{"paper_id":"28f2a969-e327-4b25-a331-6ea98db225fe","body_text":"Original Article\nObstet Gynecol Sci 2015;58(1):53-58\nhttp://dx.doi.org/10.5468/ogs.2015.58.1.53\npISSN 2287-8572 · eISSN 2287-8580\nwww.ogscience.org 53\nIntroduction\nEndometriosis is a common gynecologic condition occurring in \n10% to 15% of women of reproductive age and is associated \nwith decreased fecundity [1]. The common sites of endometriosis \nare the ovaries, fallopian tubes, pelvic peritoneum, and utero-\nsacral ligaments (USL) (alternatively called the “pelvic” site), \nwhereas the atypical sites of endometriosis include the gastro\n-\nintestinal tract, urinary tract, soft tissues, and chest (alternatively \ncalled the “extra-pelvic” site) [2]. Endometriosis lesions can be \nclassified as ovarian, exclusively extra-ovarian or mixed. \nDiagnosis of extra-pelvic endometriosis can be difficult. De\n-\npending on the involved site, women can present with various \nsymptoms including bowel obstruction, melena, hematuria, dys\n-\nuria, dyspnea, and swelling in soft tissues [2]. Precise diagnosis re-\ngarding the presence, location, and extent of endometriosis may \nbe useful for the preoperative evaluation of and surgical planning \nfor endometriosis. Since clinical information is essential for proper \ntherapeutic management with complex surgeries, the anatomic \ndistribution of lesions should be accurately examined. \nThis study presents our experience with different anatomic \nlocations of endometriosis. Herein, we report the various ana\n-\ntomic locations of surgically and pathologically proven endome-\ntriosis in 1,350 women (1,374 surgery cases and 1,376 patho-\nlogic reports) presenting at a single center.\nVarious anatomic locations of surgically proven \nendometriosis: A single-center experience\nHyun Ju Lee\n1\n, Ye Mi Park\n1\n, Byung Chul Jee\n2,3\n, Yong Beom Kim\n2,3\n, Chang Suk Suh\n2,3\nDepartment of Obstetrics and Gynecology, \n1\nSeoul National University Hospital, Seoul, \n2\nSeoul National University Bundang Hospital, Seongnam, \n3\nSeoul \nNational University College of Medicine, Seoul, Korea\nObjective\nTo report the various anatomic locations of surgically and pathologically proven endometriosis.\nMethods\nPathologic reports (n=1,376) of women who underwent surgeries at a single center between April 2005 and March 2013 \nwere retrieved from the electronic medical record system of the hospital. Pathologic reports were included after performing a \nsearch by using the key-words “endometrial cyst,” “endometriotic cyst,” “endometriosis,” or “endometrioma.” Only reports \ndealing with female patients were selected, and the pathologic reports of 1,350 women (1,374 surgery cases) were included in \nthe analysis.\nResults\nThe predominant location of endometriosis was the ovaries (96.4%), followed by the soft tissue (2.8%), gastrointestinal \ntract (0.3%) and urinary tract (0.2%). Laparoscopic surgery was the major surgical technique used for the pelvic \nendometriosis (89.2%). Adrenal gland endometriosis was found in a 55-year-old woman.\nConclusion\nWe established the various anatomic locations of surgically and pathologically proven endometriosis in Korean women.\nKeywords: Anatomic variation; Endometriosis; Gastrointestinal tract; Ovary; Urinary tract\nReceived: 2014.5.16.   Revised: 2014.7.26.  Accepted: 2014.8.5.\nCorresponding author: Byung Chul Jee\nDepartment of Obstetrics and Gynecology, Seoul National University \nBundang Hospital, Seoul National University College of Medicine, \n82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam 463-707, Korea\nTel: +82-31-787-7254  Fax: +82-31-787-4054\nE-mail: blasto@snubh.org\nArticles published in Obstet Gynecol Sci are open-access, distributed under the terms of \nthe Creative Commons Attribution Non-Commercial License (http://creativecommons.\norg/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, \nand reproduction in any medium, provided the original work is properly cited.\nCopyright © 2015 Korean Society of Obstetrics and Gynecology \n\nwww.ogscience.org54\nVol. 58, No. 1, 2015\nMaterials and methods \nWe retrieved the reports of 1,350 women who underwent \n1,374 surgeries (1,376 pathologic reports) at the Seoul National \nUniversity Bundang Hospital between April 2005 and March \n2013. The pathologic reports were retrieved from the electronic \nmedical record system of the hospital, and the searches were \nconducted using the key-words “endometrial cyst,” “endo\n-\nmetriotic cyst,” “endometriosis,” or “endometrioma.” Only \nreports dealing with female patients were included in the analy\n-\nsis. Twenty-four women underwent repeated surgeries owing \nto the recurrence of endometriosis. Two women underwent \ntwo surgeries concurrently (e.g., appendectomy and ovarian \nsurgery), which resulted in the addition of two pathologic re\n-\nports to the analysis. The institutional review board of our hos-\npital approved the use of the patients’ medical records.\nThe anatomic distribution of endometriosis was investigated \nusing the operative records. Clinico-pathologic variables includ-\ning patient age, type of surgery, bilaterality of endometriosis (in \nthe case of ovarian endometriosis), and symptoms (dysmenor\n-\nrhea, chronic pelvic pain, deep dyspareunia, and dyschezia) \nwere analyzed. Endometriosis was staged and scored according \nto the revised American Society for Reproductive Medicine clas\n-\nsification. Cul-de-sac obliteration was defined as complete or \npartial adhesion, according to the surgical reports. Endometri\n-\notic lesions were classified as pelvic (with or without cul-de-sac \nobliteration), gastrointestinal, urinary, soft tissue, or other. SPSS \nver. 18.0 (SPSS Inc., Chicago, IL, USA) was used for statistical \nanalysis, and a value of P<0.05 was considered statistically sig\n-\nnificant.\nResults \nThe mean age of the women was 36.3±7.5 years (range, 15 to \n71 years). Laparoscopic surgery was the main surgical technique \nfor pelvic endometriosis (89.2%, 1,226/1,374) (Table 1). Ac\n-\ncording to the pathological reports, ovarian endometrioma was \nthe predominant form of endometriosis (96.4%), followed by \nsoft tissue endometriosis (2.8%), gastrointestinal endometriosis \n(0.3%), and urinary tract endometriosis (0.2%) (Table 2). The \nmean age of women was similar between those with stage III \nand those with stage IV endometriosis, but cul-de-sac oblitera\n-\ntion was more prevalent in stage IV endometriosis patients (Table \n3). Unilateral ovarian involvement was more common than \nbilateral ovarian involvement (Table 4). Cul-de-sac obliteration \nwas more prevalent in patients with bilateral endometrioma. \nThirty-nine cases of pathologically proven endometriosis oc\n-\ncurred in soft tissue (Table 5). The majority of the lesions were \nlocated near a previous operation scar. The most common site \nof soft tissue endometriosis was the abdominal wall, which \nwas associated with a previous Cesarean section. Three women \npresented with vulvar endometriosis, and all of them had a \nhistory of vaginal birth. Three patients presented with inguinal \nendometriosis, and in 2 of the patients, endometriosis was as\n-\nsociated with a previous hernia operation scar.\nThree patients presented with appendiceal endometriosis, \nwhich was detected during appendectomy; in 1 patient, acute \nappendicitis was the presumptive diagnosis before surgery. In \nthe other 2 women, appendiceal endometriosis was incidentally \nfound during open gynecologic surgery.\nRectal endometriosis was found in a 36-year-old woman \n(parity 2-0-0-2). She complained of severe dysmenorrhea. Dur-\ning laparoscopic surgery, low anterior resection with lymphatic \ndissection was performed owing to severe colonic obstruction \n10 cm from the anal verge. The pathologic report showed that \nmultifocal endometriotic lesions extended from the muscularis \npropria to the mucosa. Interestingly, endometriosis affected 4 \nout of 45 lymph nodes (pericolic, 4/39; inferior mesenteric artery \nroot, 0/6). The patient had a history of open gynecologic surgery \nat 19 years of age for a uterine mass of unknown origin.\nBladder endometriosis was found in 2 women. One woman \n(43 years old, parity 2-0-0-2, and prior vaginal delivery) ex -\nperienced cyclic abdominal pain, and a protruding mass was \ndetected in the inner bladder. This patient underwent trans-\nurethral resection of the mass. In the other woman (41 years \nold, parity 2-0-0-2, and prior cesarean delivery), a bladder wall \nmass was incidentally detected by using computed tomogra\n-\nphy (CT). This patient also underwent trans-urethral resection \nof the bladder wall mass, and endometriosis was diagnosed \npathologically. The patient had a history of hysterectomy for \nTable 1. Classification of surgery type (from 1,374 patients)\nSurgery type Number Age (range)\nLaparoscopic pelvic surgery 1,226 36.0±7.5 (15–62)\nLaparotomic pelvic surgery 105 39.9±7.6 (20–71)\nSoft tissue excision 30 37.1±6.8 (23–62)\nTransvaginal surgery 6 –\nBowel surgery 3 –\nUrologic surgery 4 –\nValues are presented as number or mean±stundard deviation (range).\n\nwww.ogscience.org 55\nHyun Ju Lee, et al. Location of endometriosis\novarian endometriosis.  \nUreter endometriosis was found in 1 patient (42 years old, \nparity 1-0-0-1, and prior vaginal delivery). In this case, recur -\nrent hydronephrosis developed and a ureteral polyp and endo-\nmetriosis were detected via ureteroscopy. Transvaginal ultraso-\nnography showed no abnormal findings in both adnexa.\nAdrenal gland endometriosis, which is extremely rare, was \nfound in a 55-year-old woman. This patient experiended left \nupper quadrant abdominal discomfort; an approximately \n13-cm hemorrhagic cyst in the left abdominal cavity was ob\n-\nserved on a CT scan (Fig. 1). Laparotomic adrenalectomy was \nperformed, and endometriosis was pathologically confirmed. \nThe patient had a history of laparoscopic cholecystectomy per\n-\nformed 2 years ago.\nDiscussion\nAs outlined in our literature review, several studies have re -\nported the anatomical distribution of deeply infiltrating endo-\nTable 2. Location of pathologically proven endometriosis (from 1,376 pathological reports)\nSites Percentage Locations Number Age (range)\nPelvic 96.4 Ovary with or without posterior cul-de-sac obliteration 1,327 36.2±7.5 (15–71)\nSoft tissues 2.8 Abdominal wall 27 37.1±6.8 (23–62)\nUterine cervix and vagina 6 41.8±4.2 (35–46)\nInguinal 3 –\nVulva 3 –\nGastrointestinal 0.3 Appendix 3 –\nRectum 1 –\nUrinary 0.2 Bladder inside 2 –\nUreter inside 1 –\nOthers 0.2 Peritoneum and omentum 2 –\nAdrenal gland 1 –\nTable 4. Classification of surgery type (from 1,374 patients)\nNo. of patients Cul-de-sacs obliteration\nUnilateral 889 366 (41.2%)\nBilateral 432 262 (60.6%)\na)\nLaterally unknown 4 2\nCul-de-sacs 2 2\nTotal 1,327 632\nValues are presented as number or number (%)\na)\nCul-de-sacs obliteration was significantly prevalent in patients with \nbilateral endometrioma than those with unilateral one.\nTable 3. Distribution of endometriosis stage\na)\n (from 1,327 patients)\nStage Number Age (range) Cul-de-sacs obliteration\nI 7 39.0±5.7 (31–48) 0 (0%)\nII 15 34.7±8.4 (20–53) 5 (33.3%)\nIII 278 35.2±7.5 (19–61) 77 (27.7%)\nIV 358 35.3±7.2 (15–52) 290 (81.0%)\nb)\nUnknown 669 –  260 (28.9%)\na)\nBy the revised American Society for Reproductive Medicine classification; \nb)\nCul-de-sacs obliteration was significantly prevalent in patients with stage \nIV endometriosis than those with other stages.\nTable 5. Location of soft tissue endometriosis (from 39 patients)\nSites Number\nAbdominal wall\nPrevious cesarean scar site 25\nPrevious other surgery scar site 1\nSurgery history unknown 1\nUterine cervix and vagina\nUterine cervix 2\nVagina 4\nInguinal area\nPrevious inguinal hernia scar site 2\nSurgery history unknown 1\nVulvar area\nPrevious right episiotomy site 2\nPrevious median episiotomy site 1\n\nwww.ogscience.org56\nVol. 58, No. 1, 2015\nmetriosis (DIE), which is responsible for painful symptoms such \nas dysmenorrhea, chronic pelvic pain, deep dyspareunia, and \ndyschezia [3,4]. Dai et al. [4] analyzed 177 cases of laparoscopi\n-\ncally proven DIE, which was located in the USL (67.1%), recto-\nvaginal septum (12.7%), cul-de-sac (12.0%), ureter (3.8%), \nrectum and recto-sigmoid junction (2.8%), or bladder (1.6%); \n60.7% of the nodules on the USL were bilateral, and 44.6% \nof the cul-de-sac were completely blocked. Another study ana\n-\nlyzed the medical, operative and pathological reports of 241 \nconsecutive patients with histologically proven DIE in order to \ninvestigate the anatomical distributions of DIE [3]. In that study, \nthe most common site for endometriotic lesions was the USL \n(69.2%), followed by the vagina (14.5%), bladder (6.4%), and \nintestines (9.9%).\nWe found that the majority of the endometriotic lesions \n(96.4%) occurred in the pelvic cavity, which is consistent with \nthe results of previous study [2]. Complete obliteration of the \npouch of Douglas was found in 47.6% of the patients in a pre\n-\nvious study. This incidence rate is consistent with that reported \nby other study [5]. \nInterestingly, in our study, soft tissue was the second most \ncommon site of endometriosis (2.8%), which is more common \nthan that reported in other studies. In our study, abdominal \nwall endometriosis was relatively predominant in women with \nsoft tissue endometriosis (51.9%, 27/52). In almost all cases, \nthe endometriotic lesions were located at the site of previous \noperation scar from a Cesarean section or hysterectomy. Scar \nsite endometriosis has been reported to occur in approximately \n0.03% to 0.4% of women undergoing caesarean section [6]. A \nprevious study reported the occurrence of endometriosis at the \nsite of a previous operation scar in Korean women [7]. Fifteen \nof 30 women with extra-pelvic endometriosis showed endome\n-\ntriotic lesions at the site of a previous cesarean scar. The mean \nage (37.1 years) of the women with abdominal wall endometri-\nosis in our study was quite higher than that reported by a previ-\nous study (32.3 years) [8]. Previous studies have reported that \nthe patients usually present with a palpable erythematous skin \nnodule or mass associated with an incision scar and experience \nintermittent excruciating pain, tenderness, and enlargement of \nthe mass during menstruation [2,9-11].\nThree women presented with vulvar endometriosis, and all \nof them had a history of vaginal birth. This finding suggests \nthat vulvar endometriosis can occur in a previous episiotomy \nsite. Four patients presented with isolated vaginal endome\n-\ntriosis. However, it is unknown whether pelvic endometriosis \ncoexisted in these patients because they did not undergo \nlaparoscopic inspection. In a study, the proportion of isolated \nlesions in patients with vaginal DIE was 56.0%; this indicates \nthat multifocal lesions simultaneously involving the USL, blad\n-\nder, or intestine could exist in 44% of the patients with vagi-\nnal DIE [3]. In cases of vaginal DIE, dissection of the latero-\nrectal fossae and exeresis of the upper part of the posterior \nvaginal wall are recommended because lesions developing in \nthose areas commonly co-exist with vaginal DIE [12].\nWe found gastrointestinal endometriosis in 0.3% and \nurinary tract endometriosis in 0.2% of the patients; these \nrates are fairly lower than those reported in other studies [2]. \nWoodward et al. [13] reported that the recto-sigmoid colon \nis the most common gastrointestinal site for endometrial de\n-\nposits (70% to 85%). This is followed by the terminal ileum \n(1% to 7%), appendix, cecum, and the rest of the small \nbowel. Terminal ileal involvement usually occurs within 10 \ncm of the ileocecal valve, and it can be observed even in the \nabsence of recto-sigmoid implants [13]. Chapron et al. [3] \nalso reported that the most common site for intestinal DIE is \nthe rectum (58.9%), followed by the sigmoid colon (20.6%), \nFig. 1. Representative computed \ntomography images showing an ap-\nproximately 13-cm hemorrhagic cyst, \nwhich was proven to be an endome\n-\ntrioma, arising in the adrenal gland \nin a 55-year-old woman. (A) Coronal \nview and (B) axial view.\nA B\n\nwww.ogscience.org 57\nHyun Ju Lee, et al. Location of endometriosis\ncolon (8.8%), ileocecum or terminal ileum (5.9%) and ap -\npendix (2.9%). We were unable to determine the specific \nsite of intestinal DIE. Endometrial implants can be located \nalong the anti-mesenteric border of the bowel wall, and \ngrowth occurs from the serosa inwards [3]. \nIn the present study, bladder endometriosis was found in \nonly 2 women. A previous literature review analysis showed \nthat endometriosis involved the urinary tract in up to 20% \nof the cases [14]. In these cases, involvement of the urinary \nbladder was the most common, followed by involvement of \nthe lower ureter. Urinary bladder implants commonly occur \non the serosal surface near the dome; they can progressively \ninvade the muscularis propria and protrude in the lumen as \nintramural or intraluminal masses [15]. Urinary tract endo\n-\nmetriosis may arise from pre-existing foci of peritoneal en -\ndometriosis covering the bladder or from direct extension of \nan adenomyotic nodule, or it may develop from embryonic \nremnants [2,16-19]. In a study, the main symptom of bladder \nendometriosis was urinary frequency [20]. It was reported \nthat 20% to 30% of the affected women presented with \nmenstrual hematuria [21].\nThe most intriguing case of endometriosis in our study was \nthat of a patient with adrenal gland endometriosis. Only 1 \nsuch case has been reported previously (reported in 2008) \n[22]. In that study, a 48-year-old woman experienced left \nflank pain, which is similarly to that observed in our case. \nThe pain was intermittent and worsened with menstruation. \nA CT scan showed a 10-cm mass in the left upper quadrant \nof the abdomen, which is also similar to that observed in our \ncase. The patient’s medical history was unremarkable, except \nfor an emergency cesarean section at 26 years of age. She \nwas treated with laparoscopic adrenalectomy and pathologi\n-\ncally diagnosed with endometriosis. Adrenal gland endome -\ntriosis is an extremely rare condition, and we believe that our \ncase is the second reported case of this condition worldwide.\nEndometriosis in extra-pelvic sites may result from vascular \nor lymphatic dissemination of endometrial cells to several \ngynecologic (vulva, vagina, or cervix) and non-gynecologic \nsites (bowel, appendix, hernia sacs, lungs, skin, or nerves). \nBecause endometriosis could involve any system of the body, \none of the major challenges in diagnosing women with sus\n-\npected endometriosis is to assess the extent of the disease \nand its functional consequences for the pelvic or extra-pelvic \norgans. Many researchers have suggested classifications of \nendometriosis, but no validated system meets the clinical \nneeds yet. \nIn our study, the incidence of extra-pelvic endometriosis \nwas 3.4%. Although rare, soft tissue endometriosis showed \na relatively high incidence rate in our study and was associ\n-\nated with previous surgical sites. Therefore, endometriosis \nshould be considered when cutaneous nodules develop near \nsurgical scars in women with cyclic soft tissue pain.\nTo our knowledge, our study is the first to report the \nvarious anatomic locations of surgically and pathologically \nproven endometriosis in Korean women. Although this study \ndescribes a single-center experience, it includes a larger sam\n-\nple size of women than has been reported previously. The \nmost common site of endometriosis was the pelvic cavity, \nfollowed by soft tissues; this feature is slightly different from \nthe results by the other studies.\nConflict of interest\nNo potential conflict of interest relevant to this article was \nreported.\nAcknowledgments\nThis work was supported by grant (no. A120043) from \nthe Korea Health Care Technology R&D Project, Ministry of \nHealth and Welfare, Korea.\nReferences\n1. Dmowski WP , Lesniewicz R, Rana N, Pepping P , Noursale-\nhi M. Changing trends in the diagnosis of endometriosis: \na comparative study of women with pelvic endometrio -\nsis presenting with chronic pelvic pain or infertility. Fertil \nSteril 1997;67:238-43.\n2. Sonavane SK, Kantawala KP , Menias CO. Beyond the \nboundaries-endometriosis: typical and atypical locations. \nCurr Probl Diagn Radiol 2011;40:219-32.\n3. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset \nB, Pansini V, et al. Anatomical distribution of deeply infil\n-\ntrating endometriosis: surgical implications and proposi -\ntion for a classification. Hum Reprod 2003;18:157-61.\n4. Dai Y, Leng JH, Lang JH, Li XY, Zhang JJ. Anatomical \ndistribution of pelvic deep infiltrating endometriosis and \n\nwww.ogscience.org58\nVol. 58, No. 1, 2015\nits relationship with pain symptoms. 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Endometriosis of the \nurinary tract in women of reproductive age. Int J Urol \n2006;13:902-4.\n22. Rehman J, Yildirim G, Khan SA, Chughtai B, Nezhat F. \nA case of successful laparoscopic resection of adrenal \ngland endometriosis. Fertil Steril 2008;90:2015.e7-9.","source_license":"CC0","license_restricted":false}