Resection Of Endometriosis Research Articles

Fertility Sparing Surgical Management of Adenomyosis

<h3>Study Objective</h3> To describe the pathophysiology, diagnosis, and minimally invasive technique for fertility sparing adenomyomectomy. Postoperative outcomes including symptom control, pregnancies, and complications are also reviewed in this video. <h3>Design</h3> Video presentation. <h3>Setting</h3> University tertiary care hospital. <h3>Patients or Participants</h3> 19-year-old nulliparous patient with severe dysmenorrhea and chronic pelvic pain for 3 years who failed medical management and imaging showed a cystic adenomyoma. <h3>Interventions</h3> Adenomyosis is not uncommon in young reproductive aged women. Conservative surgical management of adenomyosis has been shown to improve painful symptoms and menorrhagia in greater than 70% of women at 1 year. The patient underwent an uncomplicated laparoscopic adenomyomectomy, endometriosis resection, diagnostic hysteroscopy, and chromopertubation. <h3>Measurements and Main Results</h3> At the 6-week postoperative follow up, the patient reported resolution of her painful symptoms. <h3>Conclusion</h3> Adenomyosis and endometriosis often coexist. Fertility sparing adenomyosis surgical management is feasible and effective when expectant or medical management is not appropriate or has failed. Patient counseling about the risks and potential uterine rupture in future pregnancies is mandatory.

Management of Pelvic Organ Prolapse with or without Hysterectomy Via Transvaginal Robotic Notes High Uterosacral Ligament

<h3>Study Objective</h3> To demonstrate stepwise techniques for the successful use of the robotic-assisted transvaginal natural orifice transluminal endoscopy surgery high uterosacral ligament suspension (RvNOTES-HUS) technique for pelvic organ prolapse with and without uterine preservation. <h3>Design</h3> Stepwise demonstration with narrated video footage (Canadian Task Force classification III). <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> Case 1: 62-year-old G0P0 with a symptomatic stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. Preoperative vaginal length was measured at 9cm. Case 2: 42-year-old G3P2 with a symptomatic fibroid uterus with stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. Preoperative vaginal length was measured at 8cm. <h3>Interventions</h3> Since the approval of the robotic platforms in gynecologic surgery by the Food and Drug Administration in 2005¹, robotic assisted surgery has been proliferating in the treatment of benign gynecological diseases including sacrocolpopexy, hysterectomy, myomectomy and endometriosis resection^2-5. In recent years, publications have demonstrated the feasibility and safety of traditional laparoscopic assisted high uterosacral ligament suspension for pelvic organ prolapse with long term follow up^6-8. However, robotic assisted RvNOTES-HUS has yet to be investigated in a publication. Utilizing the RvNOTES-HUS technique with or without uterine preservation operations greatly reduces the difficulty of intraperitoneal suture for the surgeon and postoperative pain for the patient. <h3>Measurements and Main Results</h3> Case 1: Procedure was successfully performed with a postoperative vaginal length of 8cm. Pain level was 4/10 in the first week, 2/10 in the second, 0/10 in the third. POP was stage 0. Case 2: Procedure was successfully performed with a postoperative vaginal length of 7cm. She had one day of post-operative pain. POP was stage 0. <h3>Conclusion</h3> RvNOTES-HUS is a practical technique in women with uterine prolapse while choosing whether to preserve the uterus. This technique allows for the better exposure of the ureter, while the articulating robotic joints allow for increased precision of dissection and suturing.

Novel Technique for Performing a Minimally Invasive Myomectomy: Robotic vNOTES Myomectomy

<h3>Study Objective</h3> This video demonstrates robotic vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy. <h3>Design</h3> There are various routes for myomectomy. The vaginal route is preferred for hysterectomy as it eliminates abdominal incisions and is associated with shorter hospital stays, operative time and recovery¹ and this can be assumed with myomectomy. However, visualization may be difficult with limited space. Robotic surgery offers enhanced visualization and precision. vNOTES myomectomy is previously described² however traditional laparoscopic instruments offer limited motion which makes suturing difficult. Robotic vNOTES is used for hysterectomy, sacrocolpopexy and endometriosis resection.^3,4,5,6 One study showed that for hysterectomy, there was no difference in operative time, admission length or postoperative pain between robotic and traditional vNOTES. This study proposed that robotic vNOTES was beneficial due to use of wristed instruments.³ Given advantages of vaginal and robotic surgery, the robotic vNOTES myomectomy technique was developed. <h3>Setting</h3> Academic hospital. Positioning was dorsal lithotomy, steep Trendelenburg. <h3>Patients or Participants</h3> A 28-year-old presented with pain and heavy periods. She had no significant history and had 3 prior vaginal deliveries. Imaging showed an 8cm posterior uterine fibroid and she desired fertility sparing, surgical management. <h3>Interventions</h3> A 3cm posterior colpotomy was made and an Alexis retractor with gel port was placed through the colpotomy. The Da Vinci robot was docked vaginally and myomectomy of an 8cm fibroid was performed. After the fibroid was detached, the myometrium was closed in layers. The robot was undocked and contained morcellation of the fibroid was performed using the ExCITE technique.⁷ The posterior colpotomy was closed. <h3>Measurements and Main Results</h3> The patient was discharged home same day with 100cc blood loss. <h3>Conclusion</h3> This video shows that robotic vNOTES is a feasible technique for myomectomy. It offers the benefits of minimally invasive vaginal surgery and the detail and precision of robotic surgery while maintaining quick post operative recovery and minimal blood loss.

Robotic Disc Excision with Sutured Repair for Full Thickness Deep Infiltrating Endometriosis of the Sigmoid Colon.

<h3>Study Objective</h3> To clearly demonstrate technique for full thickness disc resection and sutured closure for deep infiltrating endometriosis of the sigmoid colon. <h3>Design</h3> N/A. <h3>Setting</h3> Community Hospital. <h3>Patients or Participants</h3> A 36-year-old patient with deep infiltrating endometriosis of the rectovaginal septum, left ovary, and sigmoid colon. <h3>Interventions</h3> A robotic surgery was performed with TLH and LSO, as well as shave resection of rectal endometriosis. A large nodule of sigmoid deep infiltrating endometriosis is identified. Full thickness excision with sutured closure is demonstrated. We include instruction on proper technique for stay suture placement and mucosal suture placement to ensure a wide-lumen closure perpendicular to the axis of the colon. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Full thickness disc resection of the sigmoid colon is both feasible and reproducible using these techniques, either robotically or laparoscopically. Conservative excision techniques such as this allow full excision of diseased tissue while preserving the continuity of the bowel.

Diagnosis and Treatment of Vesico-Peritoneal Fistula after Robotic Surgical Treatment of Deep Endometriosis

<h3>Study Objective</h3> Demonstrate the diagnosis and surgical treatment of vesico-peritoneal fistula after robotic surgical treatment of deep endometriosis. <h3>Design</h3> Case report illustrated with a video. <h3>Setting</h3> Patient is placed in the semi-gynecological position on both surgical approaches. <h3>Patients or Participants</h3> A 38-year-old woman reports right iliac fossa pain, dysuria, and deep dyspareunia for 4 years. A 3 cm hard and painful nodule was palpable in the right iliac region of abdominal wall. MRI shows a 3.0 × 1.4 × 1.3 cm retrocervical lesion and irregular thickening of the uterosacral ligament insertion, suggestive of deep endometriosis. A 2.7 cm endometrioma on left ovary. And a 6 × 3 × 1.5 cm intramuscular nodule on the inferior abdominal aspect that affects virtually the entire muscle thickness. <h3>Interventions</h3> Robotic-assisted laparoscopic resection of pelvic endometriosis and abdominal wall nodules, with abdominal mesh placement. On the 7th postoperative day, the patient developed acute abdominal pain due to abdominal wall abscess and bladder catheter mechanical obstruction. Collection drainage was US-guided, but patient kept having recurrent urinary tract infections. CT showed a fistulous path communicating the bladder dome and the extraperitoneal space, and cystoscopy confirmed the fistula. Robotic-assisted laparoscopy was performed, Retzius space was developed for better exposure of the bladder and fistulous tract, with subsequent resection of the fistula and partial cystectomy with resection of the necrotic segment and part of synthetic mesh. <h3>Measurements and Main Results</h3> We obtained efficient diagnosis and treatment. The patient had complete resolution of the symptoms. <h3>Conclusion</h3> Vesico peritoneal fistula is a rare entity of epithelialized communication between peritoneal cavity and bladder, and it is usually associated with postoperative complications. As it has no specific symptoms, diagnosis is difficult.

Don't Forget to Look Up: Operating in the Upper Abdomen

<h3>Study Objective</h3> To illustrate strategies to improve efficiency and ergonomics when operating in the upper abdomen. <h3>Design</h3> A stepwise demonstration of our operating room modifications when operating in the upper abdomen with narrated video footage. <h3>Setting</h3> Given the marked improvement in laparoscopic technology, gynecologic surgeons feel comfortable operating in the pelvis for a variety of gynecologic pathologies. When pathology is found outside of the pelvis, however, gynecologic surgeons find operating in the upper abdomen challenging. Operating in the upper abdomen is difficult given the loss of ergonomics and the impression of operating backwards. It is prudent for minimally invasive gynecologic surgeons to master operating in the upper abdomen given the variety of pathologies a gynecologist can encounter outside of the pelvis. We aim to describe our operating room modifications that help simulate operating in the upper abdomen as if one was operating in the pelvic cavity. <h3>Patients or Participants</h3> A compilation of various patient procedures showcasing upper abdominal surgery including resection of pericardial endometriosis, Morrison's pouch endometriosis and a para-aortic lymphadenectomy. <h3>Interventions</h3> The patients elected to undergo laparoscopic surgery for their individualized evaluation and treatment plan. If the surgery is a combined procedure, after completion of the pelvic phase, the operating room must be modified to proceed with the upper abdomen. Strategies to improve efficiency and ergonomics when operating in the upper abdomen include: •Switching monitors to the patients' shoulders bilaterally •Changing surgeon location to the right side of the patient •Changing port configuration •30-degree camera selection <h3>Measurements and Main Results</h3> All patients recovered well without any postoperative complications. <h3>Conclusion</h3> Although gynecologic surgeons have the skills and adequate knowledge of anatomy to operate in the upper abdomen, some lack the ability to adapt their surgical set up to operate outside the pelvis. Gynecologists should familiarize themselves with strategies and techniques to be able to confidently operate in the upper abdomen.

Nerve-Sparing Laparoscopic Segmental Bowel Resection for Deep Endometriosis: The Negrar Method

<h3>Study Objective</h3> to demonstrate a nerve-sparing technique during laparoscopic segmental bowel resection for deep endometriosis. <h3>Design</h3> A step-by-step demonstration of surgical procedure of laparoscopic segmental bowel resection. <h3>Setting</h3> In several cases, segmental bowel resection may be necessary to achieve complete removal of the disease and significantly improve the quality of life. Laparoscopic complete excision of deep-infiltrating endometriosis can seriously affect bladder, rectal, and sexual function. The goal of the nerve-sparing approach is to better identify the visceral neural fibers and surgical landmarks. <h3>Patients or Participants</h3> patients who underwent nerve-sparing laparoscopic complete excision of endometriosis with segmental bowel resection (‘‘The Negrar Method''). <h3>Interventions</h3> Our surgical nerve-sparing bowel resection technique proceeds in 5 steps: Step 1 Development of the medial pararectal space (Okabayashi's space) and development of the lateral pararectal space (Latzko's space) and isolation of the ureteral course Step 2 Opening of the presacral space, development of avascular spaces, and identification and preservation of pelvic sympathetic fibers of the inferior mesenteric plexus, superior hypogastric plexus, upper hypogastric nerves. Step 3 Development of the rectovaginal space Step 4 The previously skeletonized inferior mesenteric vessels are transected Step 5 Rectal resection and colorectal anastomosis <h3>Measurements and Main Results</h3> The Nerve-sparing technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. <h3>Conclusion</h3> This kind of surgery requires uncommon surgical skills and anatomical knowledge; we believe that it should be performed only in selected reference centers.

8883 Total Laparoscopic Bladder Resection in the Management of Deep Endometriosis: “Take It or Leave It.”

<h3>Study Objective</h3> To highlight laparoscopic surgical anatomy for bladder resection in deep endometriosis (DE). <h3>Design</h3> Video article. <h3>Setting</h3> Laparoscopic 4K OR in IRCCS Sacro Cuore Don Calabria Hospital, Trendelenburg position under general anesthesia. <h3>Patients or Participants</h3> 35 years old woman complaining chronic pelvic pain and urinary specific symptoms, looking for pregnancy for 4 years. <h3>Interventions</h3> Opening and development of paravescical spaces, Bogros and Retzius spaces, bladder nodule isolation and resection of the whole-thickness portion of the nodule. En-bloc posterior eradication of DE after opening and development of para-rectal space and recto-vaginal space. <h3>Measurements and Main Results</h3> Duration of the surgical procedure was 180 minutes, blood loss 50cc, inpatient stay 12 days, Foley catheter was removed after 7 days (cystography was performed to assess bladder closure). <h3>Conclusion</h3> Laparoscopic bladder resection might be less invasive and precise if anatomical spaces are properly prepared and the resection is limited to the infiltrating portion of the nodule.

Two Methods for Adenomyotic Cyst Excision

<h3>Study Objective</h3> The objective of this video is to demonstrate two techniques for hysteroscopic resection of adenomyotic cysts. <h3>Design</h3> N/A. <h3>Setting</h3> A patient desiring fertility presents for further evaluation. Imaging is notable for two fundal cysts on ultrasound consistent with adenomyosis. After informed consent is obtained, OR hysteroscopy is performed under ultrasound guidance. <h3>Patients or Participants</h3> One patient with adenomyotic cysts is highlighted. <h3>Interventions</h3> The patient is taken to the operating room and a 5.5mm rigid hysteroscope is advanced to the fundus under ultrasound guidance. After confirming the location of adenomyotic cysts via ultrasound, hysteroscopic scissors are used to open the cysts, with adenomyosis confirmed by release of chocolate brown fluid. Cyst walls are resected in their entirety, one sharply and one with bipolar loop. <h3>Measurements and Main Results</h3> Direct visualization of the endometrial cavity as well as intraoperative ultrasound confirm complete removal of adenomyotic cysts. Pathology of the cyst walls confirmed adenomyosis. <h3>Conclusion</h3> Hysteroscopic resection of adenomyosis is safe and effective in select patients with focal disease, allowing for targeted removal under direct visualization. Here we demonstrate two hysteroscopic techniques for resection of adenomyotic cyst wall: sharp dissection, and the bipolar loop electrode.

Intraoperative Ultrasound Elastography Guided Rectal Shaving for Endometriosis

<h3>Study Objective</h3> Rectal surface endometriosis is more common in cases of cul-de-sac obstruction, and it is preferable in endometriosis surgery to remove as much of the deep endometriosis region as possible. The degree of rectal shaving may be confusing because the depth of the rectal superficial lesion cannot be assumed from the outside during surgery. For safe and appropriate resection, we attempted to confirm the location of the endometriosis lesion with intraoperative ultrasonography and elastography. <h3>Design</h3> Case report. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> A 23-years-old woman with dysmenorrhea diagnosed with left endometrioma and cul-de-sac obstruction by magnetic resonance imaging (MRI). <h3>Interventions</h3> Nerve-sparing endometriosis surgery including left ovarian cystectomy, cul-de-sac adhesiolysis, and deep endometriosis resection was planned. To evaluate the rectal surface endometriosis, a sterilized small ultrasound probe was inserted into the abdominal cavity through an abdominal trocar or small incision in the posterior vaginal fornix. Rectal surface fibrosis and the distance from the rectal muscularis were tried to be visualized with ultrasound elastography. <h3>Measurements and Main Results</h3> Intraoperative ultrasonography clearly indicated the safety distance from the rectal muscularis, and elastography showed hard fibrotic region on rectal surface with color visualization. There was no intra/post-operative complication. The pathological examination revealed the presence of endometriosis in the resected tissue. The visual analog scale (VAS) for dysmenorrhea was reduced from 70 to 10, and the VAS for dyspareunia was reduced from 50 to 0. <h3>Conclusion</h3> Intraoperative ultrasound elastography is considered to be a useful auxiliary means for safe rectal shaving by visualizing the fibrosis caused by endometriosis.

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center

Assess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO2 laser. Retrospective cohort study. University gynecologic surgery unit, referral center for endometriosis. A total of 207 women having undergone laparoscopic BE excision between January 1998and January 2019. None. Intra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n=176) for "isolated" and "non-isolated" BE groups. Forty-three patients presented with isolated BE. Bladder "shaving" without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n=132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p=.406). Age at surgery (hazard ratio 0.91 [0.84-0.98], p=.016) and postoperative pregnancy (hazard ratio 0.07 [0.01-0.91], p=.042) showed influence on disease recurrence. The study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection.

A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage

To propose a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage. A narrated video footage of the surgical approach of a clinical case with extensive adenomyosis and recurrent abortions. Institutional review board approval was obtained (No 3.725.458). A university center. We present a case of a 37-year-old patient, gravida 4 para 0 with a history of 3 first trimester miscarriages after spontaneous pregnancies, and a 20-week spontaneous abortion after an invitro fertilization pregnancy. She underwent 2 laparoscopic excisions of deeply infiltrative endometriosis and was treated with gonadotropin-releasing hormone for 6 months and dienogest for a year with no improvement of her adenomyosis. Currently, she experiences moderate dysmenorrhea and desires future fertility. For 3 months, gonadotropin-releasing hormone analogues were used before performing the robotic surgery for adenomyosis resection and abdominal cerclage. (Step 1) Control the blood supply with a tourniquet placed lateral to the uterine arteries at the level of the internal cervical os, and a diluted solution of vasopressin 20% is administered at the area to be excised. (Step 2) Uterine incision: we use a vertical uterine incision with monopolar scissors, extended anteriorly and posteriorly. (Step 3) Resection of adenomyosis: carried with monopolar scissors using pure cut current. It is recommended that 0.5-1 cm of the myometrium is maintained around the uterine cavity as well as the serosa. (Step 4) Flap 1: interrupted sutures with vicryl 2.0 are used to approximate the inner myometrium close to the endometrial cavity, and a 2.0 barbed suture is used to approximate the inner myometrium of the contralateral side of the incision to the ipsilateral outer myometrium. (Step 5) Flap 2: another 2.0 barbed suture is used to approximate the outer myometrium of the contralateral side to the base of the repaired inner myometrial layer. (Step 6) Serosal closure: the serosa is approximated with a barbed suture in a baseball fashion before the tourniquet is released and hemostasis is ensured. (Step 7) Abdominal cerclage: a mersilene tape is placed medial to the uterine arteries at the level of the internal cervical os and a tape is tied anteriorly. Description of a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage. The operating time was 255 min with minimal estimated blood loss (250ml). She was discharged with no complaints. Three months postoperatively, dysmenorrhea significantly improved, and the magnetic resonance imaging showed a good anatomic result. An embryo transfer is planned at 6 months postoperatively. A minimally invasive approach to fertility-sparing management of diffuse adenomyosis is safe and feasible with good anatomical results. However, it should be noted that after the removal of uterine adenomyosis, the patient should be advised on the high risk of uterine rupture during pregnancy. Robotic cerclage may also be performed concomitantly in cases of 2nd-trimester recurrent abortions.

Application of modified subtotal resection of adenomyosis combined with LNG-IUS and GnRH-a sequential therapy in severe adenomyosis: A case series.

Adenomyosis focus resection has always been the main surgical method for patients with uterine preservation, but its curative effect and surgical method are still controversial. We improved this method on the basis of the "double-flap method" and combined it with the levonorgestrel intrauterine delivery system (LNG-IUS) and gonadotropin-releasing hormone agonist (GnRH-a) sequential treatment to determine the clinical effect and feasibility of this scheme in the treatment of severe adenomyosis. This is a retrospective review. A total of 64 patients with severe adenomyosis were treated in the Department of Gynecology of Changzhou Second People's Hospital, which is affiliated to Nanjing Medical University, from December 2017 to September 2021. The transabdominal approach and laparoscopic approach were adopted for the purposes of treatment in this study. Hence, the patients were subdivided into the transabdominal approach subgroup and the laparoscopic approach subgroup. The hemoglobin, visual analog score (VAS) score, menstruation score, and other indices of each patient before and after treatment were observed, recorded, and analyzed. All 64 patients underwent the operation successfully. After the completion of sequential treatment, the CA125 decreased significantly 1month after the operation, the average uterine volume significantly reduced, the hemoglobin value increased to a certain extent 3months after the operation, and the menstrual score and dysmenorrhea during the first menstruation were significantly lower than they were before the operation. After the treatment, the therapeutic results of the transabdominal approach subgroup and endoscopic approach subgroup were compared on the basis of the observed indices, and no significant difference was observed (P > 0.05). Only one patient had a downward movement of the LNG-IUS, and the vaginal ultrasound showed that the upper end of the LNG-IUS was approximately 1.5 cm from the bottom of the uterine cavity. The average follow-up period was 24.02 ± 11.77months, and no lesion progression was found in any patients. For patients suffering from severe adenomyosis who have no pregnancy plans and require uterine preservation, transabdominal or laparoscopic subtotal resection of the focus of adenomyosis, combined with the LNG-IUS + GnRH-a sequential treatment, may be a safe and effective alternative when conservative treatments such as drugs fail.

Parametrial endometriosis: A predictive and prognostic factor for voiding dysfunction and complications

ObjectiveParametrial involvement (PI) in endometriosis is poorly defined resulting in an underestimation of its impact during surgical excision. The aim of our study was to assess the surgical complications associated with parametrectomy during surgery for endometriosis. Our secondary objective was to compare the surgical complications rates of a parametrectomy to the excision of other deep pelvic endometriotic locations. Study designPatients who underwent surgery for deep pelvic endometriosis from 2013 to 2018 in a French referral center were retrospectively included. Surgical complications were assessed according to whether a parametrectomy had been performed. The extent of surgery (colpectomy, torus, utero-sacral (USL) and/or rectal resection) was also assessed. Voiding dysfunction was defined as the need for self-catheterization ≥1 month and intra and postoperative complications were graded using the Clavien-Dindo classification (CDC). ResultsWe included 753 patients: 285 (37.8 %) with PI. Patients with PI had higher ASRM scores and more extensive surgery than those without. These patients also had higher rates of voiding dysfunctions (17.5 % versus 8.98 %, p < 0.01), and postoperative complications (44.6 % versus 24.6 %, p < 0.01), including major complications (CDC 3–4) (14.7 % vs 8.5 %, p = 0.01). The extent of the surgical resection of endometriosis was strongly associated with surgical complications after multivariable analysis, and the addition of a parametrectomy during surgery greatly increased rates of adverse postoperative events. Voiding dysfunction was frequent in women with combined resection of the torus, utero-sacral ligaments, parametrium and vagina (adjusted OR = 37.28, 95 %CI = 6.84–203.11, p < 0.01, reference: resection of the USL). ConclusionParametrectomy significantly impacts postoperative complications in patients undergoing surgery for endometriosis.

Long-term surgical outcomes of nerve-sparing discoid and segmental resection for deep endometriosis.

The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis. In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2). The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p < 0.001; DR group scores of 5, 0, and 1, respectively; p=0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups. Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment.

P-130 Morphokinetic analysis of early human embryo development and its relationship to endometriosis resection: a retrospective time-lapse study with the use of KIDScore D3 and D5

Abstract Study question Does complete resection of endometriosis improve embryo quality as assessed by morphokinetic parameters using time-lapse microscopy? Summary answer Complete resection of endometriosis in affected women undergoing assisted reproduction is shown to have a positive impact on embryo morphokinetic parameters represented in embryo quality. What is known already Endometriosis is one of the most common gynaecological diseases. It is characterized by the presence of cells comparable to those in the endometrium but being located outside of the uterine cavity. About 4-30% women of child-bearing age are affected by endometriosis. In vitro fertilization (IVF) studies have suggested that women with more advanced endometriosis have poor ovarian reserve, low oocyte and embryo quality and poor implantation rates. Moreover inflammatory peritoneal fluid shows a toxic effect on embryos. This might have an impact on morphokinetic timings but there is only limited data available concerning morphokinetics and endometriosis. Study design, size, duration 246 embryos (endometriosis group: n = 85; non-endometriosis control group: n = 115; complete resection of endometriosis= 46) undergoing infertility treatment at our clinics were included in this retrospective study. Inclusion criteria were female patients aged between 18 and 45 years undergoing IVF and / or ICSI treatment. The in vitro culture was performed in a closed time-lapse incubator (EmbryoScope®, Vitrolife) up to day 3 or in a prolonged culture up to day 5. Participants/materials, setting, methods Patient treatment included conventional insemination or intracytoplasmatic sperm injection. IVF inseminated or ICSI injected oocytes were culturd in the TimeLapse monitoring incubator. Embryos were cultured for 3 to 5 days without media change at 6.8% CO2 and 5% O2 at 37°C. During embryo culture morphokinetic parameters and events were constantly annotated. Analysis was performed using the EmbryoViewer software and evaluated applying KIDScoreTM D3 or KIDScoreTM D5 according to the day of embryo transfer. Main results and the role of chance The analysis revealed a median KIDScoreTM D5 of 2.3 (on a scale from 1 to 9.9) for embryos from patients suffering from endometriosis without complete resection. The control group without endometriosis achieved a score of 7.0 (p = 0.001). The median for embryos from endometriosis patients with complete resection was 7.1 which meant a significant increase compared to embryos from patients without complete resection (p = 0.002). Effect size according to Cohen showed a moderate up to strong biological effect (r = 0.4) for complete resection vs. no resection of endometriosis. For the three groups KIDScoreTM D3, pregnancy rates as well as abortion rates showed the same clinical trends. Additionally, we could describe a series of four patients undergoing IVF-cycles before and after a complete resection of their endometriosis. As expected, in three out of four cases they showed a clear increase in their embryo quality after complete resection of endometriosis. Limitations, reasons for caution The main limitation of the study is the relative small sample size of the groups, especially the number of patients with endometriosis resection. Additionally, the study is limited to its retrospective design. Wider implications of the findings Pathogenesis of endometriosis related infertility is multifactorial and not completely understood. But knowing that endometrioid lesions produce inflammatory cytokines which are toxic for oocytes and embryos, resection of the lesions in order to reduce inflammation seems to be a plausible approach. Trial registration number 20191007 01

O-308 The impact of NOSE colectomy and laparoscopic conventional segmental resection on bowel function and quality of life among patients with rectal endometriosis: prospective randomized trial

Abstract Study question What is the impact of laparoscopic conventional or NOSE colorectal resection on bowel function in patients with deep endometriosis infiltrating the rectum one year postoperatively? Summary answer Both conventional and NOSE colectomy improved the functional outcomes and quality of life among patients with deeply invasive rectal endometriosis one year after bowel surgery. What is known already Conventional laparoscopic approach to the surgical management of deep endometriosis infiltrating the rectum appears to assure improved digestive functional outcomes. NOSE technique for colorectal disease can significantly reduce the duration of hospital stay, accelerate postoperative recovery with better cosmetic results, and in particular, result in less postoperative pain and fewer complications. However, long-term solid data about gastrointestinal well-being after segmental bowel or NOSE resection for deep endometriosis are still missing. Study design, size, duration Between the 1st September 2019 - 31th of December 2020 we performed a 2-arm unblinded prospective randomized trial, enroling 91 patients with deep infiltrating rectal endometriosis up to 15 cm from the anal verge. Patients aged between 18 and 45 years, with deep endometriosis infiltrating at least the muscular layer in depth, and up to 50% of rectal circumference, complaining pain, bowel symptoms and/or infertility were included. The average follow up time was 14±2.6 months. Participants/materials, setting, methods Patients were enroled at Semmelweis University, Department of Obstetrics and Gynecology, Budapest, Hungary and had either conventional laparoscopic bowel resection or NOSE resection. Randomization was performed preoperatively using the simple randomization method. The primary endpoint was to assess the bowel function and quality of life by using the Endometriosis Health Profile 30, the Gastrointestinal Quality of Life Index and the Low Anterior Resection Syndrome score preoperatively, 1 month, 6 months, 1 year after the surgery. Main results and the role of chance A total of 91 patients were enroled. 39 patients were in the NOSE surgery arm, 49 were in the Conventional laparoscopic surgery arm. One patient was lost to follow-up and we had two cases of drop out from the trial after randomization due to performing non intended disc resection. This cases were excluded from the study. There was no conversion to laparotomy.The overall scores on Gastrointestinal Quality of Life Index (GIQLI), Low Anterior Resection Syndrome scores (LARS) and Endometriosis Health Profile 30 (EHP30) scores did not reveal significant differences between the two groups. LARS scores were improved, but did not reveal significant differences 12 months (T3) after the operation compared with the preoperative (T0) values in both groups (Conventional surgery group: T0=21.41 T3= 17.90; p = 0.934, NOSE surgery goup T0= 26.53 T3= 18.23; p = 0.229). GIQLI scores were significantly improved 12 months after the operation compared with the baseline values in Conventional surgery group T0= 95.44 T3= 111.39 p = 0.002. EHP30 scores were significantly improved concerning pain, emotion well-being, control and powerlessness, self-image, social support and sexuality scale 12 months after the operation compared with the preoperative values in both groups. Limitations, reasons for caution An obvious bias of performance is the lack of blinding, however blinding was not feasible due to the clinical nature of our study. We report no imprecision in patient selection, but a potential source of attrition bias in our data occured in a total number of three cases in NOSE-group. Wider implications of the findings Our study does not show a statistically significant difference between conventional or NOSE surgery for short and mid-term functional digestive outcomes. Occurrence of longterm bowel dysfunction does not appear to be related to a specific surgical technique. Trial registration number ClinicalTrials.gov number: NCT04109378

Robotic vaginal natural orifice transluminal endoscopic myomectomy

Robotic vaginal natural orifice transluminal endoscopic myomectomy

Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review.

The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis. Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed. CRD42021250974. A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR. Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

Ultrasound Prediction of Segmental Bowel Resection in Women with Rectovaginal Endometriosis: A Single-Center Experience

To retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis. Patients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection. We evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis. The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis. There were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and ≥2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37-34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03-33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56-3.64). Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis.