{"paper_id":"4c2fb9ca-2a61-42d9-b677-7c2bd3708859","body_text":"Original Article  | JOGCR. 2023; 8(5): 494-500 \n     Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \nAnatomical Sites and Characteristics of EndometriosisLesions: Laparoscopic \nInvestigation \n \nBehnaz Nouri1 , Malihe Arab2 , Nazli Najeddin Choukan3* \n \n1. Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran \n2. Department of Gynecology-Oncology, Imam Hossein Medical Center, Shahid Beheshti  University of Medical Sciences, \nTehran, Iran \n3. Department of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran \n \nArticle Info  ABSTRACT \n  \n          10.30699/jogcr.8.5.494 \n \n \n \nBackground & Objective:  Endometriosis is a common and benign disease of the \nfemale genital system, which is often seen in reproductive age and leads to infertility, \ndysmenorrhea, and dyspareunia. The aim of this study is to investigate the anatomical \nlocation and characteristics of endometriosis lesions in laparoscopic surgery. \nMaterials & Methods: In this cross-sectional study, 557 endometriosis patients who \nreferred to the gynecology department of Shohadaye-Tajrish Hospital and underwent \nlaparoscopic surgery during 2016-2021 were evaluated. Statistical analysis of data was \ndone using SPSS software version 24.P-value less than 0.05 was considered statistically \nsignificant level. \nResults: The results of this study show that the highest anatomical distribution of \nendometriosis lesions was ovarian endometriosis, and the lowest was vagina. Also, the \nhighest rate of surface lesions is uterus and bladder, and the lowest is superficial lesions \nof the cul-de-sac cyst.  \nConclusion: Our results demonstrate that the distribution of endometriosis lesions is \nasymmetric. \nKeywords: Endometriosis, Laparoscopy, Anatomical Site, Lesion Distribution \nCharacteristics types of Endometriosis Lesions  \nReceived:  2023/02/03; \nAccepted: 2023/07/02; \nPublished Online: 09 Sep 2023; \n \n \nUse your device to scan and read the \narticle online \n \n \nCorresponding Information:  \nNazli Najeddin Choukan, \nDepartment of Obstetrics and Gynecology, \nShahid Beheshti  University of Medical \nSciences, Tehran, Iran \n \nEmail: Nazli_chogan@yahoo.com \n \n \nCopyright © 2023, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License \nwhich permits copy and redistribution of the material just in noncommercial usages with proper citation. \n \n \nIntroduction\nEndometriosis refers to the presence and growth of \nuterine tissue outside the uterine cavity, which is a \nchronic and complex disease that affects women of \nreproductive age (1 -4). Endometriosis is related to \ninfertility and chronic pelvic pain during the menstrual \ncycle and dyspareunia (3-8). About 176 million women \nsuffer from endometriosis (3, 9, 10). The approximate \nprevalence of endometriosis in the Tehran province in \n2013 was reported about 5- 20% (3). Endometriosis \nsignificantly affects the quality of life (Qol) of females \nand their families, and burden of disease is the same as \nother chronic diseases (3, 11-14). One of the causes of \ninfertility is endometriosis that affects about 25-50% of \ninfertile women (5, 6, 15). \nThe cause and pathophysiology of endometriosis are \nunknown, however genetic and environmental factors \nmay be involved (1, 16- 18).In order to check the \nlocation, number, measurement and severity of \nendometriosis involvement, a detailed laparoscopy \nevaluation is needed to consider the appropri ate \ntreatment method depending on the severity and \nlocation of the disease (3, 7).The purpose of this study \nwas to investigate the sites and characteristics of \nendometriosis lesions in laparoscopic surgery in \npatients referred to Shohadaye- Tajrish Hospital. \n \nMethods \nPatients and study design \nThis cross -sectional study was performed on \nendometriosis patients that referred to the gynecology \ndepartment at Shohadaye-Tajrish Hospital as a referral \ncenter in Tehran, Iran, between April2016 and April \n2022. Patien ts with endometriosis that underwent \nlaparoscopic surgery enrolled in this study. The \nsampling method was convenient and according to the \n\n\n495 Characteristics of Endometriosis Lesions \n      Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \nfollowing statistical formula, the sample size \ncalculated 557 patients. \nN= [P (1-P)] × (Z 1-α/2) ² d² \nInclusion criteria in this study were: age at least 18 \nyears, diagnosis of endometriosis and laparoscopic \nsurgery. Information was collected based on a \nchecklist. Also, for each surgery, laparoscopic videos \nof the patients were observed and evaluated, and the \nanatomical location of endometriosis was determined \nusing the detailed examination of these videos. \nDemographic factors (age, weight, height), location of \nendometriosis lesion, type of lesion (superficial lesion, \nendometrioma, DIE), pelvic adhesion and  laterality of \nendometriosis were investigated in these people. \nThe ethics was approved by the ethical committee of \nShahid Beheshti University of medical sciences \n(approval number \nIR.SBMU.RETECH.REC.1401.685). \nStatistical analysis \nStatistical analysis of the data was done using (spss \nsoftware, version 24, IBM, USA). Statistical analysis \nof data was done using T-test for quantitative variables \nand square test for qualitative variables. A P-value less \nthan 0.05 was considered statistically significant. \n \nResults \nFinally, 557 patients enrolled in this study and 66.7 \n% of women them were married. The average age of \npatients was 33.35 ±7.51 years (min:18 and max:49) \nand the average body mass index (BMI) was 25.48 \n±4.35. Fifteen patients (3.7%) had family history o f \nendometriosis. Table 1 shows descriptive \ncharacteristics of lesions.  \n \nTable 1. Descriptive characteristics of lesions \n Minimum Maximum Mean Std. Deviation \nSuperficial and deep lesions \nDeep Peritoneal lesions 10 60 34.62 12.052 \nSuperficial Peritoneal lesions 20 70 33.33 19.664 \nDeep right ovarian lesions 10 10 10.00 - \nDeep left ovarian lesions 10 10 10.00 - \nSuperficial right ovarian lesions 10 30 20.00 8.165 \nSuperficial left ovarian lesions 10 30 17.78 6.667 \nOvarian adhesions \nLeft (Dense) 10 30 18.33 7.528 \nLeft (Filmy) 10 20 16.67 5.774 \nRight (Dense) 10 30 17.86 6.986 \nRight (Filmy) 20 20 20.00 0.000 \nEndometrioma size \nLeft endometrioma size 10 150 60.19 33.107 \nRight endometrioma size 20 150 57.78 36.064 \n \nOut of 557 patients, 82 (14.7%) had pelvic adhesions. \nTable 2 shows the prevalence of lesions in patients. \nAmong the patients who had pelvic adhesions, 46.3% (n \n= 38) they had no history of pelvic infection, while \n53.6% (n = 44) had a history of pelvic infection, which \naccording to chi -square test, there was no stat istically \nsignificant difference ( P-value=0.79). Table 3  shows \nsurgeries history for the patients under study.  \n \nTable 2. Prevalence of lesions in patients \n Frequency Percent \nDeep lesions \nEndometrioma 408 73.2 \nLeft uterosacral 294 52.8 \nRight uterosacral 245 44.0 \n\nBehnaz Nouri et al. 496 \n      Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \n Frequency Percent \nRectum 158 28.4 \nBladder 93 16.7 \nLeft pelvic wall 43 7.7 \nRight pelvic wall 43 7.7 \nRight ureter 38 6.8 \nLeft ureter 16 2.9 \nSigmoid 38 6.8 \nDiaphragm 27 4.8 \nParametrium 27 4.8 \ncul-de-sac 21 3.8 \nVagina 6 1.1 \nSuperficial lesions \nUterine 49 8.8 \nBladder 49 8.8 \nCul-de-sac 6 1.1 \n8.8 Endometriosis adhesions \nNo 491 88.2 \nYes 66 11.8 \nMüllerian duct anomalies \nNo 508 91.2 \nYes 49 8.8 \nMyoma \nNo 86 84.3 \nSubserous 16 15.7 \nNon-endometrioma cysts \nNo 536 96.2 \nYes 21 3.8 \nStage of endometriosis \nStage 1 26 4.7 \nStage 2 38 6.8 \nStage 3 67 12.0 \nStage 4 426 76.5 \n \nTable 3. Surgeries history for the patients under study \nSurgeries Left side Right side Both side \nOophorectomy 55 (9.9) 33(5.9) 71(12.7) \nCystectomy 98 (17.6) 120 (21.5) 120 (21.5) \nReconstructed ovary 13(2.3) 6(1.1) 22 (3.9) \nFallopian tube occlusion 16 (2.9) 32 (5.7) 13(2.3) \nSalpingectomy 59 (10.6) 22(3.9) 55 (9.9) \n \n\n497 Characteristics of Endometriosis Lesions \n      Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \nThe relationship between the average age and BMI \nof the patients and the location of the lesion is shown \nin Table 4. Independent t test shows there was a \nstatistically significant difference in left uterosacral site \nand left pelvic wall with age of patients. The \nindependent t -test showed a significant difference \nbetween BMI and pelvic wall, ureter, uterosacral and \nendometrioma lesions. \n \nTable 4. The relationship between the age and BMI of patients and location of lesions \nLocation of lesions \nYes No \nP-value Mean + SD \nAge \nMean + SD \nAge \nUterine wall 37.67 + 7.81 32.94 + 7.4 0.071 \nUreter 35.43 + 7.23 33.2 + 7.55 0.452 \nUterosacrals 34.12 + 7.9 32.34 + 6.94 0.238 \nEndometrioma 32.75 + 6.69 35.04 + 9.4 0.176 \nLeft Uterosacral 34.85+7.61 31.67+7.12 0.032 \nRight Uterosacral 33.44+7.67 33.28+7.46 0.914 \nRectum 33.48 + 7.58 3.30 + 7.54 0.913 \nBladder 32.76+8.98 33.47+7.25 0.726 \nLeft uterine wall 38.5+7.91 32.91+7.36 0.043 \nRight uterine wall 37.13+8.17 33.03+7.42 0.140 \nLeft ureter 32.67+6.66 33.37+7.57 0.873 \nRight ureter 35.43+7.23 33.2+7.55 0.452 \nSigmoid 33.14+9.28 33.37+7.43 0.939 \nParametrium 28.8+4.02 33.59+7.59 0.166 \nLocation of lesions \nMean + SD \nBMI \nMean + SD \nBMI \nP-value \nUterine wall 25.31 + 2.46 25.49 + 4.49 0.910 \nUreter 24.69 + 3.63 25.54 + 4.42 0.620 \nUterosacrals 25.48 + 4.96 25.48 + 3.44 0.998 \nEndometrioma 25.71 + 4.54 24.86 + 3.82 0.390 \nLeft Uterosacral 25.81+4.91 25.1+3.64 0.421 \nRight Uterosacral 25.42+5.31 25.53+3.47 0.906 \nRectum 26.70 + 5.71 25.01 + 3.65 0.082 \nBladder 24.5+3.95 25.68+4.43 0.309 \nLeft uterine wall 25.27+2.66 25.5+4.47 0.896 \nRight uterine wall 25.07+2.56 25.51+4.47 0.798 \nLeft ureter 26.47+3.72 25.45+4.39 0.693 \n \n \nDiscussion \nIn a study by Audebert  et al. it was shown that the \nhighest prevalence of endometriosis was in the ovary, \nuterosacral ligament, ovarian cavity, posterior cul -de-\nsac, and bladder, respectively). Also, the most common \nsite of endometriosis was on the left side of the pelvis. \nThe results of this study showed that the most adhesion \nis in the adnexa of patients. In this survey, average age \nof the patients was 33.6 years and average BMI of the \n\nBehnaz Nouri et al. 498 \n      Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \npatients was 21.5 kg/m 2. Also, the most common site \nof involvement of deep endometriosis was reported in \nthe ureter in 159 patients (14.4%) (19). \nIn another study shown by Ajani et al. (2019), the \naverage age of the patients was 35 years, and the most \ncommon site of endometriosi s lesions was the ovary \n(bilateral in 28.8% of cases) and fallopian tubes (20) . \nAlso, in a study conducted by Yasui and et al., (2015), \nthey examined 210 patients who underwent surgery. It \nwas shown that the prevalence site of endometriosis \nwas ovary, peri toneum, rectum and bladder, \nrespectively (21). \nAlso, in a study by Jenkins et al. (2008), it was shown \nthat ovarian and posterior broad ligament lesions were \nmore common and anterior cul -de-sac lesions were \nsignificantly more than posterior cul-de-sac lesions (22). \nIn the study of Kadivar et al. in 2013, it was shown \nthat the frequency of extrapelvic endometriosis was 48 \ncases (14.8%) and 40 cases of abdominal wall \nendometriosis. Also, abdominal wall endometriosis \nwas observed in 12.3% of endometriosis cases (23). In \nthis study, the frequency of endometriosis was \n11.7%cases in the cesarean scar. Also, the results \nshowed that the history of cesarean delivery in patients \nwith abdominal wall endometriosis was more than in \nother patients with endometriosis (23) . In a study \nconducted by Lee.), it was shown that the prevalence \nof endometriosis in the ovary was (96.4%) (24). \n \nConclusion \nBased on our finding and some other studies, \ndemonstrate that the distribution of endometriosis \nlesions is asymmetric. The results of this study show \nthat the anatomical distribution of endometrioma \nlesions in this study has the highest percentage related \nto ovarian endometrioma and the lowest percentage \nrelated to vagina. Most of the anatomical distribution \nafter ovarian endometrioma  is related to the left \nuterosacral, right uterosacral, rectum, bladder, uterus \nand appendix. Also, the highest rate of surface lesions \nis related to the uterus and bladder, and the lowest is \nrelated to the superficial lesions of the cul-de-sac.  \n \nAcknowledgments \nWe sincerely thank the women who participated in \nthe present study. We are also grateful to Deputy for \nResearch of Shahid Beheshti University of Medical \nSciences who supported us in this project. \n \nAuthors' Contribution \nAll authors had full access to all the data in the study \nand take responsibility for the integrity of the data and \nthe accuracy of the data analysis. Concept and design: \nBN, MA and NNC. Drafting of the manuscript: NNC, \nMA and BN. Critical revision of the manuscript for \nimportant inte llectual content: All authors. Statistical \nanalysis: NNC. Supervision: BN. \n \nFunding/Support \nThe author(s) received no financial support for the \nresearch, authorship, and/or publication of this article. \n \nConflict of Interest \nThe authors certify that they have no affiliations with \nor involvement in any organization or entity with any \nfinancial or non-financial interest in the subject matter \nor materials discussed in the manuscript.\n \n \n \n1. Zondervan KT, Becker  CM, Koga K, Missmer \nSA, Taylor RN, Viganò P. Endometriosis. Nat \nRev Dis Primers. 2018;4(1):9.  \n[DOI:10.1038/s41572-018-0008-5] [PMID] \n2. Dahaghin S, Hosseini Doust R, Mirnejad R. \nMolecular Detection of Ureaplasma urealyticum \nand Chlamydia trachomatis in Women with \nEndometriosis. Iran J Med Microbiol. 2019;13  \n(2):125-31.  [DOI:10.30699/ijmm.13.2.125] \n3. Naji Omidi F, Abolghasemi J, Chaichian S, \nRimaz S, Najmi Z, Mehdizadehkashi A. \nEvaluation of the factors influencing \nendometriosis in reproductive age women. Med \nSci J Islamic Azad Univ. 2016;26(3):188-94. \n4. Hoorsan H, Mirmiran P, Chaichian S, Moradi Y, \nAkhlaghdoust M, Hoorsan R, et al. Diet and Risk \nof Endometriosis: A Systematic Review and \nMeta-Analysis Study. Iran Red Crescent Med J. \n2017;19(9): e41248. [DOI:10.5812/ircmj.41248] \n5. Moazzami B, Chaichian S, Samie S, Zolbin MM, \nJesmi F, Akhlaghdoust M, et al. Does \nendometriosis increase susceptibility to COVID -\n19 infections? A case-control study in women of \nreproductive age. BMC Women's Health. 2021;  \n21(1):1-7. [PMID] [PMCID]  \n[DOI:10.1186/s12905-021-01270-z]  \n6. Sarbazi F, Akbari E, Karimi A, Nouri B, Noori \nArdebili SH. The Clinical Outcome of \nLaparoscopic Surgery for Endometriosis on Pain, \nOvarian Reserve, and Cancer Antigen 125 (CA -\n125): A Cohort Study. Int J Fertil Steril. 2021;  \n15(4):275-9. \nReferences \n\n499 Characteristics of Endometriosis Lesions \n      Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \n7. Hoorsan H, Alavi Majd H, Chaichian S, \nMehdizadehkashi A, Hoorsan R, Akhlaqghdoust \nM, et al. Maternal Anthropometric \nCharacteristics and Adverse Pregnancy \nOutcomes in Iranian Women: A Confirmation \nAnalysis. Arch Iran Med. 2018;21(2):61-6. \n8. Sarbazi F, Akbari E, Nouri B. Pain Management \nin Endometriosis. Interv Pain Med Neuromod. \n2022;2(1):e128043. [ DOI:10.5812/ipmn-\n128043] \n9. Nouri B, Roshandel S. Is Artificial Intelligence a \nNew Diagnos tic Approach for Patients with \nEndometriosis? Interv Pain Med Neuromod. \n2022;2(1):e128720. [ DOI:10.5812/ipmn-\n128720] \n10. Nouri B, Arab M, nasiri m. Endometriosis: \nClinical, Magnetic Resonance Imag ing and \nPathologic Findings. J Obstet Gynecol Cancer \nRes. 2022(14):61. \n11. Davoodi P, J. Ghadimi D, Rezaei M, Khazei \nTabari MA, Shirani A, Nouri B, et al. \nEndometriosis and COVID -19: Clinical \nPresentation and Quality of Life, a Systematic \nReview. J Obstet Gyne col Cancer Res. 2023;  \n8(4):314-25. \n12. Morgan-Ortiz F, López -de la Torre MA, López-\nZepeda MA, Morgan -Ruiz FV, Ortiz -Bojórquez \nJC, Bolívar -Rodríguez MA. Clinical \ncharacteristics and location of lesions in patients \nwith deep infiltrating endometriosis using the \nrevised Enzian classification. J Turk Ger Gynecol \nAssoc. 2019;20(3):133-7. [PMID] [PMCID]  \n[DOI:10.4274/jtgga.galenos.2018.2018.0120]  \n13. Angioni S, Nappi L, Sorrentino F, Peiretti M, \nDaniilidis A, Pontis A, et al. Laparoscopic \ntreatment of deep endometriosis with a diode \nlaser: our experience. Arch Gynecol Obstet. \n2021;304(5):1221-31. [PMID] [PMCID]  \n[DOI:10.1007/s00404-021-06154-z]  \n14. Agarwal SK, Chapron C, Giudice LC, Laufer \nMR, Leyland N, Missmer SA, et al. Clinical \ndiagnosis of endometriosis: a call to action. Am J \nObstet Gynecol. 2019;220(4):354-e1-12.  \n[DOI:10.1016/j.ajog.2018.12.039] [PMID] \n15. Gui B, Valentini AL, Ninivaggi V, Marino M, \nIacobucci M, Bonomo L. Deep pelvic \nendometriosis: don't forget round ligaments. \nReview of anatomy, clinical characteristics, and \nMR imaging fea tures. Abdom Imaging. 2014;  \n39(3):622-32. [PMID] [DOI:10.1007/s00261-\n014-0091-3]  \n16. Albee RB, Sinervo K, Fisher DT.  Laparoscopic \nExcision of Lesions Suggestive of Endometriosis \nor Otherwise Atypical in Appearance: \nRelationship Between Visual Findings and Final \nHistologic Diagnosis. J Minim Invasive Gynecol. \n2008;15(1):32-7. \n[DOI:10.1016/j.jmig.2007.08.619] [PMID] \n17. Foti PV, Farina R, Palmucci S, Vizzini IAA, \nLibertini N, Coronella M, et al. Endometriosis: \nclinical features, MR ima ging findings and \npathologic correlation. Insights into Imaging. \n2018;9(2):149-72. [PMID] [PMCID]  \n[DOI:10.1007/s13244-017-0591-0]  \n18. Di Giovanni A, Casarella L, Coppola M, Falcone \nF, Iuzzolino D, Rasile M, et al. Ultrasound \nEvaluation of Retrocervical and Parametrial \nDeep Endometriosis on  the Basis of Surgical \nAnatomic Landmarks. J Minim Invasive \nGynecol. 2022;29(10):1140-8.  \n[DOI:10.1016/j.jmig.2022.06.014] [PMID] \n19. Audebert A, Petousis S, Margioula -Siarkou C, \nRavanos K, Prapas N, Prapas Y. Anatomic \ndistribution of endometriosis: A reappraisal \nbased on series of 1101 patients. Eur J Obstet \nGynecol Reprod Biol. 2018;230:36-40.  \n[DOI:10.1016/j.ejogrb.2018.09.001] [PMID] \n20. Ajani MA, Salami A, Nwanji ID, Olusanya AA, \nFatunla OE. Distribution and Characteristics of  \nEndometriotic Lesions in South -Western \nNigeria: A Single Institutional Experience. Med \nJ Zamb. 2019;46(1):28-32.  \n[DOI:10.55320/mjz.46.1.227] \n21. Yasui T, Hayashi K, Nagai K, Mizunuma H, \nKubota T, Lee J -S, et al. Risk Profiles for \nEndometriosis in Japanese Women: Results From \na Repeated Survey of Self -Reports. J Epidemiol. \n2015;25(3):194-203. [PMID] [PMCID]  \n[DOI:10.2188/jea.JE20140124]  \n22. Jenkins TR, Liu CY, White J. Does Response to \nHormonal Therapy Predict Pr esence or Absence \nof Endometriosis? J Minim Invasive Gynecol. \n2008;15(1):82-6. \n[DOI:10.1016/j.jmig.2007.09.002] [PMID] \n23. Kadivar M, Vafa A, Farahzadi A, Khani S. 6 \nyears evaluation of prevalence of abdominal wall \nendometriosis in patients with definite \nhistopathological diagnosis of endometriosis \nadmitted in Rasool -Akram, Shariati and Atieh \nHospitals in Tehran. Razi J  Med Sci. 2012;  \n18(93):20-6. \n24. Lee SY, Koo YJ, Lee DH. Classification of \nendometriosis. Yeungnam Univ J Med. 2021;  \n38(1):10-8. [ DOI:10.12701/yujm.2020.00444] \n[PMID] \n \n\nBehnaz Nouri et al. 500 \n      Volume 8, September – October 2023       Journal of Obstetrics, Gynecology and Cancer Research \n \n \n \nHow to Cite This Article:  \nNouri, B., Arab, M., Najeddin Choukan, N. Anatomical Sites and Characteristics of EndometriosisLesions: \nLaparoscopic Investigation. J Obstet Gynecol Cancer Res. 2023; 8(5):494-500. \nDownload citation:                             RIS | EndNote | Mendeley |BibTeX |","source_license":"CC0","license_restricted":false}