Resection Of Endometriosis Research Articles

Urinary and Bowel Dysfunction Following Endometriosis Resection

The mainstay treatment for severe endometriosis has always been resection of all visible disease to improve symptoms, normalize anatomy and improve fertility. Current practice for the excision of severe endometriosis often includes excising parasympathetic and sympathetic nerve plexuses within the utero-cardinal complex, which is integral for bladder and bowel function. There is minimal published data that examines the potential bowel or bladder denervation and dysfunction following excision of advanced pelvic endometriosis.

Histopathological Analysis of Intestinal Endometriosis after Laparoscopic Low Anterior Resection

We histopathologically examined intestinal specimens collected during Descriptive study. University hospital. We examined specimens obtained from ten patients who underwent laparoscopic low anterior resection for intestinal endometriosis at our hospital between January 1999 and August 2007. Laparoscopic low anterior resection. Mapping endometriotic foci, degree of vertical infiltration to the intestinal layers and longitudinal spread of EMF to the intestinal plane were defined using hematoxylin-eosin (HE), estrogen receptor (ER), progesterone receptor (PR) and CD10 staining. Endometriotic foci tended to concentrically spread around a main lesion that comprised most of a resected specimen. The deepest layer containing endometriotic foci at the main lesion was the submucosal layer in 7 (70%) specimens and the internal circular muscle layer in 3 (30%). Satellite lesions comprising thickened areas that were independent of the main lesion were detected in five specimens (50%). Multiple endometriotic foci were confirmed in all satellite lesions. Endometriotic foci might not only infiltrate the main lesion in intestinal endometriosis but also disseminate to other areas. Thus, the main lesion of intestinal endometriosis with a large margin must be excised by low anterior resection.

Avoiding Neurologic Complications on Radical Endometriosis Surgery

The nerves of the posterior pelvic compartment are the ones at higher risk of lesion during radical endometriosis resection. Among the most important of those are: the hypogastric nerves, which are mixed nerves that conduct sensitive afferent signals from the pelvic viscerae and sympathetic efferent signals to the bladder, the rectum, the urethra and the anal sphincter. The objective of this video is to describe, based on clinical examples, the landmarks for nerve-sparing radical endometriosis surgery, using a “non-touch” technique; to describe the surgical steps where lesion of the pelvic splanchic nerves mat occur; to describe the symptoms and signs suggestive of endometriosis involving the pelvic nerves and, at last, how to avoid nerve lesions.

Clinical outcome after CO2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis

Laparoscopic segmental bowel resection and reanastomosis for endometriosis with colorectal wall invasion can be associated with high complication rates. This study was performed to test the hypothesis that this high complication rate can be prevented and combined with a good clinical outcome, following a multidisciplinary surgical approach. A retrospective cohort study of all patients with deep endometriosis and colorectal invasion treated by CO₂ laser laparoscopic radical excision between September 2004 and September 2006 (n = 45) to document the clinical outcome: complications, recurrence and fertility (life table analysis), pain, quality of life (QOL) and sexual function. No immediate major post-operative complications requiring surgical reintervention were recorded. Gynaecological pain (P < 0.0001), sexual function (P < 0.03) and QOL (P< 0.0001), improved significantly after a median follow-up period of 27 (range: 16-40) months. Although five patients (11%) had a surgical reintervention, histologically proven recurrent endometriosis was observed in only two (4%), with a cumulative endometriosis recurrence rate of 2.2 and 4.4% after 1 and 3 years, respectively. Thirteen of 28 patients who wanted to become pregnant conceived after surgery. One patient delivered twice. These 14 pregnancies were achieved spontaneously (n = 9) or after IVF (n = 5). The cumulative pregnancy rate was 47% after 3 years. Pain, sexual function and QOL improved significantly and were associated with a good fertility rate and a low complication and recurrence rate after a CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study

Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in post-operative digestive dysfunction. We selected patients managed by colorectal resection for rectal endometriosis, who had developed post-operative severe constipation and whose follow up was superior to 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation. Five out of 25 (20%) patients, whose age ranged from 27 to 41 years, were investigated for severe post-operative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, post-operative neurological sequelae, colonic intussusception through the colorectal anastomosis and transit constipation that developed post surgery. Post-operative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory as pathophysiologic mechanisms may vary and prove difficult to understand. The risk of post-operative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

Pelviperitonitis by colorectal perforation in the third trimester of pregnancy after surgery for deep pelvic endometriosis

To report a severe complication after colorectal resection for rectovaginal endometriosis. Case report. University hospital. A 37-year-old patient treated with colorectal resection 3 years ago for rectovaginal endometriosis was admitted with a rectal perforation at 37 weeks' gestation. Caesarean section and simple interrupted stitch of the perforation by absorbable Vicryl. Determination of the cause of the perforation in healthy rectal tissue above the anastomosis. The most likely mechanism was secondary colonic hyperpressure owing to stenosis of the colorectal anastomosis. Young patients planning to conceive but scheduled to undergo colorectal resection should be made aware of the significant complication rate associated with this procedure and the promising results of nodule excisions. We recommend close monitoring of patients suffering from chronic constipation after resection for rectosigmoid endometriosis.

Early Postoperative Outcomes After Laparoscopic Segmental Colorectal Resection for Endometriosis: The Impact of Surgical Experience

Early Postoperative Outcomes After Laparoscopic Segmental Colorectal Resection for Endometriosis: The Impact of Surgical Experience

Transvaginal sonography vs. clinical examination in the preoperative diagnosis of deep infiltrating endometriosis

The aim of this study was to compare the diagnostic performance of clinical vaginal examination with that of transvaginal sonography (TVS) in the presurgical diagnosis of deep infiltrating endometriosis. One-hundred and fifty-five women with symptoms suggestive of endometriosis were included. One-hundred and twenty-nine patients met the inclusion criteria and were prospectively and independently assessed by vaginal examination and TVS prior to a diagnostic laparoscopy and, where appropriate, radical resection and histological confirmation of endometriosis was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and positive and negative likelihood ratios (LR+ and LR-) were calculated for each test method. In total, 83 (64%) women had histological confirmation of endometriosis, 52 (40%) of whom had deep infiltrating endometriosis. The prevalence of endometriosis on the uterosacral ligaments, pouch of Douglas, vagina, bladder, rectovaginal space and rectosigmoid was 23.3%, 16.3%, 8.5%, 3.1%, 6.9% and 24%. PPV, NPV, LR+ and LR- for vaginal examination were 92%, 87%, 41.56 and 0.60 for ovarian endometriosis; 43%, 84%, 2.48 and 0.63 for uterosacral ligament disease; 64%, 95%, 9.14 and 0.26 for involvement of the pouch of Douglas; 80%, 97%, 42.91 and 0.28 for vaginal endometriosis; 78%, 98%, 46.67 and 0.23 for endometriosis of the rectovaginal space; 100%, 98%, 75.60 and 0.75 for bladder involvement; 86%, 84%, 18.97 and 0.63 for rectosigmoidal endometriosis. Values for TVS were similar with regard to vaginal and rectovaginal space endometriosis, but were clearly superior to vaginal examination in cases of ovarian (87%, 99%, 24.56 and 0.04), uterosacral ligament (91%, 90%, 31.35 and 0.37) and rectosigmoidal (97%, 97%, 88.51 and 0.1) endometriosis. TVS is a more useful test than is vaginal examination in detecting endometriosis in the ovaries and rectosigmoid.

Laparoscopic sigmoid resection with transrectal specimen extraction: a novel technique for the treatment of bowel endometriosis

Multidisciplinary laparoscopic treatment is the standard of care for radical treatment of deep infiltrating pelvic endometriosis. If bowel resection is necessary, a muscle-split or Pfannenstiel incision is also required. The avoidance of any laparotomy could decrease surgical stress response, give a faster return to normal bowel function, decrease post-operative pain and reduce wound complications and incisional hernias. We assessed post-operative outcome after a full laparoscopic sigmoid resection for bowel endometriosis. Twenty-one patients who underwent elective full laparoscopic sigmoid resection for bowel endometriosis from September 2009 to September 2010 were matched for age, American Society of Anesthesiologists class and BMI to 21 patients who underwent a conventional laparoscopic sigmoid resection. Groups were compared for peri-operative factors, complications, length of hospital stay, post-operative pain (Visual Analog Scale: VAS), analgesics consumption and inflammatory response (plasma C-reactive protein: CRP). Median operating time was 15 min shorter with transrectal specimen extraction (P = 0.003). VAS-scores and use of analgesics were higher in the conventional laparoscopic group (P = 0.0005). Mean CRP-level tended to be higher in the transrectal specimen extraction group (38%, P = 0.054) but there was no difference in increase in CRP level between groups (P = 0.15). There were no anastomotic leaks or reinterventions in either group, and the median hospital stay was similar. At follow-up, no wound infections or incisional hernias were observed and no patients reported anal dysfunction. Full laparoscopic sigmoid resection reduced operating times and decreased post-operative VAS-scores and analgesic requirements compared with the conventional laparoscopic sigmoid resection for bowel endometriosis.

Erratum to: A new technique for laparoscopic anterior resection for rectal endometriosis

Erratum to: A new technique for laparoscopic anterior resection for rectal endometriosis

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery

To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility. Prospective study. Tertiary-care university hospital. Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery. Laparoscopically assisted vs. open colorectal resection. Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy. The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group. This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.

Erratum to: A new technique for laparoscopic anterior resection for rectal endometriosis

Erratum to: A new technique for laparoscopic anterior resection for rectal endometriosis

Response to Dennerstein letter: Bowel resection for severe endometriosis: an Australian series of 177 cases

Response to Dennerstein letter: Bowel resection for severe endometriosis: an Australian series of 177 cases

Urinary dysfunction after colorectal resection for endometriosis: results of a prospective randomized trial comparing laparoscopy to open surgery

To evaluate urinary symptoms before and after colorectal resection for endometriosis using validated questionnaires. We randomly assigned 52 patients with colorectal endometriosis to undergo laparoscopically assisted or open colorectal resection. The median follow-up was 19 months. Urinary symptoms were evaluated using the International Prostate Score Symptom and the Bristol Female Low Urinary Tract Symptoms questionnaires. Dysuria was observed in 29% of cases postoperatively. Using Bristol Female Low Urinary Tract Symptoms and International Prostate Score Symptom scores, an alteration was observed for voiding symptoms (P = .01 and P = .006, respectively). No difference was observed between the laparoscopy and the open surgery group. An alteration of the International Prostate Score Symptom voiding symptoms was observed in the group that did not undergo nerve sparing surgery (P = .048). An alteration of the International Prostate Score Symptom voiding symptoms was observed for patients who underwent vaginal resection (P = .01) and parametrial resection (P = .02). Our findings confirm that colorectal resection for endometriosis is a source of urinary dysfunction whatever the surgical route.

Editor’s Choice

Editor’s Choice

Follow-up of dysfunctional bladder and rectum after surgery of a deep infiltrating rectovaginal endometriosis

The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. Major goal of this review article is to compare different surgical techniques of deep infiltrating endometriosis and their follow-up results. The research strategy included the online search of databases [MEDLINE, EMBASE, SCOPUS] for the diagnosis of deep infiltrating endometriosis with the indication of an operative resection. The outcome of the follow-up terms were noticed and compared. All in all, 16 trials could be identified with included follow-up. In all patients at least single-sided resection of the uterosacral ligaments were performed. Follow-up was heterogeneous in all trials ranging from 1 to 92 months. Postoperative symptoms, such as dysmenorrhoea, pelvic pain, and dyspareunia were commonly described in the majority of trials. Nevertheless, a tendency towards lower comorbidity after nerve sparing resection of endometriosis could be observed. Identification of the inferior hypogastric nerve and plexus was feasible in the minority of trials. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Laparoscopic sigmoid resection with transrectal specimen extraction has a good short-term outcome

Transrectal specimen extraction in laparoscopic sigmoid resection avoids a muscle-split incision for specimen retrieval. A technique for transrectal specimen extraction is described, and the results of a pilot study concerning feasibility are presented. All consecutive patients undergoing laparoscopic sigmoid resection with transrectal specimen extraction were included in this observational study. A specimen retrieval pouch was used to facilitate specimen extraction. All preoperative and operative data, postoperative morbidity, and short-term outcome were gathered in a database. The described technique was used to treat 21 patients. The median age of the patients was 41 years (interquartile range [IQR], 34-66 years). The median body mass index (BMI) was 23 kg/m2 (IQR, 22-26 kg/m2), and 90% of the patients were women. Of the 21 patients, 13 (62%) underwent a resection for endometriosis, 5 (24%) had resection for diverticular disease, and 3 (14%) underwent a tumor resection. The median operating time was 105 min (IQR, 90-110 min), and the median intraoperative blood loss was 10 ml (IQR, 0-20 ml). All the procedures except one (95%) were performed within 2 h. The median length of the extracted specimen was 20 cm (IQR, 13-25 cm). There was one anastomotic leak (5%), treated by emergency laparotomy and creation of a new colorectal anastomosis. None of the patients required a temporary diverting stoma, and no postoperative mortality occurred. The median hospital stay was 6 days (IQR, 5-7 days). All the patients did well during a median follow-up period of 3.6 months, and none reported any anal dysfunction. Laparoscopic sigmoid resection with transrectal specimen extraction is feasible and has a good short-term outcome.

Scarless reconstruction of circular umbilical defects after resection of endometriosis

Objective: Approximately 0.5–1% of patients diagnosed with endometriosis present with cutaneous lesions in the umbilicus. For symptomatic patients complete excision is mandatory and frequently results in resection of the entire umbilicus. The resulting circular defects require umbilical reconstruction to achieve a cosmetically satisfying result in these mostly young patients. Methods: We report on our surgical technique of choice used in patients with circular defects in projection of the umbilicus. The umbilical mass is widely excised down to the level of the fascia of the rectus muscle. When indicated diagnostic laparoscopy can be performed using the same incision. Defatted skin flaps of the surrounding tissue are mobilized and the apical flap is attached to the aponeurosis of the rectus muscle using non-resorbable suture. Without further incisions two lateral flaps are folded in the centre and attached to fascia using two non-resorbable stitches forming a 'neo'-umbilicus. Results: Postoperative course and wound healing was uneventful. The cosmetic result was satisfying for the patients. Conclusion: We report about a simple surgical technique applicable in patients with circular defects in projection of the umbilicus, which provides satisfying cosmetic results without prominent visible scars. Supplementary laparoscopic inspection of the abdominal cavity can be performed without further incisions.

Do patients manage to achieve pregnancy after a major complication of deeply infiltrating endometriosis resection?

ObjectiveTo evaluate the fertility status in women suffering from major postoperative complications following deep endometriosis surgery. Study designA retrospective study in teaching and research hospitals (tertiary centers) including 23 women submitted to the surgical treatment for deep endometriosis and presenting a major postoperative complication. Postoperatively, women desiring pregnancy who conceived were compared to those who did not conceive using Mann–Whitney test and Fisher's exact test. Main outcome measure included the pregnancy rate among these women. ResultsThe overall intrauterine pregnancy rate was 47.8% and the live birth rate was 30.4%. There were 10 spontaneous conceptions and 3 IVF conceptions among 11 patients. Women who did not conceive were older than those who conceived (33.9 vs. 29.3 years; p=0.02). The pregnancy rate after intestinal complications was lower than after urinary complications (33.3% vs. 83.3%; p=0.04). ConclusionFertility remains preserved among women experiencing a major complication after removal of deep endometriosis with a live birth rate of 30.4%. Women experiencing bowel complications have a reduced probability of conception compared with those who experience a urologic complication.

Bowel resection for deep endometriosis: a systematic review

deep endometriosis involving the bowel often is treated by segmental bowel resection. In a recent review of over 10000 segmental bowel resections for indications other than endometriosis, low rectum resections, in particular, were associated with a high long-term complication rate for bladder, bowel and sexual function. to review systematically segmental bowel resections for endometriosis for indications, outcome and complications according to the level of resection and the volume of the nodule. all published articles on segmental bowel resection for endometriosis identified through MEDLINE, EMBASE and ISI Web of Knowledge databases during 1997-2009. the terms 'bowel', 'rectal', 'colorectal', 'rectovaginal', 'rectosigmoid', 'resection' and 'endometriosis' were used. Articles describing more than five bowel resections for endometriosis, and with details of at least three of the relevant endpoints. data did not permit a meaningful meta-analysis. thirty-four articles were found describing 1889 bowel resections. The level of bowel resection and the size of the lesions were poorly reported. The indications to perform a bowel resection were variable and were rarely described accurately. The duration of surgery varied widely and endometriosis was not always confirmed by pathology. Although not recorded prospectively, pain relief was systematically reported as excellent for the first year after surgery. Recurrence of pain was reported in 45 of 189 women; recurrence requiring reintervention occurred in 61 of 314 women. Recurrence of endometriosis was reported in 37 of 267 women. The complication rate was comparable with that of bowel resection for indications other than endometriosis. Data on sexual function were not found. after a systematic review, it was found that the indication to perform a segmental resection was poorly documented and the data did not permit an analysis of indication and outcome according to localisation or diameter of the endometriotic nodule. Segmental resections were rectum resections in over 90%, and the postoperative complication rate was comparable with that of resections for indications other than endometriosis. No data were found evaluating sexual dysfunction.