European Journal of Obstetrics & Gynecology and Reproductive Biology
Radical resection of invasive endometriosis with bowel or bladder involvement—Long-term results
Introduction
Endometriosis is defined as the presence of endometrial gland and stroma outside the endometrial layer of the uterus and is a common finding in women of reproductive age suffering from infertility or chronic pelvic pain (CPP). The incidence in the general female population lies in the 3–10%, and about 5–12% of these have gastrointestinal involvement of endometriotic lesions [1], [2], [3]. Patients presenting with symptomatic disease show a broad variety of symptoms ranging from infertility to pelvic pain and gastrointestinal symptoms. Especially in cases of deep pelvic endometriosis the disease must be considered progressive [4]. Classifying patients according to their chief complaint – infertility, pelvic pain or both – is essential for choosing the most effective individual form of therapy.
In infertility patients the incidence of endometriosis found during laparoscopy ranges from 20–68% [4]. Laparoscopic surgery for minimal or mild disease has been shown to improve infertility and pregnancy outcome [5]. If there is, with respect to fertility, a role for surgery in severe cases with deep infiltration has yet to be defined. However, patients have the option of an individualized regimen of hormonal therapy or assisted reproduction techniques.
Patients with pelvic pain as chief complaint may experience a variety of cyclic and non-cyclic symptoms. Endometriosis can be found in up to 71% of cases [4]. Dysmenorrhea, dyspareunia, dyschezia and chronic back pain are the most frequent forms of presentation. Clinical pain symptoms of invasive endometriosis seem to be related to the anatomic site of location: dyspareunia seems to be correlated with the infiltration of the uterosacral ligaments, dyschezia with endometriosis of the vagina, non-cyclic pelvic pain with bowel involvement, lower urinary tract symptoms with bladder infiltration, and gastrointestinal symptoms with bowel and vagina extension [6]. Patients with endometriosis associated pain have a wide range of therapeutic options. Non-surgical treatment includes hormonal approaches with progestagenes, danazol and GnRH agonists which, as in the case of danazol, exhibit severe side effects or provide relief only for a limited period of time [7], [8]. The median time to the recurrence of pain is 6.1 months after discontinuation of danazol and 5.2 months after discontinuation of GnRH agonist therapy [8].
Bowel or bladder infiltration is a special form of presentation of deep invasive endometriosis [9]. In addition to the classic symptoms patients may present with bowel obstruction, voiding problems, rectal bleeding and hematuria. Bowel endometriosis mostly occurs in the rectosigmoid [10]. As these patients frequently do not respond successfully to conservative treatment, radical resection is often the only remaining therapeutic option [11]. The type of resection, whether it is performed by laparoscopy or by open surgery depends on the technical feasibility of a radical resection requiring both a laparoscopically skilled gynecologic and a laparoscopically skilled colorectal surgeon.
The aim of the present analysis was to reevaluate patients undergoing bowel or bladder resection for invasive endometriosis and to show their long-term results.
Section snippets
Patients and methods
All consecutive cases of endometriosis with bladder or bowel involvement in our department over the last 8 years were included in this retrospective descriptive analysis. Preoperative work-up included IV-urography, vaginal and abdominal ultrasound exam, recto-sigmoidoscopy and cystoscopy in all patients. A MRI-Scan of the small pelvis was performed only in a minority of patients in whom clinical extent of disease remained unclear. Patients were intraoperatively classified according to the 1996
Results
All 23 patients were available for analysis and for follow-up telephone interviews. Mean age was 31.9 ± 3.5 years, patients had an average interval between aggravation of symptoms and surgery of 14.1 ± 7.4 months. Mean hospital stay was 12.7 ± 3.9 days with an average operating room time of 343 ± 85 min (Table 1).
All but 1 patient had previous treatment, 18 underwent previous laparoscopy (78.3%), 7 laparotomy (30.4%), and 3 patients did not respond successfully to a 6 month GnRH analoga therapy.
Role of surgery in deep invasive endometriosis involving rectum and bladder
Bowel endometriosis is a rather rare entity with an incidence of 5% [3] to 12% [2] of patients with endometriosis. The main sites of occurrence are the rectum and the rectosigmoid. The deep infiltration of the urinary bladder is even rarer [13], although involvement of the bladder peritoneum can be frequently observed. Diagnosis is difficult but patients’ typical symptoms including dyschezia, deep dyspareunia and hematochezia or hematuria in combination with the pelvic exam are leading to the
Conclusion
Radical surgery for deep endometriosis with bowel or bladder involvement leads to a persistent relief of pain symptoms. Thereby, although not tested in this study, it is likely to enhance patients’ quality of life. Especially the symptoms deep dyspareunia and dyschezia might be eliminated by this procedure. Although some patients relapse most respond to a medical treatment with Cox2 inhibitors. The decision between open surgery and laparoscopy is depending on the expertise of the performing
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