segment. A window was created in the posterior leaf of the right broad ligament lateral to the cervicouterine junction and medial to the ureter. The uterine vessels were then skeletonized, and the needle was placed through the lateral cervical isthmus medial to the vascular bundle going posterior to anterior. The procedure was repeated on the contralateral side with the needle going in the anteroposterior direction. The tape was pulled tightly against the anterior cervical isthmus. The tape ends were tied together posteriorly. There was minimal blood loss with no complications. ConclusionA robotic-assisted abdominal cerclage can be performed safely and effectively in patients with advanced-stage endometriosis.

(Partial) Loss of BAF250a (ARID1A) in rectovaginal deep-infiltrating endometriosis, endometriomas and involved pelvic sentinel lymph nodes.

Loss of protein BAF250a (ARID1A) expression is present in women with rectovaginal deep-infiltrating endometriosis (DIE) and endometriosis affecting the pelvic sentinel lymph nodes (PSLN). Partial loss of protein BAF250a was found in some of our patient samples, comprising all endometriosis entities, including rectovaginal DIE and endometriosis affecting the PSLN. Loss of BAF250a (BRG-associated factor 250a)/ARIDIA (AT-rich interactive domain 1A) protein expression was identified among endometriosis-associated ovarian carcinomas and ovarian endometriosis, and this phenomenon was described as a possible early event in the transformation of endometriosis into cancer. DIE affecting the bowel/rectovaginal site is the most aggressive presentation of endometriosis and its 'risk' of malignant transformation has not been studied so far. We evaluated the immunohistochemical expression of BAF250a protein in 70 samples from patients enrolled in this study who were surgically treated at a tertiary center, university Hospital. The samples submitted to investigation were from rectovaginal DIE (n= 25/30), endometriosis affecting the PSLN (n= 5/7), ovarian endometriosis (n= 20/20) and endometrium from patients without endometriosis used as controls (n= 20/20). Partial loss (i.e. in one tissue section some cells stained positive for BAF250a while other cells, usually an adjacent group, were negative) of BAF250a protein was identified in 36% (9/25) of rectovaginal DIE samples, 40% (2/5) of endometriosis lesions involving the PSLN, 30% (6/20) of endometriomas, and also in 25% (5/20) of endometrium from controls. We found no statistical correlation between occurrence of partial loss of BAF250a protein and the use or not of hormone medications (P = 0.106), cycle phase (P = 0.917) and stage of disease (P = 0.717). We only found partial loss of BAF250a protein expression, and in a small population of women, with relatively high frequency in all benign tissues assessed in the present analysis. Therefore, this finding alone should not be correlated directly with the risk of malignant transformation in these lesions. The occurrence of partial loss of BAF250a protein expression in women with rectovaginal DIE and endometriosis affecting the PSLN is described for the first time. The value of this finding as a predictor of malignant transformation in endometriosis must still be clarified and further studied in association with other molecular events, such as PTEN (phosphatase and tensin homolog) deletion and PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) mutation. We might then be able to identify in the future which patients with endometriosis are at higher risk of cancer. This study was supported by an internal Charité grant to the Endometriosis Research Center and the authors declare no conflicts of interest.

Combined vaginal-laparoscopic-transanal approach for reducing bladder dysfunction after conservative surgery in large deep rectovaginal endometriosis

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 45 - N° 6 - p. 546-548