{"paper_id":"407fdb70-aae0-40d3-8bc2-8e67e71b0fb8","body_text":"R E S E A R C H Open Access\nDoes laparoscopic management of deep\ninfiltrating endometriosis improve quality of life?\nA prospective study\nMohamed Mabrouk 1,2†, Giulia Montanari 1†, Manuela Guerrini 1†, Gioia Villa 1†, Serena Solfrini 1†, Claudia Vicenzi 1†,\nGiuseppe Mignemi 1†, Letizia Zannoni 1†, Clarissa Frasca 1†, Nadine Di Donato 1†, Chiara Facchini 1†,\nSimona Del Forno 1†, Elisa Geraci 1†, Giulia Ferrini 1†, Diego Raimondo 1†, Stefania Alvisi 1† and Renato Seracchioli 1*\nAbstract\nBackground: Deep infiltrating endometriosis (DIE) can affect importantly patients ’ quality of life (QOL). The aim of\nthis study is to evaluate the impact of the laparoscopic management of DIE on QOL after six months from\ntreatment.\nMethods: It is a prospective cohort study. In a tertiary care university hospital, between April 2008 and December\n2009, 100 patients underwent laparoscopic management of DIE and completed preoperatively and 6-months\npostoperatively a QOL questionnaire, the short form 36 (SF-36).\nQuality of life was measured through the SF-36 scores. Intra-operative details of disease site, number of lesions,\ntype of intervention, period of hospital stay and peri-operative complications were noted.\nResults: Six months postoperatively all the women had a significant improvement in every scale of the SF-36 (p <\n0,0005). Among patients with intestinal DIE, significant differences in postoperative scores of SF-36 were not\ndetected between patients submitted to nodule shaving and segmental resection (p > 0.05). There was no\nsignificant difference in the SF-36 scores at 6 months from surgery between patients who received postoperative\nmedical treatment and patients who did not (p > 0.05).\nConclusions: Laparoscopic excision of DIE lesions significantly improves general health and psycho-emotional\nstatus at six months from surgery without differences between patients submitted to intestinal segmental resection\nor intestinal nodule shaving.\nBackground\nDeep infiltrating endometriosis (DIE) defined as the\ninfiltration of anatomic structures, pelvic organs, or\nboth, is a source of pelvic pain and altered quality of life\n[1-4]. The exact incidence of DIE in the general popula-\ntion is not known, but it is estimated to affect 20% of\nwomen with endometriosis [5].\nAlthough many studies demonstrated that surgical\nresection of all endometriotic lesions is recommended\nto relieve pain, its effectiveness is still debated [5-16]. In\naddition, the risk of serious complications inherent to\nthis type of surgery has been estimated between 4 and\n6% of cases [17,18] with a high rate of de novo neurolo-\ngical disorders [19]. It has been demonstrated that the\nsecondary effects of surgical treatment and the persis-\ntence of some symptoms can have an impact on the\npatient’s quality of life [20]. Furthermore, when we treat\nendometriosis we have to consider that it is a benign\ndisease which affects young, professionally active\nwomen, who may plan to conceive.\nIn our opinion, quality of life (QOL) evaluation is\nimportant to assess the overall effects of radical excision\nof DIE, taking in consideration that endometriosis is a\npathology that has symptoms which may disrupt work-\ning ability, social relationships and sexual functioning.\n* Correspondence: gongiov@tin.it\n† Contributed equally\n1Minimally Invasive Gynaecological Surgery Unit, S.Orsola Hospital, University\nof Bologna, Italy\nFull list of author information is available at the end of the article\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\n© 2011 Mabrouk et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative\nCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and\nreproduction in any medium, provided the original work is properly cited.\n\nSeveral general questionnaires have been recom-\nmended for QOL assessment ([2,3,20-23]). Between\nthem, the short form 36 (SF-36) has been used to evalu-\nate the improvement in QOL in patients submitted to\nlaparoscopic surgery [4,24] for endometriosis and, in\ngeneral, to evaluate the impact of endometriosis and its\ntreatment on women ’s health-related quality of life [25].\nTwo surgical approaches are usually employed in\nmanagement of deep endometriosis with intestinal mus-\ncularis involvement: segmental resection and nodule\nexcision. This latter approach may be performed with-\nout opening the intestinal lumen (shaving) or by remov-\ning the nodule along with the surrounding intestinal\nwall (full thickness or disc excision). A strong debate\ncontinues between advocates of the nodule excision\ntechniques and supporters of segmental resection. To\ndate, there is no consensus made about the surgical\nmanagement of deep intestinal endometriosis [26].\nRecently SF-36 has been proposed as a complementary\ntool to select and inform women who might benefit\nfrom laparoscopic segmental resection for endometriosis\n[27].\nIn the present study we sought to prospectively evalu-\nate the impact of laparoscopic management of DIE on\nthe patients ’ QOL. We also aimed to investigate whether\nor not a greater level of QOL improvement can be\nachieved by performing segmental resection rather than\nnodule excision in patients with deep intestinal\nendometriosis.\nMethods\nFull ethical approval was obt ained from the local ethics\ncommittee to the study protocol (155/2008U/Oss).\nProtocol and surgical treatment\nFrom April 2008 through December 2009, in the Mini-\nmally Invasive Gynaecological Surgery Unit, S. Orsola-\nMalpighi Hospital, University of Bologna, a consecutive\nseries of 120 patients with preoperative diagnosis of\ndeep infiltrating endometriosis agreed to take part to\nthe study protocol.\nExclusion criteria were as follows: major medical con-\nditions, psychiatric disorders, current or past (within 6\nmonths from study enrolment) use of drugs affecting\ncognition, vigilance and/or mood.\nFor each patient, general data were assessed together\nwith history of surgical treatment for endometriosis and\nthe scoring of pelvic pain symptoms using a 10-point\nvisual analogue scale (VAS).\nAll women underwent gynaecological examination,\npelvic trans-vaginal and abdominal ultra-sonography in\norder to evaluate the presen ce of pelvic endometriosis\nbefore surgery. Other diagnostic tests were performed\nwhen indicated, as previously described [28,29].\nAll women were scheduled for laparoscopic manage-\nment of deep infiltrating endometriosis and they gave\ninformed written consent to surgical treatment and the\npossible use of their anonymous data for research pur-\nposes. The surgical strategy was complete laparoscopic\nexcision of all visually suspected endometriotic lesions\nand the laparoscopic procedures were performed by the\nsame surgeon (R.S.). The surgical team had a consistent\nbackground in laparoscopic treatment of patients with\nDIE. Laparoscopic resectio n of endometriosis was per-\nformed as previously described [28-32]. In particular,\nwomen were scheduled for segmental recto-sigmoid\nresection when bowel function was greatly impaired and\nwhen radiological diagnosis o f intestinal endometriosis\nconfirmed the presence of intestinal lesions associated\nwith marked restriction of the bowel lumen. Moreover,\ndeciding the necessity of intestinal resection or intestinal\nnodule shaving, we took into account endometriosis and\nintestinal symptoms, impairment of quality of life due to\nintestinal symptoms, desire of pregnancy and finally the\nintra-operative evaluation performed by the gynaecologi-\ncal surgeon and the general surgeon. Only after histolo-\ngical confirmation of diagnosis, the patients were asked\nto continue the postoperative phase of the study. Deep\ninfiltrating endometriosis ( DIE) was considered histolo-\ngically confirmed when the lesion penetrates >5 mm\nunder the peritoneal surface [33]. We considered intest-\ninal DIE when the lesion infiltrated the muscularis [34].\nAfter surgical treatment patients were recommended\nto use medical therapy to prevent anatomical lesion\nrecurrences and symptoms relapse. All patients were\nasked to undergo a follow-up visit six months after sur-\ngery. During the follow-up visit, patients underwent\nphysical examination and trans-vaginal ultrasonography\nto evaluate symptoms and/or anatomical relapse of\nendometriotic nodules. Women were asked to complete\nthe SF-36 Questionnaire and to rank their symptom\ni n t e n s i t yu s i n gt h es a m en u m e r i c a l l yr a t e dV A Su s e d\npreoperatively.\nQOL assessment\nThe SF-36 is a multi-purpose health survey with 36\nquestions. It yields an eight-scale profile of functional\nhealth and well-being scores, as well as psychometrically\nbased physical and mental health summary measures\n(standardized). The eight scales are hypothesized to\nform two distinct higher-ordered clusters due to the\nphysical and mental health variance that they have in\ncommon. Among the eight scales, three [physical func-\ntioning (PF), role physical (RP), bodily pain (BP)] corre-\nlate most strongly with the physical component and\ncontribute most to the Physical Component Summary\n(PCS) score. The mental component correlates best with\nthe mental health (MH), role emotional (RE) and social\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\nPage 2 of 7\n\nfunctioning (SF) scores, which also contribute most to\nthe Mental Component Summary (MCS) score. Two of\nthe scales [vitality (VT) and general health (GH)] have\nnoteworthy correlations with both components. All the\nwomen completed preoperatively and 6-months post-\noperatively the SF- 36 questionnaire, Italian version,\nrelease 1.6 [35].\nStatistical Analysis\nAll continuous variables were expressed in terms of\nmean ± standard deviation of the mean. The Kolmo-\ngorov Smirnov test was performed to assess the normal\ndistribution. The Paired t test was performed to assess\nthe difference between score means when the data were\nnormally distributed; otherwise the Wilcoxon Test was\nused to check T test results. One Way ANOVA was\nperformed to assess the difference of the score means\nbetween patients with and without the studied charac-\nteristic. When the Levene test for homogeneity of var-\niances was significant (p < 0.05) the Mann Whitney test\nwas used to check ANOVA results. Pearson ’s Chi square\ntest, calculated by Exact Method, was performed to\ninvestigate the relationships between grouping variables.\nPearson’s correlation analysis was used to test relationship\nbetween continuous variables. For all tests p < 0.05 was\nconsidered significant. Statistical Analysis was performed by\nmeans of the Statistical Package for the Social Sciences\n(SPSS) software version 15.0 (SPSS Inc., Chicago, USA).\nResults\nOf the 120 patients assessed for eligibility, 20 were\nexcluded. Seven did not have a histologically confirmed\nDIE following laparoscopic excision of their disease.\nNine did not complete the questionnaire. Four did not\ncome to the 6 months follow-up visit. Consequently,\n100 patients were enrolled in our study. Average age at\nthe time of surgery was 34.2 ± 4 years (range [23-39])\nand mean body mass index was 21.6 ± 2.7 Kg/m² (range\n[19-32]). Regarding previou ss u r g i c a lt r e a t m e n t sf o r\nendometriosis, 27% (27/100) had one previous proce-\ndure, 4% (4/100) had two and one patient had three pre-\nvious interventions. Operative findings, surgical\nprocedures, additional procedures performed and com-\nplications are summarized in Table 1.\nSF 36 Scores\nAfter laparoscopic surgery for DIE, at 6-months follow\nup, a significant improvement was observed in the SF-\n36 total score, in the SF-36 component summaries and\nin every scale of the SF-36 (p < 0.0005) (Table 2).\nAmong patients with intestinal DIE, significant differ-\nences in postoperative scores of SF-36 were not detected\nbetween patients submitted to intestinal nodule shaving\nand segmental intestinal resection (p > 0.05) (Table 3).\nPain scores were significantly improved after six\nmonths from surgical treatment (p < 0.05). Preopera-\ntively 99% of women had dysmenorrhea (mean VAS\nTable 1 Surgical procedures, additional surgical\nprocedures, intra-operative and postoperative\ncomplications of the laparoscopic management of DIE\nNumber\nSurgical procedures:\n- Recto-vaginal septum nodule resection 62\n- Intestinal nodule shaving 50\n- Segmental intestinal resection 16\n- Vagina nodule resection 32\n- Utero-sacral ligaments nodule resection 44\n- Bladder nodule resection 41\n- Ureteral nodule resection: 18\n- Ureterolyisis 15\n- Segmental ureteral resection with end to end anastomosis 3\nAdditional surgical procedures performed:\n- Appendectomy 4\n- Nephrectomy 1\n- Temporary colostomy 1\nIntra-operative complications\n- Bowel injury 0\n- Bladder injury 0\n- Ureteral injury 0\n- Vascular injury 1\n- Blood loss exceeding 500 ml\n- Conversion to laparotomy\n1\n0\nPostoperative complications\n- Transient fever > 38 °C 8\n- Transient urinary retention 3\n- Urinary incontinence 1\n- Uretero-vaginal fistula 1\n- Recto-vaginal fistula 1\nTable 2 Mean (± Standard deviation) preoperative and\npostoperative scores of the scale of SF-36\nBEFORE AT 6 MONTHS\nFOLLOW-UP\nP value\nSF-36 total score 49 ± 20 71 ± 17 < 0.0005\nPhysical Component\nSummary\n49 ± 19 70 ± 17 < 0.0005\nPhysical Function 77 ± 23 90 ± 14 < 0.0005\nRole - Physical 40 ± 39 77 ± 35 < 0.0005\nBody pain 38 ± 20 68 ± 24 < 0.0005\nMental Component\nSummary\n47 ± 20 66 ± 17 < 0.0005\nSocial Functioning 50 ± 22 72 ± 22 < 0.0005\nRole Emotional 40 ± 40 76 ± 33 < 0.0005\nMental Health 54 ± 18 65 ± 16 < 0.0005\nGeneral Health 47 ± 21 59 ± 19 < 0.0005\nVitality 46 ± 19 57 ± 17 < 0.0005\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\nPage 3 of 7\n\nscore of 7 ± 3), 76% dyspareunia (mean VAS score of 5\n± 3), 63% chronic pelvic pain (mean VAS score of 4 ±\n3), 67% dyschezia (mean VAS score 5 ± 4) and 34% had\ndysuria (mean VAS score of 2 ± 3). Postoperatively, at 6\nmonths follow up, 23% of women reported dysmenor-\nrhea (mean VAS score 1 ± 3), 23% dyspareunia (mean\nVAS score of 1 ± 2), 18% chronic pelvic pain (mean\nVAS score of 1 ± 2), 17% dyschezia (mean VAS score of\n1 ± 2) and 6% dysuria (mean VAS score of 0 ± 1).\nOn pelvic examination and through ultrasound exam,\nthere were no cases of anatomical recurrence at 6-\nmonths follow-up.\nSeventy-one percent of patients (71/100) assumed\npostoperative hormonal treatment (33 with cyclic, 27\nwith continous oral estro-p rogestogenic; 4 with cyclic\nestro-progestogenic, 2 with continous vaginal ring; 3\nwith oral progestins and 2 with estro-progestogenic cyc-\nl i cp a t c h ) .T h e r ew e r en os i g n i f i c a n td i f f e r e n c ei nt h e\nSF-36 postoperative scores between patients who\nreceived postoperative medical treatment and patients\nwho did not (p > 0.05). outcomes after surgical treat-\nment of DIE.\nDiscussion\nBy performing this trial and re viewing the available lit-\nerature, we tried to answer some questions related to\nthis particular pathology, DIE:\n1) Is it important to consider objective QOL evaluation in\npatients with DIE?\nIn 2000, Garry et al. affirmed that endometriosis exerts\na profoundly adverse effect on the personal life and rela-\ntionships of patients [2]. The intensity and frequency of\nsymptoms, their association and concomitant infertility,\nthe secondary effects of medical and surgical manage-\nment, symptoms persistence after treatment, disease\nrelapse and the need of continuing a therapy for a long\nterm affect negatively quality of life [20]. We believe\nthat one of the primary goals of the management of\nendometriosis is not only symptom reduction, but also\nimprovement of the overall patient ’s quality of life. In\nthis perspective, the evaluation of the efficacy of surgical\nmanagement of endometriosis only in terms of pain and\nsymptoms improvement seems insufficient. Recently\nDubernard et al. proposed SF-36 questionnaire as a tool\nthat can predict the degree of change in QOL after\nlaparoscopic management of posterior DIE [27], deli-\nneating a new approach of DIE in which QOL evalua-\ntion can guide the management of the disease.\n2) Does laparoscopic management of DIE improve QOL?\nAfter laparoscopic surgery for DIE, at six-month follow\nup, we observed a significant improvement in all scales\nof the SF-36.\nMany studies confirmed that laparoscopic treatment\nof endometriosis is effective in relieving dysmenorrhoea,\ndyspareunia, non-menstrual pelvic pain and dyschezia\n([2,33,34,36]).\nIn a randomized placebo-controlled trial of 39 women,\nAbbott et al. demonstrated that laparoscopic excision of\nendometriosis is more effective than placebo on pain\nreduction and quality of life improvement at 12 months\nfrom surgery [21]. However, in this trial, authors evalu-\nated all rAFS stages of endometriosis and not DIE.\nJones et al. included in their study on laparoscopic\nablative surgery for endometriosis, the evaluation not\nonly of pain scores, but also of patient satisfaction\nscores. They showed that women with rAFS stage III-IV\nof endometriosis who underwent treatment presented a\nhigh rate (87.7%) of satisfaction [36].\nIn 2000, Garry et al showed that radical laparoscopic\nexcision of endometriosis stage III and IV of rAFS sig-\nnificantly improved the physical component score of the\nQOL questionnaire, return ing the score value to a\nTable 3 Mean improvement (± Standard deviation) of SF-36 scores six months after surgery.\nINTESTINAL RESECTION\n(16 patients)\nNODULE EXCISION\n(50 patients)\nP value\nΔSF-36 total score 37 ± 36 35 ± 42 0.08\nΔPhysical Component Summary 36 ± 35 35 ± 41 0.23\nΔPhysical Function 14 ± 25 13 ± 24 0.30\nΔRole - Physical 41 ± 46 43 ± 40 0.06\nΔBody pain 32 ± 31 30 ± 26 0.41\nΔMental Component Summary 24 ± 42 26 ± 36 0.09\nΔSocial Functioning 21 ± 32 21 ± 26 0.08\nΔRole Emotional 35 ± 51 38 ± 41 0.07\nΔMental Health 8 ± 24 10 ± 19 0.09\nΔGeneral Health 10 ± 22 11 ± 20 0.06\nΔVitality 10 ± 22 11 ± 18 0.07\nComparison between patients submitted to segmental intestinal resection and patients submitted to intestinal nodule excision.\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\nPage 4 of 7\n\nnormal range. The mental component score improved\ntoo, but this was not statistically significant and failed to\nreach a normal range four months after treatment [2].\nThis study analyzed prospectively 57 patients and was\nperformed using Short Form 12 (SF12) and Euro QOL\n(EQ-5D) questionnaire preoperatively and 4 months\nafter surgery. However, SF-12 questionnaire reproduces\nthe eight scale profile with fewer levels than SF-36 scales\nand yields less precise scores [27].\nIn 2003, Abbott et al. studied 176 women who under-\nwent laparoscopic excision of endometriosis, evaluating\nlong term outcome through the use of QOL question-\nnaire [3]. The results evidenced that women with endo-\nmetriosis have an impaired QOL which improve after\ntreatment in a significant manner. The increase in the\nphysical component appeared greater than the mental\ncomponent of the score. However the results of this\nprospective study with an evaluation of the QOL in the\nlong-term may be affected by the high rate of women\nwho did not respond to the follow-up questionnaire\n(26%).\n3) Is there a difference in QOL improvement between\npatients who undergo nodule shaving or segmental\nintestinal resection?\nWe found that there was no significant difference in the\nsix-month postoperative im provement of SF-36 scores\namong women with intestinal DIE who underwent\nnodule shaving or segmental intestinal resection.\nIn the literature the debate regarding the surgical\nmanagement of intestinal DIE is current [37]. While\nsome studies evidenced a significant QOL improvement\nin women treated with colorectal segmental resection\n[38-41], others suggested nodule excision or shaving, as\na first choice procedure. These authors retrieved an\nincreased risk of postoperative complications together\nwith de novo intestinal and urological symptoms\nappearance in patients submitted to segmental intestinal\nresection [37,40,42-44]). Recently Roman et al. in a ret-\nrospective study evidenced that women undergoing col-\norectal resection when compared with women managed\nby nodule excision, were more likely to present several\nunpleasant functional digestive outcomes and urinary\ndysfunctions [37]. However, the choice of colorectal\nresection is supported by th ef a c tt h a tt h ea b s e n c eo f\nbowel resection in women with DIE and intestinal endo-\nmetriosis is the factor most strongly associated with\nrecurrence rate [8]. Moreover, there are studies which\nshowed that microscopic end ometriotic lesions usually\nexist around the main rectal nodule [15,45]. In our opi-\nnion, important issues to be considered, when deciding\nthe need and the type of surgery in women with intest-\ninal endometriosis, are the actual status and the\nexpected improvement of the patient ’s QOL, as well as\nthe potential functional ou tcomes of surgery. Finally,\nfurther prospective randomized studies are necessary to\nassess which surgical management is more indicated in\npatients with intestinal DIE.\n4) Does postoperative hormonal treatment influence QOL\nat six-month follow up?\nWe did not find any significant difference in all SF-36\nscores between patients submitted to the surgical treat-\nment alone and patients who received six-month post-\noperative hormonal treatment.\nConsidering DIE, it has been shown that continuous\npost-operative hormonal treatment might prevent pain\nrecurrences after surgical removal of deep infiltrating\nnodules [46]\nRegarding the elective postoperative management of\nendometriosis, data from the randomized trials are con-\ntroversial in terms of pain recurrence and anatomical\nrelapse. A Cochrane review of 2004 showed that post-\nsurgical hormonal suppression of endometriosis com-\npared to surgery alone (either no medical therapy or\nplacebo) showed no benefit for the outcomes of pain\n[47]. Muzii et al [48] found no significantly difference in\nthe recurrence rates of pain at follow-up between\npatients receiving oral contraceptives pills (9.1%) and\nuntreated patients (17.1%). Furthermore, Koga et al.\nfound in their retrospective study that a mean post-\noperative treatment of 9.5 months did not influence\nrecurrence [49]. Recently, different studies evidenced an\nimportant role of long term postoperative use of oral\ncontraceptive on symptoms and disease recurrence\n[50-52].It seems that the length of the treatment is,\ntherefore, an important factor in the long-term efficacy\nof therapy. However, all these trials considered only\npain recurrence and anatomical relapse, ignoring QOL\nevaluation. Further trials are necessary to assess whether\npostoperative medical therapy impact on the QOL.\nRecently, some authors adopted the concept that in the\ntreatment of DIE, it is most likely that medical and sur-\ngical treatments should be associated [26,53].\nCertain limitations of this study must be underlined.\nOur results may be influenced by the fact that one third\nof the women (31%) involved in the study had pre-\nviously been surgically treated for endometriosis. In\nthese women, the previous failed surgery may bias the\nQOL perception with lower preoperative SF-36 scores.\nSecond, more than an half of patients (56%) were taking\nhormonal therapy before surgical treatment and a large\nproportion (71%) of women was given postoperative\nhormonal treatment. This may potentially have a signifi-\ncant bias on the symptoms and QOL perception of\nthese women. However, as it has been stated by recent\nstudies, long term outcomes of the surgical treatment of\nendometriosis are positively correlated with the\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\nPage 5 of 7\n\nassumption of postoperativ e medical therapy leading to\nthe conclusion that only the combination of surgery\nplus medical therapy may guarantee long term effect\n[ 5 3 ] .T h i r d ,o u rs t u d ye v aluated QOL after only six\nmonths postoperatively, which seems to be a short time\nto complete the recovery from this complex surgery.\nHowever, there is an ongoing study in our centre aiming\nto assess long term QOL outcomes after surgical treat-\nment of DIE.\nConclusion\nWe found that laparoscopic excision of DIE lesions\nappreciably improves general health and psycho-emo-\ntional status at six-month follow up without differences\nbetween patients submitted to intestinal segmental\nresection or nodule shaving. We strongly believe that\nobjective QOL assessment should be considered as a\ncomplementary index to evaluate need and success of\ntherapeutic interventions in DIE.\nList of abbreviations\nThe abbreviations used in the manuscript are summarized: BP: bodily pain;\nDIE: deep infiltrating endometriosis; GH: general health; MCS: mental\ncomponent summary; MH: mental health; PCS: physical component\nsummary; PF: physical functioning; RE: role emotional; RP: role physical; QOL:\nquality of life; SF: social functioning; SF-36: short form 36; VAS: visual\nanalogue scale; VT: vitality.\nAuthor details\n1Minimally Invasive Gynaecological Surgery Unit, S.Orsola Hospital, University\nof Bologna, Italy. 2Department of Obstetrics and Gynecology, Alexandria\nUniversity, Egypt.\nAuthors’ contributions\nAll authors read and approved the final manuscript. They contributed to the\nmanuscript as follows: GM, MM and SR were involved in the conception and\ndesign of this study, in the analysis and interpretation of data, and in\ndevelopment and review of the manuscript for intellectual content. MG and\nGM were involved in the analysis and interpretation of data and in\ndevelopment and review of the manuscript for intellectual content. VG, MG\nand VC were involved in the interpretation of data and in review of the\nmanuscript for intellectual content.\nFC, SA, DDN and FC were involved in the collection of data. FG, DFS, GE, SS\nand RD were involved in the statistical analysis. ZL was involved in the\nmanuscript revision.\nCompeting interests\nThe authors declare that they have no competing interests.\nReceived: 18 February 2011 Accepted: 6 November 2011\nPublished: 6 November 2011\nReferences\n1. Anaf V, Simon P, El Nakadi I, Fayt I, Buxant F, Simonart T, Peny MO, Noel JC:\nRelationship between endometriotic foci and nerves in rectovaginal\nendometriotic nodules. Hum Reprod 2000, 15:1744-1750.\n2. Garry R, Clayton R, Hawe J: The effect of endometriosis and its radical\nlaparoscopic excision on quality of life indicators. BJOG 2000, 107:44-54.\n3. Abbott JA, Hawe J, Clayton RD, Garry R: The effects and effectiveness of\nlaparoscopic excision of endometriosis: a prospective study with 2-5\nyear follow-up. Hum Reprod 2003, 18:1922-1927.\n4. Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E: Quality of life\nafter laparoscopic colorectal resection for endometriosis. Hum Reprod\n2006, 21:1243-1247.\n5. Chapron C, Dubuisson JB, Fritel X, Fernandez B, Poncelet C, Béguin S,\nPinelli L: Operative management of deep endometriosis infiltrating the\nutero-sacral ligaments. J Am Assoc Gynecol Laparosc 1999, 6:31-37.\n6. Hurd WW: Criteria that indicate endometriosis is the cause of chronic\npelvic pain. Obstet Gynecol 1998, 92:1029-1032.\n7. Howard FM: Chronic pelvic pain. Obstet Gynecol 2003, 101:594-611.\n8. Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotsch F: Long-term follow-up\nafter conservative surgery for rectovaginal endometriosis. Am J Obstet\nGynecol 2004, 190:1020-1024.\n9. Fedele L, Bianchi S, Zanconato G, Berlanda N, Borruto F, Frontino G:\nTailoring radicality in demolitive surgery for deeply infiltrating\nendometriosis. Am J Obstet Gynecol 2005, 193:114-117.\n10. Angioni S, Peiretti M, Zirone M, Palomba M, Mais V, Gomel V, Melis GB:\nLaparoscopic excision of posterior vaginal fornix in the treatment of\npatients with deep endometriosis without rectum involvement: surgical\ntreatment and longterm follow-up. Hum Reprod 2006, 21:1629-1634.\n11. Fauconnier A, Chapron C: Endometriosis and pelvic pain: epidemiological\nevidence of the relationship and implications. Human Reproduction\nUpdate 2005, 11(6):595-606.\n12. Bailey HR, Ott MT, Hartendorp P: Aggressive surgical management for\nadvanced colorectal endometriosis. Dis Colon Rectum 1994, 37:747-753.\n13. Tran KT, Kuijpers HC, Willemsen WN, Bulten H: Surgical treatment of\nsymptomatic rectosigmoid endometriosis. Eur J Surg 1996, 162:39-141.\n14. Chapron C, Jacob S, Dubuisson JB, Vieira M, Liaras E, Fauconnier : A\nLaparoscopically assisted vaginal management of deep endometriosis\ninfiltrating the rectovaginal septum. Acta Obstet Gynecol Scand 2001,\n80:349-354.\n15. Kavallaris A, Kohler C, Kuhne-Heid R, Schneider : A Histopathological\nextent of rectal invasion by rectovaginal endometriosis. Hum\n Reprod\n2003, 18:1323-1327.\n16. Thomassin I, Bazot M, Detchev R, Barranger E, Cortez A, Darai E: Symptoms\nbefore and after surgical removal of colorectal endometriosis that are\nassessed by magnetic resonance imaging and rectal endoscopic\nsonography. Am J Obstet Gynecol 2004, 190:1264-1271.\n17. Koninckx PR, Timmermans B, Meuleman C, Penninckx F: Complications of\nCO2-laser endoscopic excision of deep endometriosis. Hum Reprod 1996,\n11:2263-2268,.\n18. Varol N, Maher P, Healey M, Woods R, Wood C, Hill D, Lolatgis N, Tsaltas J:\nRectal surgery for endometriosis-should we be aggressive? J Am Assoc\nGynecol Laparosc 2003, 10:182-189.\n19. Dubernard G, Rouzier R, David-Montefiore E, Bazot M, Daraï E: Urinary\nComplications After Surgery for Posterior Deep Infiltrating Endometriosis\nare Related to the Extent of Dissection and to Uterosacral Ligaments\nResection. Journal of Minimally Invasive Gynecology 2008, 15:235-240.\n20. Darai E, Coutant C, Bazot M, Dubernard G, Rouzier R, Ballester M: Relevance\nof quality of life questionnaires in women with endometriosis.\nGynecologie Obstetrique & Fertilite 2009, 37:240-245.\n21. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R: Laparoscopic\nexcision of endometriosis: a randomized, placebo-controlled trial. Fertil\nSteril 2004, 82:878-884.\n22. Ford J, English J, Miles WA, Giannopoulos T: Pain, quality of life and\ncomplications following the radical resection of rectovaginal\nendometriosis. BJOG 2004, 111:353-356.\n23. Petta CA, Ferriani RA, Abrao MS, Hassan D, Rosa E, Silva JC, Podgaec S,\nBahamondes L: Randomized clinical trial of a levonorgestrel-releasing\nintrauterine system and a depot GnRH analogue for the treatment of\nchronic pelvic pain in women with endometriosis. Hum Reprod 2005,\n20(7):1993-8.\n24. Vercellini P, Aimi G, Busacca M, Apolone G, Uglietti A, Crosignani PG:\nLaparoscopic uterosacral ligament resection for dysmenorrhea\nassociated with endometriosis: results of a randomized, controlled trial.\nFertil Steril 2003, 80(2):310-9.\n25. Bodner CH, Garratt AM, Ratcliffe J, Macdonald LM, Penney GC: Measuring\nhealth-related quality of life outcomes in women with endometriosis –\nresults of the Gynaecology Audit Project in Scotland. Health Bull (Edinb)\n1997, 55(2):109-17.\n26. Roman H, Vassilieff M, Gourcerol G, Savoye G, Leroi AM, Marpeau L,\nMichot F, Tuech JJ: Surgical management of deep infiltrating\nendometriosis of the rectum: pleading for a symptom- guided\napproach. Hum Reprod 2011, 26(2):274-81.\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\nPage 6 of 7\n\n27. Dubernard G, Rouzier R, Montefiore ED, Bazot M, Darai E: Use of the SF-36\nquestionnaire to predict quality of life improvement after laparoscopic\ncolorectal resection for endometriosis. Hum Reprod 2008, 23(4):846-851.\n28. Seracchioli R, Mabrouk M, Montanari G, Manuzzi L, Concetti S, Venturoli S:\nConservative laparoscopic management of urinary tract endometriosis\n(UTE): surgical outcome and long-term follow-up. Fertil Steril 2009, 29.\n29. Seracchioli R, Poggioli G, Pierangeli F, Manuzzi L, Gualerzi B, Savelli L,\nRemorgida V, Mabrouk M, Venturoli S: Surgical outcome and long-term\nfollow up after laparoscopic rectosigmoid resection in women with\ndeep infiltrating endometriosis. BJOG 2007, 114(7):889-95.\n30. Villa G, Mabrouk M, Guerrini M, Mignemi G, Montanari G, Fabbri E,\nVenturoli S, Seracchioli R: Relationship between site and size of bladder\nendometriotic nodules and severity of dysuria. J Minim Invasive Gynecol\n2007, 14(5):628-32.\n31. Seracchioli R, Mabrouk M, Manuzzi L, Guerrini M, Villa G, Montanari G,\nFabbri E, Venturoli S: Importance of retroperitoneal ureteric evaluation in\ncases of deep infiltrating endometriosis. J Minim Invasive Gynecol 2008,\n15(4):435-9.\n32. Marana R, Caruana P, Muzii L, Catalano GF, Mancuso S: Operative\nlaparoscopy for ovarian cysts. Excision vs. aspiration. J Reprod Med 1996,\n41(6):435-8.\n33. Garry R: Laparoscopic excision of endometriosis: the treatment of\nchoice? Br J Obstet Gynaecol 1997, 104(5):513-5.\n34. Redwine DB, Wright JT: Laparoscopic treatment of complete obliteration\nof the cul-de-sac associated with endometriosis: long-term follow-up of\nen bloc resection. Fertil Steril 2001, 76(2):358-365.\n35. Apolone G, Mosconi P: The Italian SF-36 Health Survey: translation,\nvalidation and norming. J Clin Epidemiol 1998, 51(11):1025-36.\n36. Jones KD, Sutton C: Patient satisfaction and changes in pain scores after\nablative laparoscopic surgery for stage III-IV endometriosis and\nendometriotic cysts. Fertil Steril 2003, 79:1086-1090.\n37. Roman H, Loisel C, Resch B, Tuech JJ, Hochain P, Leroi AM, Marpeau L:\nDelayed functional outcomes associated with surgical management of\ndeep rectovaginal endometriosis with rectal involvement: giving\npatients an informed choice. Hum Reprod 2010, 25(4):890-9.\n38. Chopin N, Vieira M, Borghese B, Foulot H, Dousset B, Coste J, Mignon A,\nFauconnier A, Chapron C: Operative management of deeply infiltrating\nendometriosis: results on pelvic pain symptoms according to a surgical\nclassification. J Minim Invasive Gynecol 2005, 12:106-112.\n39. Keckstein J, Wiesinger H: Deep endometriosis, including intestinal\ninvolvement- the interdisciplinary approach. Minim Invasive Ther Allied\nTechnol 2005, 14:160-166.\n40. Darai E, Bazot M, Rouzier R, Houry S, Dubernard G: Outcome of\nLaparoscopic colorectal resection for endometriosis. Curr Opin Obstet\nGynecol 2007, 19:308-313.\n41. Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L, Landi S,\nPomini P, Scambia G: Laparoscopic colorectal resection for bowel\nendometriosis: feasability, complications, and clinical outcome. Arch Surg\n2009, 144:234-239.\n42. Mereu L, Ruffo G, Landi S, Barbieri F, Zaccoletti R, Fiaccavento A,\nStepniewska A, Pontrelli G, Minelli L: Laparoscopic treatment of deep\nendometriosis with segmental colorectal resection: short-term morbidity.\nJ Minim Invasive Gynecol 2007, 14:463-469.\n43. Slack A, Child T, Lindsey I, Kennedy S, Cunningham C, Mortensen N,\nKoninckx P, McVeigh E: Urological and colorectal complications following\nsurgery for rectovaginal. BJOG 2007, 114:1278-1282.\n44. Ret Davalos ML, De Cicco C, D ’Hoore A, De Decker B, Koninckx PR:\nOutcome after rectum or sigmoid resection: a review for gynecologists.\nJ Minim Invasive Gynecol 2007, 14:33-38.\n45. Remorgida V, Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E: How\ncomplete is full thickness disc resection of bowel endometriotic lesions?\nA prospective surgical and histological study. Hum Reprod 2005,\n20:2317-2320.\n46. Donnez J, Squifflet J: Complications, pregnancy and recurrence in a\nprospective series of 500 patients operated on by the shaving\ntechnique for deep rectovaginal endometriotic nodules. Hum Reprod\n2010, 25:1949-1958.\n47. Yap C, Furness S, Farquhar C: Pre and post operative medical therapy for\nendometriosis surgery. Cochrane Database Syst Rev 2004, 3.\n48. Muzii L, Marana R, Caruana P, Catalano GF, Margutti F, Panici PB:\nPostoperative administration of monophasic combined oral\ncontraceptives after laparoscopic treatment of ovarian endometriomas:\na prospective, randomized trial. Am J Obstet Gynecol 2000, 183:588-592.\n49. Koga K, Takemura Y, Osuga Y, Yoshino O, Hirota Y, Hirata T, Morimoto C,\nHarada M, Yano T, Taketani Y: Recurrence of ovarian endometrioma after\nlaparoscopic excision. Hum Reprod 2006, 21:2171-2174.\n50. Seracchioli R, Mabrouk M, Frasca C, Manuzzi L, Montanari G, Keramyda A,\nVenturoli S: Long-term cyclic and continuous oral contraceptive therapy\nand endometrioma recurrence: a randomized controlled trial. Fertil Steril\n2010, 93(1):52-6.\n51. Seracchioli R, Mabrouk M, Frascà C, Manuzzi L, Savelli L, Venturoli S: Long-\nterm oral contraceptive pills and postoperative pain management after\nlaparoscopic excision of ovarian endometrioma: a randomized\ncontrolled trial. Fertil Steril 2009, 12.\n52. Seracchioli R, Mabrouk M, Manuzzi L, Vicenzi C, Frascà C, Elmakky A,\nVenturoli S: Post-operative use of oral contraceptive pills for prevention\nof anatomical relapse or symptom-recurrence after conservative surgery\nfor endometriosis. Hum Reprod 2009, 24(11):2729-35.\n53. Roman H: Postoperative long-term amenorrhea avoids recurrence of\nendometriosis: finally the proof! Gynecol Obstet Fertil 2009, 37(10):771-2.\ndoi:10.1186/1477-7525-9-98\nCite this article as: Mabrouk et al .: Does laparoscopic management of\ndeep infiltrating endometriosis improve quality of life? A prospective\nstudy. Health and Quality of Life Outcomes 2011 9:98.\nSubmit your next manuscript to BioMed Central\nand take full advantage of: \n• Convenient online submission\n• Thorough peer review\n• No space constraints or color figure charges\n• Immediate publication on acceptance\n• Inclusion in PubMed, CAS, Scopus and Google Scholar\n• Research which is freely available for redistribution\nSubmit your manuscript at \nwww.biomedcentral.com/submit\nMabrouk et al . Health and Quality of Life Outcomes 2011, 9:98\nhttp://www.hqlo.com/content/9/1/98\nPage 7 of 7","source_license":"CC0","license_restricted":false}