{"paper_id":"1403e0c1-1c64-4db6-83e1-ae81ac907d30","body_text":"Received\n 01/10/2014 \nReview began\n 01/11/2014 \nPublished\n 01/29/2014\n© Copyright \n2014\nNezhat et al. This is an open access\narticle distributed under the terms of the\nCreative Commons Attribution License\nCC-BY 3.0., which permits unrestricted\nuse, distribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nUse of Laparoscopic Modified Nerve-Sparing\nRadical Hysterectomy for the Treatment of\nExtensive Endometriosis\nCamran Nezhat\n, \nJames Xie\n, \nDiana Aldape\n, \nLouise P. King\n, \nRugeen Rose Soliemannjad\n, \nErika Balassiano\n, \nFarr\nNezhat\n1.\nCorresponding author: \nCamran Nezhat, \nnezhatinstitute@gmail.com\nAbstract\nINTRODUCTION:  Endometriosis is an estrogen-dependent chronic inflammatory condition affecting 6-10%\nof reproductive-aged women.  Chronic pelvic pain impacts the quality of life of patients with endometriosis.\nHere, we describe the use of laparoscopic modified radical hysterectomy for the treatment of extensive and\ndeeply infiltrating endometriosis.\nMETHODS: A retrospective chart review was conducted on patients with Stage IV endometriosis who\nunderwent laparoscopic modified radical hysterectomy. All patients had a history of extensive\nendometriosis that failed medical and conservative surgical treatment and caused significant recurrent\nsymptoms.  The objective of this study is to show the feasibility of treatment of Stage IV endometriosis by\nlaparoscopic modified radical hysterectomy.\nRESULTS: A total of 52 patients underwent laparoscopic modified nerve-sparing radical hysterectomy for\nendometriosis between October 2006 and September 2013. The most common preoperative symptom was\nchronic pelvic pain. Adjunctive procedures, including salpingo-oophorectomy, appendectomy, disc excision\nof the bowel and ureteroneocystostomy, and in one case bowel resection, were performed as indicated. Mean\npatient age was 44 years (range 32-55). Mean hospital stay was one day (range 0-3). Postoperative\ncomplications included one case of urinary retention, one vaginal cuff abscess, and one infected ureteral\nstent. Mean follow-up was 33 months (range 13-65). Out of 52 patients, 33 had at least one prior surgery for\nthe treatment of endometriosis.  All patients reported dramatic pain relief, and there were no reports of\nsymptom recurrence.\nCONCLUSION: In cases of severe endometriosis, the use of laparoscopic modified nerve-sparing radical\nhysterectomy is a feasible and effective method for achieving long-term improvement in pain symptoms.\n There was no difference noted between symptom recurrences in the group of patients with bilateral\nsalpingo-oophorectomy versus those with ovarian conservation in contrast to prior studies.  Of note,\n14 patients underwent bilateral oophorectomy, nine patients underwent unilateral oophorectomy, and two\npatients underwent removal of ovarian remnant.\nCategories:\n Obstetrics/Gynecology, General Surgery\nKeywords:\n endometriosis, laparoscopic hysterectomy, chronic pelvic pain, radical hysterectomy, robotic surgery,\nlaparoscopic surgery\nIntroduction\nEndometriosis affects 6-10% of reproductive-aged women \n[1]\n. The quality of life of patients with severe\nendometriosis can be greatly limited, most commonly by symptoms of pelvic and abdominal pain.\nManagement of endometriosis includes medical, surgical, and combinations of both medical and surgical\ntherapy. Medical therapies include gonadotropin-releasing hormone, progestins, estrogen-progestin\ncombination pills, and aromatase inhibitors. The use of these medications in conjunction with conservative\nablative laparoscopic treatments has become routine for pelvic pain secondary to endometriosis. When\nendometriosis is treated with conservative surgery, approximately 25% of patients will require subsequent\nsurgery due to recurrent endometriosis or progression of microscopic disease \n[2]\n.\nSevere endometriosis and infiltrating lesions of the pelvis, intestine, and genitourinary tract can cause\ndebilitating pain and even secondary problems, such as bowel and ureteral obliteration and end-organ\ndamage. This may lead to more radical treatment in the form of extirpative surgical procedures.\nThere is no consensus on the optimal surgical management of severe endometriosis. Several authors have\ndescribed radical surgery by laparoscopic excision of all detected endometriosis, while conserving non-\ninvolved structures to achieve improvement in quality of life \n[3-4]\n. This technique can often require an\nextensive laparoscopic \"en bloc\" resection of the area between the uterosacral ligaments, rectovaginal\n \n Open Access Original\nArticle\n \nDOI:\n 10.7759/cureus.159\nHow to cite this article\nNezhat C, Xie J, Aldape D, et al. (January 29, 2014) Use of Laparoscopic Modified Nerve-Sparing Radical Hysterectomy for the Treatment of\nExtensive Endometriosis. Cureus 6(1): e159. \nDOI 10.7759/cureus.159\n\nseptum, and anterior rectum \n[5]\n.\nAfter a thorough literature search, only one study was found which investigated the role of radical excision\nof deep endometriosis, the result of which was encouraging \n[6]\n. The prospective study consists of 57\nconsecutive patients who underwent radical laparoscopic excision of deep endometriosis. These\npatients answered a questionnaire preoperatively and four months postoperatively related to their pain and\nquality of life. In this study, patients with radical laparoscopic excision of endometriosis had significant\npain relief postoperatively. This report represents the first description of the role of laparoscopic radical\nexcision of deep endometriosis. \nMaterials And Methods\nA retrospective chart review was conducted on patients with Stage IV endometriosis who underwent\nlaparoscopic modified radical hysterectomy between October 2006 and September 2013. All patients had a\nhistory of extensive endometriosis, had failed medical or surgical treatment, and had significant recurrent\nsymptoms, such as pelvic and abdominal pain. Six of these patients underwent robot-assisted laparoscopic\nradical hysterectomy and the rest had standard laparoscopic radical hysterectomy. Out of 52 patients, 33\nhad at least one prior surgery (range: one--five) for the treatment of endometriosis.\nAll patients received standard outpatient preoperative evaluation, perioperative antibiotic prophylaxis,\nnasogastric or orogastric tube placement, sequential compression devices, examination under anesthesia,\nplacement of Foley catheter, and uterine manipulator \n[7]\n.\nModified nerve-sparing radical hysterectomy, in the context of our chart review, was defined as\nhysterectomy involving full dissection of the paravesical, pararectal, and recto-vaginal spaces and obturator\nspaces, isolation and ligation of the uterine arteries at their origins, dissection of the tunnels of Wertheim\nbilaterally with unroofing and skeletonizing of the ureters, and removal of at least half of the uterosacral\nligaments, cardinal ligaments, and a portion of the paracolpos. In this group of patients, endometriotic\nimplants were present in at least some, if not all, of these locations \n[8]\n.\nThe surgical technique was as follows: abdominal entry was performed with Veress needle and needle\nmapping \n[7]\n. Four trocar ports were placed (10 mm umbilical port, 5 mm suprapubic, and two 5 mm ports at\nthe lower abdominal quadrants) \n[9]\n. Adhesiolysis was performed when necessary to restore anatomy for\nplacement of the ports. \n[8]\n Thorough exploration of the abdomen and pelvis was performed to assess the\nextent of endometriosis, rule out any possible malignant disease, and evaluate the feasibility of the intended\nprocedure.\nBefore the hysterectomy was started, any pelvic pathology and extrapelvic endometriosis and adhesions\nwere treated to try to return the anatomy to “normal” as much as possible with use of either CO2 laser,\nPlasmaJet, laparoscopic scissor, or blunt dissection. Radical hysterectomy was then started with sharp\nanteversion of the uterus and development of the rectovaginal space by sharp and blunt dissection. Next, the\nretroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments. The round\nligaments were isolated, divided, and ligated close to the pelvic wall. The peritoneum overlying the\nvesicouterine fold was incised, and the bladder was mobilized using a combination of blunt and sharp\ndissection. The pararectal and paravesical spaces were opened. The utero-ovarian ligaments were then\nisolated, divided, and ligated. \nThe ureters were dissected free from the medial leaf of the peritoneum. Extensive bilateral ureterolysis was\nrequired and encompassed dissection from the pelvic brim to the bladder as well as exploration of the\nureteric canal. When the crossover of the uterine artery was reached, and the artery was isolated at its\norigin, it was divided and ligated. The uterine artery pedicle was dissected anteriorly over the ureter. The\nsuperior vesical arteries were preserved, if possible. Care was taken to avoid trauma to the adjacent viscera. \nThe peritoneum across the cul-de-sac was further divided, and the rectovaginal space was further developed.\nAt least half of the uterosacral ligament was excised, and in some cases, the ligaments were ligated at their\npoint of origin. The anterior and posterior colpotomies were performed using a moistened sponge stick or\nright angle retractor placed in the anterior and posterior fornix.\nA significant portion of the posterior wall of the vagina and rectovaginal septum was removed where\nendometriosis was involved. The uterus, cervix, and a portion of vagina were thus amputated and removed\nvaginally. The vaginal vault was closed with running suture.  During the entire procedure, care was taken to\navoid any trauma to the pelvic nervous system.\nPatients were discharged to home on the same day of surgery once they met recovery room criteria, such as\ntolerating oral intake, ambulating, and voiding freely. Out of our 52 patients, 11 were admitted overnight\nfor pain control or observation. Only one patient, who underwent bowel resection, was admitted for three\ndays until she was able to tolerate oral intake.   \n2014 Nezhat et al. Cureus 6(1): e159. DOI 10.7759/cureus.159\n2\n of \n5\n\nResults\nA total of 52 patients underwent laparoscopic modified nerve-sparing radical hysterectomy for\nendometriosis between October 2006 and September 2013. Six of these patients underwent robot-assisted\nlaparoscopic radical hysterectomy.\nThe most common preoperative symptom was chronic pelvic and abdominal pain. All patients had a history\nof extensive endometriosis with failed medical treatments that caused significant recurrent symptoms\nlimiting their quality of life. Out of 52 patients, 33 had at least one prior surgery (range: 1-5) for the\ntreatment of endometriosis.\nThe mean patient age was 44 years (range 32-55). All patients were found to have Stage IV endometriosis.\nThe mean hospital stay was one day (range: 1-3). Adjunctive procedures, including salpingo-oophorectomy,\nappendectomy, disc excision of the bowel and ureteroneocystotomy, enterocele repair, and in one case,\nbowel resection, were performed as indicated. Of note, nine patients had a history of unilateral\noophorectomy prior to surgery. At the time of modified radical hysterectomy, 14 patients underwent bilateral\noophorectomy, nine patients underwent unilateral oophorectomy, and two patients underwent removal of\novarian remnant.\nPatient characteristics\nAge\nRange 32-55\nPrior surgery for treatment of endometriosis\n33 out of 52\nNumber of surgeries for treatment of endometriosis\nRange 0-5 surgeries\nPrior unilateral or bilateral oophorectomy\n9 unilateral oophorectomies\nUnilateral oophorectomy at time of hysterectomy\n9\nBilateral oophorectomy at time of hysterectomy\n14\nRemoval of ovarian remnant at time of hysterectomy\n2\nPostoperative complications\n3 (urinary retention, vaginal cuff abscess, infection of ureteral stent)\nLength of hospital stay\nRange 1-5 days\nFollow-up\nRange 1-65 months\nTABLE\n 1: Results\nPostoperative complications included one case of urinary retention, one vaginal cuff abscess, and one\ninfected ureteral stent. All patients reported dramatic pain relief, and there were no reports of symptom\nrecurrence on follow-up which was, on average, 32 months (range: 1-65).\nDiscussion\nMinimally invasive surgery has revolutionized modern day surgery.\n[10]\n Despite advances in the field of\nminimally invasive surgery, a recent large cross-sectional study of nationwide hysterectomy rates found that\namong the almost 600,000 hysterectomies, 14% of them were performed laparoscopically. The majority of\nhysterectomies are still done by laparotomy. The general trend, however, is that more and more\nhysterectomies are performed by laparoscopy \n[11]\n.\nRadical surgery may be needed in patients with severe endometriosis, especially after failed medical\ntherapies or conservative surgeries. A number of studies focusing on the feasibility of bowel and bladder\nresection, with or without hysterectomy, by either laparotomy or laparoscopy for deep infiltrating\nendometriosis, showed acceptable morbidity and improvement of pelvic pain and fertility outcome \n[11, 18-\n21]\n. Fedele, et al. reported the only study comparing the use of modified radical hysterectomy versus\nextrafascial hysterectomy via laparotomy as extirpative treatment of such conditions. \n[6]\n  The mean follow-\nup of the extrafascial hysterectomy was 68.9 +/- 21.1 months with 31% of women in this group reporting\nrecurrent pain symptoms between six and 18 months of surgery. The mean follow-up of the radical\nhysterectomy group was 31.3 +/- 8.7 months with no patients reporting recurrent pain symptoms or\nrequiring further surgery.\nSince the first laparoscopic radical hysterectomy was reported by Nezhat, et al. \n[12-16]\n in 1989 for the\n2014 Nezhat et al. Cureus 6(1): e159. DOI 10.7759/cureus.159\n3\n of \n5\n\ntreatment of cervical cancer, the feasibility and efficacy of this procedure have been supported in both\nminimally invasive gynecology and gynecologic oncology literature \n[24-26]\n. The use of such technique for\ncomplete excision of severe endometriosis has not been reported in the literature. This case series\nrepresents the first such report of laparoscopic radical hysterectomy for such an indication.\nWomen who undergo ovarian preservation surgery have a higher recurrence rate than those who undergo\nradical surgical treatment. The recurrence rate of endometriosis after radical surgical treatment reported is\napproximately 3% \n[27-28]\n. All patients in this study, some with long-term follow-up (average follow-up 32\nmonths with a range of 1-65 months), experienced significant pain relief after hysterectomy. There was no\ndifference noted between symptom recurrences in the group of patients with bilateral oophorectomy versus\nthose with ovarian conservation, in contrast to prior studies. Of note, nine patients had a history of\nunilateral oophorectomy prior to surgery. At the time of modified radical hysterectomy, 14 patients\nunderwent bilateral oophorectomy, nine patients underwent unilateral oophorectomy, and two patients\nunderwent removal of ovarian remnant. \nAdjunctive procedures, such as disc excision of the bowel and ureteroneocystotomy, were needed in certain\npatients to achieve complete excision of endometriotic lesions. The absence of intraoperative complications\nand low rate of postoperative complications in this series, however, is consistent with reported complication\nrates in the literature for laparoscopic radical hysterectomy for malignancy \n[26, 29-30]\n. This case series\nfurther supports the use of extirpative surgical treatment for patients with severe endometriosis causing\nsignificant lifestyle-limiting pelvic pain that is resistant to medical and conservative surgical treatments.\nLimitations to this series include its retrospective nature and small sample size. It is possible that more\nrecurrences could occur if a larger sample size were involved.\nIn some cases, hysterectomy and full debulking of disease can be beneficial. With extensive and deeply\ninfiltrating endometriosis, this case series has demonstrated that it is feasible and safe with acceptable\noutcomes. The advantages of minimally invasive surgery can thus be offered even the most severe cases of\ndisease. \nConclusions\nIn cases of severe endometriosis, the use of laparoscopic modified nerve-sparing radical hysterectomy is a\nfeasible and effective method for achieving long-term improvement in pain symptoms. There was no\ndifference noted between symptom recurrences in the group of patients with bilateral salpingo-\noophorectomy versus those with ovarian conservation, in contrast to prior studies. Of note, 14 patients\nunderwent bilateral oophorectomy, nine patients underwent unilateral oophorectomy, and two patients\nunderwent removal of ovarian remnant.\nAdditional Information\nDisclosures\nHuman subjects:\n All authors have confirmed that this study did not involve human participants or tissue.\nAnimal subjects:\n All authors have confirmed that this study did not involve animal subjects or tissue.\nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors declare the\nfollowing: \nPayment/services info:\n All authors have declared that no financial support was received from\nany organization for the submitted work. \nFinancial relationships:\n We declare(s) a grant from Johnson &\nJohnson. We declare(s) a grant from Storz. We declare(s) a grant from Intuitive Surgical. We declare(s) a grant\nfrom Stryker. \nOther relationships:\n All authors have declared that there are no other relationships or\nactivities that could appear to have influenced the submitted work.\nReferences\n1\n. \nBurney RO, Giudice LC: \nEndometriosis\n. Nezhat’s Video Assisted Laparoscopy and Hysteroscopy. Nezhat C,\nNezhat F, Nezhat C (ed): Cambridge Press, New York; 2013. 252.\n2\n. \nSchenken RS. Malinak LR: \nReoperation after initial treatment of endometriosis with conservative surgery\n.\nAm J Obstet Gynecol. 1978, 131:416-24.\n3\n. \nNezhat C, Nezhat F, Pennington E: \nLaparoscopic treatment of infiltrative rectosigmoid colon and\nrectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser\n. Br J Obstet\nGynaecol. l992, 49:664-7.\n4\n. \nNezhat C, Hajhosseini B, King LP: \nLaparoscopic management of bowel endometriosis: Predictors of severe\ndisease and recurrence\n. JSLS. 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Int J Gynecol Cancer. 2007, 17:1075-82.\n28\n. \nFrumovitz M, dos Reis R, Sun CC, Milam MR, Bevers MW, Brown J, Slomovitz BM, Ramirez PT: \nComparison\nof total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer\n.\nObstet Gynecol. 2007, 110:96-102.\n29\n. \nNamnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA: \nIncidence of symptom recurrence after\nhysterectomy for endometriosis\n. Fertil Steril. 1995, 64:898-902.\n30\n. \nMatorras R, Elorriaga MA, Pijoan JI, Ramón O, Rodríguez-Escudero FJ: \nRecurrence of endometriosis in\nwomen with bilateral adnexectomy (with or without total hysterectomy) who received hormone\nreplacement therapy\n. Fertil Steril. 2002, 77:303-308.\n2014 Nezhat et al. Cureus 6(1): e159. DOI 10.7759/cureus.159\n5\n of \n5","source_license":"CC0","license_restricted":false}