Surgical Treatment Of Deep Endometriosis Research Articles

Diagnostics and Surgical Treatment of Deep Endometriosis—Real-World Data from a Large Endometriosis Center

Background: Deep endometriosis (DE) is a special form of endometriosis, one of the most common benign diseases in gynecology. In the specific case of DE, ectopic endometrium can be found not only in peritoneal but also in deeper tissue layers or even as parenchymal organ infiltration. Symptoms include dysmenorrhea, dyspareunia, dyschezia, and dysuria, as well as asymptomatic hydronephrosis or other organ dysfunctions. Due to a pathogenesis of the disease that has not been conclusively clarified to date, no causal therapy exists, which is why surgical resection of DE is still the gold standard for symptomatic cases. Methods: This article retrospectively describes the challenges in diagnosis and surgical treatment of DE at a German Level III Endometriosis Center, with a focus on diagnosis and surgical treatment, as well as the analysis of perioperative and postoperative complications. Results: The surgical treatment of DE is performed in most cases by minimally invasive laparoscopy (94.1%), whereas complex procedures such as ureterolysis, adhesiolysis, or preparation of the rectovaginal septum are considered standard procedures as well. The complexity of the procedures is further underlined by a high need for interdisciplinary operations (28%). Despite high complexity, severe postoperative complications occurred in only 3.1% of surgeries, with the complication rate being significantly higher whenever bowel surgery was necessary for DE resection. Conclusions: Our results emphasize the complexity and interdisciplinary nature of the disease. Therefore, treatment should preferably take place at an endometriosis center of the highest level with experienced, well-coordinated teams.

Experience of using robot-assisted (da Vinci) operations in the treatment of common endometriosis

Background. Currently, genital endometriosis is considered as one of the most severe conditions in women of reproductive age, which has detrimental consequences for social, professional and psychological functioning. It ranks third in the structure of gynecological diseases after inflammatory diseases of the female reproductive system and uterine fibroids. Because of this, it acquires a more pronounced social significance and ceases to be only a medical problem. Aim. To study the results of surgical treatment of patients with severe forms of genital endometriosis using the da Vinci surgical robotic complex.Materials and methods. A retrospective analysis of the treatment results of 51 patients operated on at the N.I. Pirogov National Medical and Surgical Center for the period from January 2015 to July 2024, who underwent robot-assisted (da Vinci) operations for deep endometriosis involving neighboring organs. The duration of surgery and hospital stay, the amount of blood loss, the frequency of intra- and postoperative complications, the clinical course of the disease in the long-term postoperative period, the frequency of detection of residual infiltration in the postoperative period, and the implementation of reproductive plans were analyzed.Results. The duration of the surgical intervention was 220.8 ± 21.87 minutes. The postoperative bed-day was 6.9 ± 1.5 bed days. The average blood loss was 160.2 ± 67.58 ml. There were no intraoperative complications. Postoperative complications accounted for 7.8 %. Residual infiltration occurred in 11.7 % of cases. 94.1 % of the patients had no clinical symptoms of endometriosis in the long-term postoperative period. The pregnancy rate was 31.9 %.Conclusion. Surgical treatment of deep endometriosis using da Vinci surgical robotic complex in the amount of radical removal of endometrioid infiltrate has a positive effect on both the clinical course of the disease and the reproductive potential of a woman. Real-time fluorescence navigation has demonstrated additional imaging capabilities in robotic surgery for deep endometriosis, potentially increasing the radicalism of surgical treatment of infiltrating endometriosis and may lead to a reduction in recurrence rates.

The impact of surgical treatment for deep endometriosis: metabolic profile, quality of life and psychological aspects.

To evaluate the effects of surgical treatment of deep endometriosis on the metabolic profile, quality of life and psychological aspects. Prospective observational study, carried out with women of reproductive age diagnosed with deep endometriosis, treated in a specialized outpatient clinic, from October/2020 to September/2022, at a University Hospital in Fortaleza - Brazil. Standardized questionnaires were applied to collect data on quality of life and mental health, in addition to laboratory tests to evaluate dyslipidemia and dysglycemia, at two moments, preoperatively and six months after surgery. The results were presented using tables, averages and percentages. Thirty women with an average age of 38.5 years were evaluated. Seven quality of life domains showed improved scores: pain, control and impotence, well-being, social support, self-image, work life and sexual relations after surgery (ES ≥ 0.80). There was an improvement in mental health status with a significant reduction in anxiety and depression postoperatively. With the metabolic profile, all average levels were lower after surgery: total cholesterol 8.2% lower, LDL 12.8% lower, triglycerides 10.9% lower, and fasting blood glucose 7.3% lower (p < 0.001). Surgical treatment of deep endometriosis improved the quality of life and psychological aspects of patients. The lipid profile of patients after laparoscopy was favorable when compared to the preoperative lipid profile.

SUBTYPES OF DEEP ENDOMETRIOSIS ACCORDING TO LAPAROSCOPIC REVISION

A detalied description of the various manifestation of deep endometriosis should be reflected in classification #Enzian, which requires clinicians to understand the anatomical polymorphism of the disease. The purpose of the work is to explore the types of anatomical polymorphism of deep endometriosis, frequency and options for their combination to determine the main and rare subtypes of the disease. Materials and research methods. Deep endometriosis in 98% of cases is a polymorphic disease with a combination of peritoneal and ovarian endometriosis, and in 91.3% of women it is accompanied by adhesions of the pelvic organs of varying severity; in 2% of patients, deep endometriosis is an isolated form with severe damage to hollow organs; this requires proper preparation for surgical intervention in such patients with the involvement of a multidisciplinary team. Research results. Conclusions. Analysis of the identified subtypes in the future will form the basis for the development of an algorithm for standardized surgical intervention to improve the results of surgical treatment of deep endometriosis.

Surgical Treatment of Deep Endometriosis.

In deep endometriosis (DE), clusters of endometrium-like cells penetrate more than 5 mm below the peritoneum: The affected organs and tissue structures can eventuate in an alteration of the anatomy with eliminated organ boundaries, which in some cases can pose a real surgical challenge, even for experienced surgeons. A comprehensive description of the different manifestations of the disease can be found in the #Enzian classification. Since the operation is usually the foundation for the successful treatment of DE, what is important are conclusive indications, appropriate preoperative preparation and, above all, appropriate experience on the part of the surgical team. This article aims to provide a review of the surgical options that are currently available.

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.

DEEP ENDOMETRIOSIS: OVERWIEW OF CURRENT RECOMMENDATIONS AND OWN DATA

Endometriosis is a chronic inflammatory disease characterized by the presence of endometrial-like tissue outside the uterine cavity. Deep endometriosis is a lesion of the tissue of the abdominal cavity, similar to the endometrium, which spreads on the surface of the peritoneum or under it, is able to penetrate into adjacent structures and is accompanied by fibrosis and a violation of normal anatomy. Treatment of endometriosis includes pain reduction, improvement of fertility due to hormonal suppression of the level of endogenous estrogens, proapoptotic and anti-inflammatory effects on endometrioid tissue, as well as surgical removal or destruction of endometriosis foci and pelvic inflammatory process. But despite numerous studies, the optimal management of patients with deep endometriosis is still the subject of numerous discussions.&#x0D; An analysis of modern recommendations for the management of patients with deep endometriosis, the role of medical and surgical treatment in reducing the symptoms of pelvic pain and improving the fertility and quality of life of patients was carried out.&#x0D; The standardization of the procedure for surgical treatment of deep endometriosis proposed by us will help reproduce the sequence of surgical steps, which will lead to balancing the completeness of excision of tissues affected by endometriosis, and prevention of intra- and postoperative complications, preservation of female fertility.

Intestinal endometriotic nodules with a length greater than 2.25 cm and affecting more than 27% of the circumference are more likely to undergo segmental resection, rather than linear nodulectomy.

To analyze the efficacy of intestinal ultrasonography with bowel preparation (TVUSBP) for endometriosis mapping in evaluating intestinal endometriosis to choose the surgical technique (segmental resection or linear nodulectomy) for treatment. Cross-sectional observational study. University Hospital-Center for Advanced Endoscopic Gynecologic Surgery from April 2010 to November 2014. One hundred and eleven women with clinically suspected endometriosis and intestinal endometriotic nodule or intestinal adherence in TVUSBP for endometriosis mapping. All patients with suspected endometriosis underwent TVUSBP for endometriosis mapping prior to videolaparoscopy for complete excision of endometriosis foci, including intestinal foci, using the linear nodulectomy or segmental resection techniques, depending on the characteristics of the intestinal lesion with confirmation of endometriosis on anatomopathological examination. Preoperative ultrasonographic assessment of the length of the intestinal nodule, circumference of the intestinal loop affected by the endometriotic lesion, distance from the anal verge and intestinal wall layers infiltrated by endometriosis, as well as other endometriosis sites. Of the 111 patients who participated in the study, 63 (56.7%) presented intestinal endometriotic nodules in ultrasonography, performed by a single examiner (A.L.A.N.), and underwent intestinal surgical treatment of deep endometriosis-linear nodulectomy or segmental resection. The analysis of the receiver operating characteristic (ROC) curve showed that a longitudinal length of the intestinal nodule of 2.25 cm and a loop circumference of 27% are cutoff points separating linear nodulectomy from segmental resection techniques for excising intestinal endometriosis. The information obtained by TVUSBP helps the surgeon and patient, in the preoperative period, to select the surgical technique to be performed for resection of intestinal endometriosis and plan the surgical procedure while taking into account postoperative morbidity.

Surgical treatment of deep endometriosis with adenomyosis externa: a challenging case in an infertile woman

To describe the management and the fertility-enhancing potential of surgery in an infertile patient with deep-infiltrating endometriosis and adenomyosis externa. Video case report. Minimally invasive and robotic gynecologic surgery unit of a university hospital. A 31-year-old nulliparous patient with dysmenorrhea, dysuria, dyspareunia, and primary infertility. Bimanual examination, transvaginal ultrasound, and magnetic resonance imaging (MRI) were performed as a comprehensive preoperative workup. The findings were consistent with bladder endometriosis and a 4-cm right pararectal cystic mass suggestive of adenomyosis externa. Laparoscopic excision of all visible endometriosis was performed. A pararectal lesion was found, completely developing in the retroperitoneal spaces, from the right medial pararectal space to the rectovaginal space, reaching the pelvic floor fascia without infiltration of the levator ani muscle. According to Koninckx classification, this kind of lesion corresponds to type III endometriosis or adenomyosis externa. Nerve-sparing eradication of the nodule was performed. The decision to use these techniques was taken with the intention to treat the patient, and not with the aim of testing the procedures performed. Therefore, as a common clinical practice in our institution and for the above reasons, there was no need for consultation of the institutional review board for approval. Improvement of symptoms and spontaneous conception after surgical removal of all endometriotic implants. There were no intraoperative or postoperative complications, and the patient was discharged after 3 days. She discontinued postoperative hormone therapy with gonadotropin-releasing hormone analogue after 3 months because she desired fertility. She conceived spontaneously after 2 months of attempting. She delivered vaginally and had no complications during pregnancy and labor. Neither recurrence of pain symptoms nor voiding or rectal dysfunctions were reported by the patient. In the management of a case of deep endometriosis, the preoperative assessment should be carefully carried out to give the surgeon the most accurate information about the extent of the disease and the patient's main objectives. Imaging techniques such as ultrasound and MRI play a fundamental role along with the clinical evaluation in also detecting lesions that are not visible at first laparoscopic inspection. In this case of a young woman without any detectable fertility issues except for endometriosis, the laparoscopic excision of endometriosis was feasible, safe, and effective in improving the patient's fertility and pain symptoms. The fertility-enhancing potential of complete eradication of pelvic endometriosis, including removal of deep posterior localizations such those presented in this case, has been hypothesized by various investigators. It has been suggested that skilled surgical management for symptomatic deep endometriosis may be followed by a high pregnancy rate, with most pregnancies resulting from postoperative natural conception even in patients with primary infertility.

The current management of deep endometriosis: a systematic review.

Endometriosis is a chronic inflammatory disease that affects young women in reproductive age. It has mainly three different clinical presentations: superficial (peritoneal), ovarian (endometriomas) and deep endometriosis (DE). The last one is the most advanced form of the disease, frequently impairing fertility and harming women's quality of life (QoL). We conducted a systematic review on the surgical treatment of DE in the last ten years focusing on its benefits to improve QoL and for pain relief as well as related surgical complications. Twenty-three studies were included for qualitative analysis. Overall, included studies showed a relevant improvement in QoL as well as in pain scores using specific questionnaires and the ten-point Visual Analogue Scale (VAS) for pain. Until further comparative studies regarding medical versus surgical treatment for DE are concluded, currently, surgery is the best option for patients with DE and severe pain (VAS>7).

Incidental Appendectomy in the Surgical Treatment of Deep Endometriosis Infiltrating the Bowel: Anatomopathological Findings in a Series of 109 Patients.

Incidental Appendectomy in the Surgical Treatment of Deep Endometriosis Infiltrating the Bowel: Anatomopathological Findings in a Series of 109 Patients.

Surgical Strategy for the Treatment of Deep Endometriosis

Deep endometriosis is characterized by infiltrated lesions in the retroperitoneal space or in pelvic organs wall. Usually it gives anatomical distortion of the pelvis, retraction and adhesions. Surgical treatment of deep endometriosis is not an easy procedure and should be performed by surgeons which know all the disease and how to deal with it. For a good surgical treatment of deep endometriosis, we think that we must have a surgical strategy in order to remove all the endometriotic lesions as possible to obtain the relief of the symptoms. In this video we show our surgical strategy for treatment of deep endometriosis. We present all our surgical steps and the reasons of each one.

Surgical treatment of deep endometriosis and risk of recurrence

Study objective To evaluate the risk of recurrence of deep endometriosis after conservative surgery. Design Retrospective analysis (Canadian Task Force classification II-3). Setting Tertiary care university hospital. Patients One hundred fifteen symptomatic patients operated on in our department from 1996 through 2002 with postoperative follow-up of at least 12 months. Intervention All patients underwent conservative surgery for deep infiltrating endometriosis. Measurement and main results Risk factors for recurrence of symptoms and clinical findings and for repeated surgery were evaluated by univariate and multivariate analysis. During follow-up, we observed 28 patients with pain recurrence and 15 patients with recurrent clinical findings, and 12 patients required reoperation for deep endometriosis. Recurrence rates of pain and clinical findings during 36 months were 20.5% and 9%, respectively. Multivariate analysis showed that only age was a significant predictor of pain recurrence (OR 0.9, 95% CI 0.81-0.99, p <.05), enhancing the risk in younger patients. Recurrence of clinical signs of deep endometriosis was predicted by obliteration of the pouch of Douglas (OR 1.46, 95% CI 1.16-16.2, p <.05). Reoperation for deep endometriosis was predicted only by the incompleteness of first operation (OR 21.9, 95% CI 3.2–146.5, p <.001). Conclusion Our study indicates that age, obliteration of the pouch of Douglas, and surgical completeness may have a significant influence on the recurrence of the disease.

Surgical treatment of deep endometriosis and risk of recurrence

Surgical treatment of deep endometriosis and risk of recurrence