Posterior Deep Endometriosis What is the best approach

12/01/2016
Posterior Deep Endometriosis
What is the best approach ?
Dept Gyn Obst
Polyclinique Hotel Dieu
CHU Clermont Ferrand
France
Posterior Deep Endometriosis
Organs involved
- Peritoneum
- Uterine cervix
- Rectum
- Vagina
Should we perform a routine
excision of the vagina ??
janvier 16
WES Melbourne
2008
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Deep disease in the
Posterior cul de sac
The lesion is visible
vaginally.
We have two signs
- blue cysts
- pseudo
polyps
Postoperative clinical examination
< 1998
n
No nodule preop
Normal post op clinical exam.
Lost to follow up
Persistent nodule
%
≥1998
n
%
46
140
4
20.0
60.7
1.7
19
138
15
10.8
78.4
8.5
30
13.0
4
2.2
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Background
The first line management of deep infiltrating
endometriosis is surgery; however, which surgical
technique to use is an ongoing debate.
It is unclear whether the posterior vaginal fornix must
routinely be excised.
Objective
To evaluate histologically whether
the routine excision of the posterior vaginal fornix
was necessary in the surgical management of patients
with large rectovaginal endometriotic nodules.
Patients
Prospective database: Oct./2001-Mar./2007
Rectovaginal endometriotic nodules > 2 cm in size
61 patients: for the present histological analysis
- 29 patients: 3cm > nodule >2cm ,
- 32 patients: nodule ≥ 3 cm.
rASRM stage I: 3 patients; stage II: 18 patients
stage III: 8 patients; stage IV: 32 patients
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Methods
The minimum distance on histological sections
was measured using a computerized analysis system
V
H&E
E
V
E
E
V
V: Vaginal mucosal epithelium; E: Endometriotic lesions
Results
The minimum distance between the vaginal mucosal
epithelium and the endometriotic glands
Distance (m)
No. of
patients
500 <
500-1000
1000-2000
2000-3000
3000-4000
4000-5000
20
(32.8%)
10
(16.4%)
14
(23.0%)
5
(8.2%)
5
(8.2%)
6
(9.8%)
30 patients (49.2 %) <1000 m
44 patients (72.1%) < 2000 m
60 patients (98.4% ) < 5000 m
Results
The minimum distance:
with or without pre-operative medical treatment
Treatment group
No treatment
(n=21)
Distance
(m)
1829±1697
GnRHa
(n=18)
1033±1047
Continuous
oral P (n=14)
1893±1517
Continuous
OC (n=3)
Cyclic
OC(n=5)
2169±2457
1505±1127
Data: mean ± SD
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Conclusion
Excision of posterior vaginal fornix is
necessary for the complete removal
of large rectovaginal endometriotic nodules
in more than 70% of the cases.
If we avoid vaginal excision to perform a
safer bowel resection
Do we transform the treatment of a
gynecological disease in a colo rectal
procedure ?
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Preoperative management
Clinical symptoms +++++
Imaging
Bowel prep
Multidisciplinary team
- Colo rectal surgeon
- Urologist
- Pain specialist
- Plastic surgeon
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Clinical
Symptoms
Pain
No digestive sign
Significant digestive
complaints
No pain
No
surgery
Surgical technique: Initial steps
• Effective uterine manipulator
• Exposure of the pelvis
• Adhesiolysis of the sigmoid colon up to the superior pelvic brim so
as to facilitate the identification of the left ureter
• Identification of the ureters
• Dissection of the ureter if the nodule involves the US or is more
than 2 cm in diameter
• Dissection of the para rectal area on both sides
• Dissection of the lateral and inferior surface of the nodule in the
para rectal spaces
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Limits (1e)
Limits (1f)
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Limits (1g)
Limits (1h)
Initial steps
• It is essential to identify vulnerable structures in a
normal area
• It is essential to increase the mobility of the nodule so
as to facilitate the following steps of the procedure
• It is essential to preserve the hypogastric and
splanchnic nerves whenever possible (both sides are
rarely involved, but when the nerves are involved by
the nodule they cannot be preserved
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Then ……
The nodule is fixed to the uterus, to the
vagina anteriorly and to the rectum
posteriorly
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The best surgical approach ?
• Dissection of the rectum from the nodule first
• Excision of the vagina first
Dissection of the rectum first
Examples
Exemple (1)
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Technique (2)
Technique (3)
Technique (10)
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Technique (1)
Technique (4)
Technique (5)
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Technique (6)
Technique (7)
Technique (8)
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2 nd look after recto vaginal nodule
Advantages of the rectum first
• Most difficult part of the operation at the beginning of
the procedure
• The nodule is retracted by the vagina and or the
cervix
• The vision from the ombilicus is good behind the
cervix
• Earlier diagnosis of the bowel involvement
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Uneventful postoperative course
And uneventful pregnancy the following year
1998 - 2002
Indications for surgery
N




Dysmenorrhea
Dyspareunia
Bowel symptoms
Infertility
164
91
53
99
%
81.0
45.0
26.0
47.0
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Objectives of the treatment



Complete excision of the nodule
Including bowel and vagina when necessary
Conservative surgery to preserve fertility was
mandatory in most of these patients
Results




Between January 1998 and December 2002
176 patients were treated for deep infiltrating
endometriosis involving the bladder or the posterior cul de
sac
Mean age was 31.5 ± 7.5 years old
Mean diameter of the nodule (pathology) 2.2 cm (0.5-6cm)
Procedures performed
(201 cases)
%

Conversion to laparotomy

Adhesiolysis (severe)

Ureterolysis

Bladder excision

Vaginectomy




1
0.5
148
73.0
99
49.0
3
1.5
113
56.0
Hysterectomy *
8
4.0
Adnexectomy
3
1.5
Colon resection
10
5.0
Partial or full thickness bowel excision
46
22.5
* Decided with the patient before the procedure patients ≤ 40 years old
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Postoperative clinical examination
< 1998
n
≥1998
%
n
n
No nodule preop
46
Normal post op clinical exam. 140
Lost to follow up
4
20.0
60.7
1.7
19
138
15
10.8
78.4
8.5
n
Persistent nodule
13.0
4
2.2
n
n
30
%
Recurrences



10 % of these patients were reoperated for
recurrent pelvic pain or for an ovarian
endometrioma
Persistent deep disease was found in only 20% of
these patients (less than 5% of all the patients)
The follow up is shorter
Severe complications
N = 230







Rectovaginal fistula
Ureteral fistula
Ureteral stenosis
Ureteral injury
Hemorrhage
Septicemia
Pelvic abscess







1
1
1
1
2
1
-
1998 - 2002
N =176
7
1
2
3
P< 0.02
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Severe complications increased



Diameter of the nodule increased
The conversion rate decreased
The surgical approach was more agressive


The incidence of vaginal excision, rectal procedure and patients
with extensive adhesion increased
Main explanations for recto vaginal fistula were
Surgical mistakes (if you have a complication, you have to accept
that you did something wrong)
 Very large nodule ≥ 4 cm
 Previous surgery for deep disease

Feasibility and clinical outcome of laparoscopic
colorectal resection for endometriosis.
Darai E et al
Thirty-six women (90%) underwent laparoscopic
segmental colorectal resection and 4 required
laparoconversion. Major complications occurred in 4 cases
(10%), including 3 rectovaginal fistulae and 1 pelvic
abscess.
Prevention of the complications

Omental flap
Increased indication for bowel resection ?
Avoid incision of both the vagina and the bowel ?
Routine ileostomy when both are opened

Careful indication for re operation in such patient

Earlier diagnosis and treatment of deep endometriosis







Patients and women education
Physician education
Listen to the patient’s pain
Careful palpation of the posterior cul de sac
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« The reverse technique »
The Reverse technique: Rationale
The most important part of the procedure is the treatment of the rectum either
« skinning » or bowel resection
Vaginal excision is easier !
Exposure is the key of surgery
Mobility of the treated organs is the key to exposure
To achieve the most important part of the procedure the exposure should be optimal
To improve the exposure mobility should be improved
The only way to improve the mobility of the nodule before the treatment of the
rectum is to separate it from the uterus and from the normal vagina
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The reverse technique
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The reverse technique
2
1
3
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The reverse technique
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The reverse technique
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Vagin ouvert
1
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2
3
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2
3
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1
2
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The reverse technique
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2
3
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3
2
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The reverse technique
The « reverse technique »
Comparative Results
• 2002 – 2009
• 75 patients
– 35 patients treated with the standard technique
– 40 patients treated with the reverse technique
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Data of the groups
Standard technique
N = 35
Reverse Technique
N = 40
Mean age
30.7 ± 5.1
30.8 ± 6
Mean BMI
21.9 ± 3
22.6 ± 3
0 (0-3)
0 (0-3)
2 (0.5-5)
2 (0.5 – 4.5)
Parity
Size of the nodule
Perioperative outcomes
Standard
N = 35
Operating time
Blood loss
Ureterolysis
Reverse
N = 40
p value
215.4 ± 108.8
192.4 ± 76.2
0.3
50 (20 – 700)
50 (20 – 700)
0.18
32 (91.4 %)
33 (82.5%)
0.26
32 (91.4%)
37 (92.5%)
3 (8.6%)
3 (7.5%)
Rectal surgery
0.86
Shaving
Resection
Post operative outcomes
Standard
N = 35
Reverse
N = 40
1 (2.9%)
0
0
0
1
24 (12 – 72)
24 (12 – 48)
0.14
Mean hospital stay (d)
3 (1 - 22)
3 (1 – 24)
0.59
Size of the nodule (cm Path)
3.4 ± 1.4
3.4 ± 1.1
0.94
Major per op Complication
Conversion
Paralytic ileus (h)
p value
0.28
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Post operative complications
Standard
N = 35
Reverse
N = 40
p value
Minor
4 (11.4%)
4 (10%)
0.84
Major
8 (22.9%)
2 (5%)
0.02
Recto vaginal fistula *
1 (2.9%)
1 (2.5%)
0.92
Standard group: 3 Post operative bleeding, 2 pelvic abscess, 2 ureteral fistulae,
1 recto vaginal fistula
Reverse group : 1 pelvic abscess, 1 stenosis of the ileostomy
Conclusion
• In the present study, the use of reverse laparoscopic
technique in patients with rectovaginal endometriosis
who required both rectal surgery and vaginal
resection reduced the major postoperative
complication rate compared to the standard
technique.
• Further and larger studies are necessary to confirm
this initial finding.
Conclusion
• Shorter learning curve ??
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There are bowel resection which
should be performed
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There are rectal resection which
are not necessary !
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Conclusion today !
Do we need a routine bowel resection ?
Prospective randomised studies are necessary
Omental flap almost routinely in difficult cases
Routine colostomy or ileostomy when the vaginal and
the rectum are both openned at the same time ?
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Bladder endometriosis
Tubes
Bladder
endometriosis
Bladder endometriosis
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Bladder endometriosis
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Bladder Endometriosis
Bladder endometriosis
Ureteral endometriosis
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Ureteral endometriosis
Ureteral endometriosis
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