{"paper_id":"6806003f-4928-45c1-b993-bd7913373c6a","body_text":"REVIEW ARTICLE\nSurgical treatment of rectovaginal endometriosis with rectal\ninvolvement\nVicente Payá & Juan José Hidalgo-Mora &\nCesar Diaz-Garcia & Antonio Pellicer\nReceived: 6 December 2010 / Accepted: 26 January 2011 / Published online: 12 February 2011\n# Springer-V erlag 2011\nAbstract Rectovaginal endometriosis (RVE) is one of the\nmost serious and incapacitating forms of presentation of\nthis disease. Traditionally, medical treatment has not been\nconsidered effective for the majority of patients, being\nsurgery the only reasonable and therapeutic choice in these\ncases. This exposes patients to a potentially serious\nmorbidity, thus a careful evaluation should be done by a\nsurgical board considering the impact of the disease as well\nas the quality of life of the patients. The main surgical\ntechniques used are the shaving of the rectal wall affected\nby the endometriosic implants, the discoid excision of the\nfront rectal wall, and the segmental intestinal resection, and\nthere is no consensus concerning which is the most\neffective and suitable between them. The bibliography\npublished in the last 10 years relating to the surgical\ntreatment of RVE is being reviewed with the intention of\nupdating the knowledge base about the topic and looking\nfor common ground between different studies, allowing us\nto come closer to reaching a consensus about treatment for\nthis pathology.\nKeywords Deep endometriosis . Deeply infiltrating\nendometriosis . Laparoscopy . Rectovaginal endometriosis .\nSurgery . Surgical management\nIntroduction\nEndometriosis is a chronic illness defined by the presence\nof functional endometrial tissue outside of the uterus. It\naffects 6 –10% of women of reproductive age, 50 –60% of\nwomen and adolescents with pelvic pain, and up to 50% of\ninfertile women [ 1, 2]. It is one of the pathologies that\ncause a large effect on the quality of life of young women,\nentailing a large social and economic impact on them and\non the health care system [ 3].\nDeep endometriosis is an aggressive form of endometriosis\ninfiltrating more than 5 mm under the peritoneum. This term\nusually includes infiltrative forms involving structures such as\nbowel, ureters, bladder, and rectovaginal wall. Intestinal\ninvolvement occurs up to 12% of women with endometriosis,\nbeing its most common sites the rectosigmoid (65%), the\nileocecal (20%) junctions, and the rectum (15%) [ 4, 5].\nRectovaginal endometriosis (RVE) is characterized by its\neffect on the vagina, rectum, rectovaginal septum, Douglas\npouch, and sometimes even the ureters [ 6–8]. The rectum is\naffected on its anterior wall and rarely the whole thickness of\nthe intestinal wall [ 9].\nClinically, although it involves a benign process, RVE can\nalter the quality of life for patients due to dysmenorrhea,\ndyspareunia, limitation of sexual activity, and the severe\ndyschezia that are provoked [10]. Pharmacological treatment\nis not very effective for the majority of patients. Surgery is\nthe best therapeutic option for symptomatic RVE, even\nthough it implies a greater morbidity. Laparoscopy is the\nchosen approach [ 11–16].\nThe preoperative diagnosis for RVE is crucial in order to\nestablish the precise distribution of the deeply infiltrating\nendometriotic lesions, which is the most relevant tool to\nhelp the surgeon decide how to treat these patients.\nV . Payá: J. J. Hidalgo-Mora ( *) : C. Diaz-Garcia : A. Pellicer\nDepartment of Gynecology and Human Reproduction,\nLa Fe University Hospital,\nBulevar Sur,\n46026 V alencia, Spain\ne-mail: hidalmo@yahoo.es\nGynecol Surg (2011) 8:269 –277\nDOI 10.1007/s10397-011-0663-y\n\nDistinguishing retrocervical and rectovaginal involvement\nand the depth of lesions are important in the surgical\nmanagement of patients. Clinical history, vaginal and rectal\npelvic examination, transvaginal and transrectal ultrasounds,\nmagnetic resonance imaging (MRI) and double-contrast\nbarium enemas have been used for this purpose. Nevertheless,\nphysical examination does not allow prediction of the\nextension of RVE, and the value of transvaginal sonography\nfor assessment deep pelvic endometriosis is uncertain. Rectal\nendoscopic sonography has been recommended for detection\nof endometriosis in rectal, rectovaginal, uterosacral, or\nrectosigmoid locations, and MRI has demonstrated high\nsensitivity, specificity, positive and negative predictive values,\nand accuracy in prediction of the locations and in evaluation\nof the extension of lesions. The gold standard examination for\nclassification of endometriosis is laparoscopy, and the\ndiagnosis is confirmed by the histology obtained by laparos-\ncopy or laparotomy or by the biopsy of visible endometriosic\nlesions in the posterior fornix [ 17–21]. The preoperative\nstudy should be done with an ultrasound of the urinary and\nkidney tracts, an intravenous pyelography to rule out an\nasymptomatic ureteral stenosis, and a rectosigmoidscopy to\nconfirm the involvement of the rectal mucosa.\nSeveral techniques have been proposed for the treatment\nof RVE with rectal involvement, with no consensus existing\non which could be the best when the muscular rectal layer\nis affected [ 22]. In these cases, different surgical procedures\nhave been described in terms of parameters, such as the size\nof the nodule and the affected bowel circumference, the\ndepth of lesions on the rectal wall, the presence of other\nendometriosic foci, and the experience of the surgeon in the\nexecution of each procedure [ 23, 24]. The most common\nsurgical procedures used in the treatment of RVE are\nsuperficial thickness excision (shaving), the resection of the\nnodule with excision of the anterior side of the rectum (full\nthickness discoid resection) and the colorectal segmental\nresection.\nAt present, some gynecological surgeons prefer colorectal\nresection for symptomatic patients, as they are convinced that\nresection of all intestinal endometriosic foci is the choice of\ntreatment to improve pain and to avoid relapses [5, 13, 25–27].\nOn the other hand, other groups prefer the excision of the\nendometriosic nodule to colorectal resection, since the rate of\nmorbidity is lower and the recurrence of pain is similar\n[3, 28–30].\nUntil now, there has not been a randomized study that\ncompares the different techniques, and few review articles\nhave been published in relation to surgical treatment of\nRVE. If we add to this the great variety of results from\nobservational studies and the lack of clinical trials, a review\nof the medical literature published on this topic over the last\n10 years is valuable. The main objective of our paper is to\nassess, standardize, and analyze the data and results\nobtained in different studies regarding the surgical techniques\nemployed in the treatment of RVE with rectal involvement.\nMethods\nThe review of medical literature was done through an\nelectronic search for articles in the databases of the US\nNational Library of Medicine (PubMed database) and the\nCochrane Library (Cochrane database). Its objective was to\nidentify all of the observational studies, clinical trials,\nsystematic and nonsystematic reviews, and meta-analysis\npublished in English between January of 2000 and June of\n2010 regarding the surgical treatment of endometriosis of\nthe rectovaginal septum. The medical terms combined in\nthe search included RVE, deep endometriosis, deeply\ninfiltrating endometriosis, surgical management, surgical\ntreatment, surgery, and laparoscopy. The complete text was\nobtained for all the selected articles and the list of\nbibliographic references for each one was reviewed with\nthe aim of identifying other studies that could also be\nincluded in our review. Summaries of congress communi-\ncations and scientific meetings were not included in the\nselected literature.\nArticles in press whose text and complete results were\navailable at the time of our search were included. To be\nselected, the studies needed to have a series of characteristics\nthat were considered inclusion criteria: Patients must be\ndiagnosed with RVE by means of physical examination,\nvaginal or transrectal ultrasound, MRI, and biopsy with\nhistological confirmation; analysis of the results of one or\nmore surgical techniques performed as treatment for RVE\nmust be performed. The initial selection of the papers was\ndone independently by two authors (VP and JJH) in terms of\nthe title and abstract. In cases of discrepancy between the two\nauthors, the decision to include or exclude the article was\nmade by a third author (AP).\nThe year of publication, the type and design of the study,\nthe number of patients, the surgical technique analyzed, and\nthe primary and secondary results were taken from the\nselected papers. The studie s were classified by their\nmethodological design in observational studies, clinical trials,\nsystematic and nonsystematic reviews, and meta-analysis.\nThe two reviewers independently evaluated all the articles and\nproduced a summary of each one according to a previously\nestablished format. The summaries were compiled into a\nsingle summary for each selected paper, reaching agreement\nby consensus in case of discrepancies.\nThis paper was not conceived as a systematic revision of\nthe literature following QUOROM norms [ 31] since the\ndifferent procedures described in the studies make it\ndifficult to draw a direct comparison of the results.\nMoreover, the different papers do not provide results of\n270 Gynecol Surg (2011) 8:269 –277\n\nthe complications in detail or favorable effects of the\nsurgery in terms of each technique. Therefore, we did not\nperform a qualitative analysis of the selected studies or a\ngrouped analysis of the data obtained from them.\nForty one potentially relevant studies were identified. Of\nthem, 36 corresponded to observational studies and five to\nnonsystematic revisions. No systematic revisions, clinical\ntrials, or meta-analyses were identified.\nFindings\nThe great heterogeneity of the studies in relation to the\nsurgical treatment of RVE proves the difficulty of standard-\nizing data collected and establishing general conclusions\nregarding the results. All of the analyzed studies are non-\ncomparative observational studies with a limited number of\npatients. There were also five nonsystematic revisions\npublished [3, 28, 32–34]. In some of the studies, a radical\ntreatment was assessed [ 5, 13, 15, 25–27, 40–56], while\nothers assessed a conservative one [ 57–63]. There were six\nnonrandomized papers in which groups of patients with\ndifferent therapeutic options were compared [ 30, 35–39].\nThe follow-up time was not uniform within studies, neither\nwere the criteria used to establish the diagnosis, the extent of\nthe RVE, or the result variables.\nIn relation to the type of surgical approach, two main\ngroups can be observed: those who propose a more\naggressive approach and tend to defend the systematic\nintestinal resection under the premise that a more radical\napproach would be more effective (segmental resection of\nthe rectum and/or sigmoid colon) and those that argue for a\nmore conservative approach basing their argument on the\nlack of scientific evidence of better results with more\nradical techniques and the association of these techniques\nwith higher long-term morbidity and a lower quality of life\nfor patients (shaving of the rectal wall, disc excision of the\nanterior rectal wall).\nIn this review, the studies are grouped according to the\nsurgical approach evaluated: a radical approach, a conservative\napproach, or a comparative approach between different\ntreatment methods.\nRadical surgery with intestinal resection\nSurgery for endometriosis of the rectovaginal septum was\ndescribed for the first time in 1991 by Reich et al. [ 64].\nInitially, the majority of papers defended a conservative\nsurgical approach directed toward the extirpation or ablation\nof the endometriosic lesions with minimal excisional surgery\nof the rectum [ 6, 12, 65–68]. However, in the last decade,\nmultiple authors have proposed more aggressive techniques\nincluding intestinal resection, especially in those cases with\nan affected muscularis propia of the rectum but also in those\nhaving an intact mucosa [ 5, 13, 15, 25–27, 40–56]. The\nargument used for the practice of this radical surgery is that\nof achieving the greatest resection possible of the endome-\ntriosic lesions, diminishing the postoperative symptomatology\nand avoiding any early relapse of the disease [ 41,\n42].\nMost of the studies summarized in our review consider\ncomplications, symptomatic improvement (dysmenorrhea,\ndyspareunia, chronic pelvic pain, and dyschezia), rate of\nrecurrence, and postoperative indices of gestation as main\noutcomes. The results of these studies are shown in Table 1.\nThe largest casuistry of colorectal resections by laparos-\ncopy with 436 cases was published this year by the group\nin V erona [56]. In this long series, the rate of complications\nin the immediate postoperative period was 10.7%, with\n3.2% being rectovaginal fistulas. In the later postoperative\nperiod, 9.5% of patients showed urinary retention and 4.2%\nconstipation. The same authors published a previous report\nin 2009. In this publication, 357 cases were followed up for\n20 months showing a recurrence rate of symptomatology of\n6.3% and a recurrence rate of endometriosic nodules in\n3.5% of the patients [ 27]. When they compared these\nresults to those obtained after laparotomic colorectal\nresection, they found a similar rate of complications [ 51].\nKeckstein and Weisinger [ 25] found a 7.4% complications\nrate and Daraï et al. [ 26] reported a 10% complications rate,\nwith 6% being rectovaginal fistulas. When the laparotomic\napproach is used, Dousset et al. [ 5] reported a 16%\ncomplications rate, with 4% being rectovaginal fistulas.\nAfter 60 months follow-up, there were no relapses, but\nbladder and intestinal dysfunction reached 16% and 85%,\nrespectively.\nIn 2006, Landi et al. [ 20] studied 45 women and\ncompared the results of segmental intestinal resection by\nlaparoscopy in two groups of patients according to whether\n(n=20) or not ( n=25) neural preservation was done. While\nthe surgical complications were not statistically significant\nbetween the groups, a difference was noted in favor of the\ngroup doing neural preservation in terms of recuperation\ntime for urinary function (3 days compared to 12.5 days) as\nwell as the level of subjective satisfaction among the\npatients during the follow-up period.\nIn 2008, Zanetti-Dällenbach et al. [ 53] compared a new\ncombined technique, vaginal –laparoscopic –abdominal,\ndone on 30 patients compared to the 18 intestinal resections\nperformed using traditional techniques. The authors describe\nfewer complications in the group using the combined\ntechnique (10% vs. 39%) as well as lesser time of hospitali-\nzation (13.7 days compared to 15.8 days).\nIn 2009, Pereira et al. [ 54] analyzed the postoperative\nresults of 168 women with RVE in which the intervention\nwas conducted by gynecologi sts, without the initial\nGynecol Surg (2011) 8:269 –277 271\n\nTable 1 Results from the main studies with radical surgical techniques on rectovaginal endometriosis\nNumber\n(n)\nFollow-up\n(months)\nTechnique Complications Improvement Fertility Relapse\nPossover et al. [ 13] 34 16 Laparoscopic colorectal\nresection\nCA: 6.6% PR: 53% (8/15) No\nRedwine and Wright [ 40] 84 55 Laparoscopic colorectal\nresection\nID: 20% Dysmenorrhoea: 68%,\nDyspareunia: 66%,\nPelvic pain: 78%\nPR: 43% (12/28), SP:\n25%, ART: 18%\nDarai et al. [ 44, 45] 40 24 Laparoscopic colorectal\nresection\nRVF: 7.5%, PA: 2.5%,\nBD: 17.5%, ID: 37.5%\nDysmenorrhoea: 97%,\nDyspareunia: 82%,\nPelvic pain: 100%\nPR: 45.5% (10/22),\nSP: 32%, ART: 13%\nThomassin et al. [ 43] 27 15 Laparoscopic colorectal\nresection\nBD: 7.5%, ID: 15% Dysmenorrhoea: 96%,\nDyspareunia: 75%, Pelvic\npain: 100%, Dyschezia: 95%\nSP: 15% (4/27)\nFleisch et al. [ 46] 23 45 Laparoscopic/laparotomic\ncolorectal resection\nCA: 4% Global: 91.3% PR: 23.5% (4/17), SP:\n17.5%, ART: 6%\nSymptoms: 34.8%\nKeckstein and Weisinger [ 25] 142 Laparoscopic rectal\nsegmentary resection\nCA: 6% Dyspareunia: 87%, Pelvic\npain: 96%, Dyschezia: 88%\nPR: 50% (47/95)\nSeracchioli et al. [ 51] 22 42 Laparoscopic colorectal\nresection\nCA: 4.5%, BD: 14% Dysmenorrhoea: 86%,\nDyspareunia: 78%, Pelvic\npain: 50%, Dyschezia: 100%\nNo\nFord et al. [ 42] 60 12 Laparoscopic ( n=48) or\nlaparotomic ( n=12)\ncolorectal resection\nCA: 3.3% Global: 86% Nodules: 13%\nDubernard et al. [ 47] 58 22 Laparoscopic colorectal\nresection\nRVF: 10.3%, PA: 2% Dysmenorrhoea: 92%,\nDyspareunia: 88%,\nPelvic pain: 80%,\nDyschezia: 78%\nMinelli et al. [ 27] 357 20 Laparoscopic colorectal\nresection\nRVF: 3.9%, CA:\n3.1%, BD: 9.5%\nGlobal: 93.7% PR: 41.6% (47/113),\nSP: 9%, ART: 32.6%\nSymptoms: 6.3%,\nNodules: 3.5%\nDousset et al. [ 5] 100 60 Laparotomic subtotal\n(n=84) or total ( n=16)\nrectal excision\nRVF: 4%, CA: 2%,\nBD: 16%, ID: 85%\nGlobal: 94% No\nRVF Rectovaginal fistula, CA complications of the anastomosis, PA pelvic abscess, BD bladder dysfunction, ID intestinal dysfunction, PR pregnancy rate, SP spontaneous pregnancy, ART assisted\nreproductive techniques\n272 Gynecol Surg (2011) 8:269 –277\n\nparticipation of colorectal surgeons. In these patients, the\ninterventions included shaving resection, discoid resection,\nand segmental resection. The results were comparable to\nthe studies in which the intervention of the intestine was\ndone by a colorectal surgeon, with a percentage of global\ncomplications of 7.3% and a significant improvement in all\nthe assessed clinical parameters. The authors conclude that,\nafter adequate training, endometriosis with intestinal in-\nvolvement could be treated safely and efficiently by\ngynecologists who specialized in pelvic surgery.\nThe most frequent complication of the radical colorectal\nsurgery is bladder and intestinal dysfunction. The first is\ndefined in the majority of the studies as persistent urinary\nretention 30 days after the intervention, in the context of the\ndenervation of the inferior hypogastric plexus. In some\nstudies, the proportion of patients affected by this side\neffect of the surgery reaches 16 –17% [ 5, 45]. Intestinal\ndysfunction in these patients is defined by the existence of\nconstipation or diarrhea during several weeks after the\nsurgery, due to a mechanical effect by rectal reduction as\nwell as a neural disorder because of the denervation of the\nrectal plexus. This is the most frequent complication, being 15–\n20%, although it can reach 85% in some [5, 40, 45, 49, 56].\nThe second most frequent and very important complica-\ntion due to its severity is the rectovaginal fistula, which\nreaches rates of 10% [ 45, 47]. Other complications that are\nnormally described in these papers are related to alterations\nof rectal anastomosis and pe lvic infectious processes\n(Table 1).\nThe indices of symptomatic improvement for patients\ntreated with radical rectovaginal surgery in the majority of\nthe analyzed studies stand around 90% as much in their\nglobal form as for each one of the assessed symptoms. This\nimprovement is greater during the first year after the\nintervention, although it can stay above 70% of the patients\nafter 3 and 5 years, especially for those specific intestinal\nsymptoms such as dyschezia [ 46, 51].\nIn some reports, a subjective improvement is shown in\nthe patients ’ global quality of life with respect to the time\nprior to the surgery [ 42, 45, 47, 48, 50]. Dubernard et al.\n[47] evaluated the quality of life in 58 women after\nlaparoscopic colorectal resection using the validated ques-\ntionnaire Medical Outcomes Study SF-36 and observed that\nall its items improved after surgery. Similar results were\nobtained by Ford et al. [ 42] in 60 patients following radical\nresection of RVE and by Lyons et al. [ 48] in seven patients\nundergoing laparoscopic colorectal surgery, both using the\nEQ-5D questionnaire.\nSymptomatic recurrence was also analyzed by Fedele et\nal. [ 41] after following up 83 patients with RVE during\n36 months. Thirty of them underwent laparotomic intestinal\nresection because of an involvement in the rectal wall. The\nrate of pain recurrence was 28%, and the necessity for new\nintervention and/or medical treatment was 27%. The factors\nwhich the authors correlated with a lessened probability of\nrecurrence were pregnancy and intestinal resection. On the\nother hand, the youngest patients and those that had\npreviously been treated for endometriosis showed a greater\nprobability of recurrence. In the rest of the evaluated\nstudies, the rate of relapse for the disease varies, ranging\nfrom some showing no reappearance of the disease to those\nthat show 35% 4 years after the intervention [ 5, 46].\nIn the studies in which reproductive results were\nanalyzed, a general improvement was noted in their\ngestation rate after radical surgery [ 13, 40, 44]. This rate\nvaried between the studies depending on the antecedents of\nsterility or the wish to gestate, standing around 50% in the\nmajority of the patients. In some studies, no difference has\nbeen noted upon comparing the expectant attitude with the\nsurgical technique [ 36]. Moreover, it is not specified in each\nseries if the gestations were achieved spontaneously or after\nreproductive assistance treatment, making the interpretation\nof the results difficult. What does appear uniform between\nthe papers is the conclusion that improvement of reproductive\nfunction after surgery for RVE is greater the younger the\npatient and the earlier the intervention is made [ 44, 45, 55].\nConservative surgery without intestinal resection\nThe authors who propose conservative treatment of RVE\npoint out as fundamental that it achieves lower indices of\ncomplications and similar rates of symptomatic improvement\nand preservation of fertility when compared with intestinal\nresection [68].\nThe most frequent conservative surgical techniques in\nthe treatment of RVE are those aiming for simple lesional\nresection after separating the endometriosic nodule from the\nrectal wall [ 57], layer-to-layer excision shaving of the\nlesion without resecting the entire thickness of the intestinal\nwall [63], and discoidal resection with complete excision of\nthe affected area of the intestinal wall by the endometriosic\nnodule [ 35]. In addition, in some papers, the technique\nproposed was in-block excision of the posterior vaginal\nfornix in an attempt as much to eliminate the greatest\npossible part of the disease as to avoid its progression\n[58, 60, 61]. This same proposal was done by Matsuzaki et\nal. [ 62] by studying histological samples from 61 patients\nafter in-block resection for RVE. Every single sample was\ninfiltrated by endometriosic tissue.\nThe main results of the papers, which assessed the\nconservative surgery for ERV , are shown in Table 2.\nThe largest casuistry using a conservative approach (the\nshaving technique) is that recently published by Donnez\nand Squifflet [ 63] with 500 cases. In this study, the rate of\nserious complications was 3.2%, the rate of relapse was\nGynecol Surg (2011) 8:269 –277 273\n\n8%, and 84% of women gestated after the intervention,\n57% spontaneously. With this technique, there were no\nfunctional alterations of the bladder or intestine 1 month\nafter the intervention.\nThe effectiveness of the discoidal resection technique\nwas put in doubt by Remorgida et al. [ 59]. A segmental\nintestinal resection was done systematically after discoidal\nresection. The histological study of the enlarged piece, a\npriori free from disease, revealed that. in 7 of the 16 cases\n(43.8%), endometriosic tissue could still be found infiltrat-\ning up to the muscular intestinal layer, with a maximum\ndistance of 2.6 cm from the edge of the nodulectomy,\nalthough other studies demonstrate that intestinal resection\ndoes not guarantee the complete elimination of endome-\ntriosic foci either [ 69, 70].\nThe in-block excision techniques of the posterior vaginal\nfornix are accompanied by resection of the endometriosic\nnodule and, as what happens with these techniques, there\nare low rates of complications and high rates of pain\nimprovement [ 58, 60, 61]. In terms of fertility, the indices\nof gestation were 57% [ 58].\nComparative studies\nFew studies have been published up until now comparing\ngroups of patients with RVE treated with different\ntherapeutic attitudes. All of them are observational studies\nin which the treatment option was not decided randomly;\nrather, it was made in terms of clinical criteria or in\nconsensus with the patients [ 30, 35–39].\nIn four of these studies [ 30, 35, 37, 39], they compared\nthe postoperative results between different techniques used\nfor RVE. Although some of the outcomes and the way they\nwere assessed are not directly comparable between papers,\none can see a tendency that points to a similar symptomatic\nimprovement among the different techniques and a greater\nrate of surgical complications among the most radical\napproaches.\nThe results for discoidal resection analyzed in comparative\nstudies (Table 3) show that the rate of severe complications\nremains low, the symptomatic improvement stands around\n90%, and the rate of relapse between 5% and 14% [ 30, 35,\n37, 39]. Gestation rates, though low as they are, are still\nhigher than those obtained with radical treatments [ 37, 39].\nFanfani et al. [ 39] compared two groups of symptomatic\npatients, with nodules smaller than 3 cm and stenosis of the\nintestinal lumen less than 60%, and observed that the group\nof 48 patients treated conservatively by laparoscopic\ndiscoidal resection showed less postoperative morbidity\nand similar rates of relapse when compared with the group\nof 88 patients treated via laparoscopic segmental intestinal\nresection. In another study, Roman et al. [ 30] achieved a\nTable 2 Results from studies done with conservative surgical techniques for rectovaginal endometriosis\nNumber ( n) Follow-up\n(months)\nTechnique Complications Improvement Fertility Recurrence\nChapron et al. [ 57] 29 12 Laparoscopic nodular\nresection\nRVF: 3.5% Dysmenorrhea: 91.7%,\nDyspareunia: 100%,\nPelvic pain: 93%\nHollett-Caines et al. [ 58] 81 96 Laparoscopic shaving\nand posterior vaginal\nfornix resection\nFallopian tube\nabscess: 1.2%\nSymptoms: 88% PR: 57% (26/46),\nSP: 31%, ART: 26%\nAngioni et al. [ 60] 31 60 Laparoscopic nodular\nresection and posterior\nvaginal fornix resection\nDysmenorrhea: 60%,\nDyspareunia: 70%,\nPelvic pain: 60%\nNo relapse after\n5 years follow-up\nKristensen and Kjer [ 61] 48 18 Laparoscopic rectovaginal\nseptum and posterior\nvaginal fornix resection\nPeritonitis: 2%, Bladder\nperforation: 2%,\nV aginal rupture: 2%\nSymptoms: 92%, Quality\nof life improvement: 73%\nNodules: 10%,\nSymptoms: 9%\nDonnez and Squifflet [ 63] 500 36 Laparoscopic shaving Rectal Perforation: 1.4%,\nUreteral damage: 0.8%,\nBD: 0.8%\nPR: 84% (328/388),\nSP: 57%, ART: 27%\nSymptoms: 7.8%\nRVF Rectovaginal fistula, CA complications of the anastomosis; PA pelvic abscess, BD bladder dysfunction, ID: intestinal dysfunction, PR pregnancy rate, SP spontaneous pregnancy, ART assisted\nreproductive techniques\n274 Gynecol Surg (2011) 8:269 –277\n\nlesser rate of urinary and intestinal disorders after discoidal\nresection even when they did not set up any nodule size limit.\nV ercellini et al. [36] compared the effect of conservative\nnodulectomy through laparotomy and the expectant attitude\nin 44 and 61 infertile patients with RVE respectively,\naffirming that this type of surgery does not modify the\nreproductive outcome compared to the expectant attitude.\nConclusions\nEndometriosis generally affects otherwise healthy young\nwomen with high expectations of well-being and quality of\nlife. In this population, complications and side effects of\nsurgery are tolerated with difficulty, and the recurrence of\nsymptoms can be especially frustrating. In addition, the\ncase of RVE is a complex pathology with difficult\ntreatment, so that a careful and individualized evaluation\nin consensus with the patient must be taken into account at\nthe time of choosing any surgical technique so that there is\na balance between the expected benefit and the morbidity\nrelated to each technique. Surgical treatment of this form of\nendometriosis is necessary when the disease causes a\nreduction in the patients ’ quality of life, given that, in\ngeneral, patients without symptoms will benefit from an\nexpectant therapeutic attitude.\nLaparoscopic treatment of RVE with rectal affectation\nthrough discoidal or segmental resection is safe and\nfeasible, achieving similar or better results than laparotomic\nsurgery [ 16, 27]. When surgical treatment does not include\nintestinal resection, the rates of surgical complications are\nlow, in the majority of papers not reaching 5%, with\nbladder and intestinal dysfunction practically nonexistent.\nThis lower morbidity is not accompanied by a greater rate\nof relapse [ 39]; therefore, colorectal resections should be\nreserved for those cases where the nodule is so large that it\nmakes the suture of the intestine technically impossible or\nwhen the patient would like to gestate immediately, ruling\nout prolonged hormonal treatments [ 30].\nUnanimity exists in that the preoperative symptoms as\nwell as the quality of the patients ’ lives improve signifi-\ncantly in the years after RVE surgery. This improvement\nstands above 90% of patients, fundamentally with relation\nto pain symptoms (dysmenorrhoea, dyspareunia, dyschezia,\nand chronic pelvic pain), with no significant difference\nbetween resection surgery and conservative surgery.\nAlthough the studies published to this point to assess the\neffect of different surgical techniques on the treatment of\nRVE show a great heterogeneity in their characteristics and\nmethodology, we can say that, whenever technically\npossible, the more conservative techniques, shaving and\ndiscoidal intestinal resection, would be recommended since\nthey present a lower rate of complications with similar\nrecurrence and greater rates of gestation. Nevertheless, it\nwould be worthwhile to develop randomized trials with a\ngreater number of patients with longer-term follow-up to\ncompare the results of intestinal resection and conservative\ntreatment of rectovaginal endometriosis.\nTable 3 Results of comparative studies between different surgical techniques for rectovaginal endometriosis\nMohr et al. [ 35]\n(24 months)\nBrouwer and Woods [ 37]\n(68 months)\nFanfani et al. [ 39]\n(32 months)\nRoman et al. [ 30]\n(26 months)\nShaving Number ( n) 100 18\nComplications Total: 6% Total: 17%, PA: 5.6%\nImprovement 80%\nRelapse 22.2%\nFertility 17%\nDiscoidal excision Number ( n)3 9 5 8 4 8 1 6\nComplications Total: 23%,\nRVF: 3%, PA: 5%\nTotal: 2%, CA: 2% Total: 31.4%, RVF: 2.1%,\nPA: 2.1%, ID: 2.1%\nID: 19%\nImprovement 92% 88.8% 86%\nRelapse 5.17% 13.8%\nFertility 11% 13%\nSegmental intetinal\nresection\nNumber ( n) 48 137 88 25\nComplications Total: 38%,\nBD: 2%, CA: 6%\nTotal: 8%, PA: 1.4%, CA:\n2.2%, BD: 1.4%, ID: 9%\nTotal: 59.7%, RVF: 3.4%,\nPA: 2.2%, BD: 14.7%,\nCA: 1.1%, ID: 4.5%\nBD: 8%, ID: 64%\nImprovement 92% 93% 83%\nRelapse 2.19% 11.5%\nFertility 3% 12%\nRVF Rectovaginal fistula, CA complications of the anastomosis, PA pelvic abscess, BD bladder dysfunction, ID intestinal dysfunction\nGynecol Surg (2011) 8:269 –277 275\n\nConflicts of interest None.\nReferences\n1. Kennedy S, Bergquist A, Chapron C, D ’Hooghe T, Dunselman G,\nGreb R et al (2005) ESHRE guideline for the diagnosis and\ntreatment of endometriosis. Hum Reprod 20:2698 –2704\n2. Giudice LC (2010) Endometriosis. N Engl J Med 362:2389 –2398\n3. V ercellini P , Crosignani PG, Abbiati A, Somigliana E, Vigano P ,\nFedele L (2009) The effect of surgery for symptomatic endometri-\nosis: the other side of the story. Hum Reprod Update 15:177 –188\n4. Bergqvist A (1993) Different types of extragenital endometriosis:\na review. Gynecol Endocrinol 7:207 –221\n5. Dousset B, Leconte M, MD BB, Millischer AE, Roseau G,\nArkwright S, Chapron C (2010) Complete surgery for low rectal\nendometriosis. Long-term results of a 100-case prospective study.\nAnn Surg 251:887 –895\n6. Koninckx PR, Timmermans B, Meuleman C, Penninckx F (1996)\nComplications of CO2-laser endoscopic excision of deep endo-\nmetriosis. Hum Reprod 11:2263 –2268\n7. Martin DC, Batt RE (2001) Retrocervical, rectovaginal pouch, and\nrectovaginal septum endometriosis. J Am Assoc Gynecol Lapa-\nrosc 8:12 –17\n8. Donnez J, Nisolle M, Squifflet J (2002) Ureteral endometriosis: a\ncomplication of rectovaginal endometriotic (adenomyotic) nod-\nules. Fertil Steril 77:32 –37\n9. Chapron C, Fauconnier A, Dubuisson JB, Barakat H, Vieira M,\nBréart G (2003) Deep infiltrating endometriosis: relation between\nseverity of dysmenorrhoea and extent of disease. Hum Reprod\n18:760–766\n10. V ercellini P , Crosignani PG, Somigliana E, Berlanda N, Barbara\nG, Fedele L (2009) Medical treatment for rectovaginal endome-\ntriosis: what is the evidence? Hum Reprod 24:2504 –2514\n11. Redwine DB, Sharpe DR (1991) Laparoscopic segmental resec-\ntion of the sigmoid colon for endometriosis. J Laparoendosc Surg\n1:217–220\n12. Nezhat C, Nezhat F, Pennington E (1992) Laparoscopic treatment\nof infiltrative rectosigmoid colon and rectovaginal septum\nendometriosis by the technique of videolaparoscopy and the\nCO2 laser. Br J Obstet Gynaecol 99:664 –667\n13. Possover M, Diebolder H, Paul K, Schneider A (2000) Lapa-\nroscopically assisted vaginal resection of rectovaginal endometriosis.\nObstet Gynecol 96:304–307\n14. Duepree HJ, Senagore AJ, Delaney CP , Marcello PW, Brady KM,\nFalcone T (2002) Laparoscopic resection of deep pelvic endome-\ntriosis with rectosigmoid involvement. J Am Coll Surg 195:754 –\n758\n15. Landi S, Ceccaroni M, Perute lli A, Allodi C, Barbieri F,\nFiaccavento A, Ruffo G, McV eigh E, Zanolla L, Minelli L\n(2006) Laparoscopic nerve-sparing complete excision of deep\nendometriosis: is it feasible? Hum Reprod 21:774 –781\n16. Daraï E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M\n(2010) Randomized trial of laparoscopically assisted versus open\ncolorectal resection for endometriosis: morbidity, symptoms,\nquality of life, and fertility. Ann Surg 251:1018 –1023\n17. Fedele L, Bianchi S, Portuese A, Borruto F, Dorta M (1998)\nTransrectal ultrasonography in the assessment of rectovaginal\nendometriosis. Obstet Gynecol 91:444 –448\n18. Goncalves MO, Podgaec S, Dias JA Jr, Gonzalez M, Abrao MS\n(2010) Transvaginal ultrasonography with bowel preparation is\nable to predict the number of lesions and rectosigmoid layers\naffected in cases of deep endometriosis, defining surgical strategy.\nHum Reprod 25:665 –671\n19. Kinkel K, Chapron C, Balleyguier C, Fritel X, Dubuisson JB,\nMoreau JF (1999) Magnetic resonante imaging characteristics of\ndeep endometriosis. Hum Reprod 14:1080 –1086\n20. Landi S, Barbieri F, Fiaccavento A, Mainardi P , Ruffo G, Selvaggi\nL, Syed R, Minelli L (2004) Preoperative double-contrast barium\nenema in patients with suspected intestinal endometriosis. J Am\nAssoc Gynecol Laparosc 11:223 –228\n21. Del Frate C, Girometti R, Pittino M, Del Frate G, Bazzocchi M,\nZuiani C (2006) Deep retroperitoneal pelvic endometriosis: MR\nimaging appearance with laparoscopic correlation. Radiographics\n26:1705–1718\n22. CNGOF Guidelines for the Management of Endometriosis\nCollège National des Gynécologues et Obstétriciens Français,\n2006. http://www.cngof.asso.fr/D TELE/RPC endometriose en\nBM.pdf\n23. Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, V acher-\nLavenu MC et al (2006) Deeply infiltrating endometriosis:\npathogenetic implications of the anatomical distribution. Hum\nReprod 21:1839 –1845\n24. Abrao MS, Podgaec S, Dias JA, Averbach M, Silva LF, Marino de\nCarvalho F (2008) Endometriosis lesions that compromise the\nrectum deeper than the inner muscularis layer have more than\n40% of the circumference of the rectum affected by the disease. J\nMinim Invasive Gynecol 15:280 –285\n25. Keckstein J, Wiesinger H (2005) Deep endometriosis, including\nintestinal involvement – the interdisciplinary approach. Minim\nInvasive Ther Allied Technol 14:160 –166\n26. Daraï E, Bazot M, Rouzier R, Houry S, Dubernard G (2007)\nOutcome of laparoscopic colorectal resection for endometriosis.\nCurr Opin Obstet Gynecol 19:308 –313\n27. Minelli L, Fanfani F, Fagotti A, Ruffo G, Ceccaroni M, Mereu L,\nLandi S, Pomini P , Scambia G (2009) Laparoscopic colorectal\nresection for bowel endometriosis: feasibility, complications, and\nclinical outcome. Arch Surg 144:234 –239\n28. Donnez J, Squifflet J (2004) Laparoscopic excision of deep\nendometriosis. Obstet Gynecol Clin N Am 31:567 –580\n29. Ret Davalos ML, De Cicco C, D ’Hoore A, De Decker B,\nKoninckx PR (2007) Outcome after rectum or sigmoid resection:\na review for gynecologists. J Minim Invasive Gynecol 14:33 –38\n30. Roman H, Loisel C, Resch B, Tuech JJ, Hochain P , Leroi AM,\nMarpeau L (2010) Delayed functional outcomes associated with\nsurgical management of deep rectovaginal endometriosis with\nrectal involvement: giving patients an informed choice. Hum\nReprod 25:890 –899\n31. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF\n(1999) Improving the quality of reports of meta-analyses of\nrandomised controlled trials: the QUOROM statement. Quality of\nreporting of meta-analyses. Lancet 354:1896 –1900\n32. Koh CH, Janik GM (2002) The surgical management of deep\nrectovaginal endometriosis. Curr Opin Obstet Gynecol 14:357–364\n33. Emmanuel KR, Davis C (2005) Outcomes and treatment options\nin rectovaginal endometriosis. Curr Opin Obstet Gynecol 17:399–402\n34. V ercellini P , Barbara G, Abbiati A, Somigliana E, Viganò P ,\nFedele L (2009) Repetitive surgery for recurrent symptomatic\nendometriosis: what to do? Eur J Obstet Gynecol Reprod Biol\n146:15–21\n35. Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR (2005)\nFertility considerations in laparoscopic treatment of infiltrative\nbowel endometriosis. JSLS 9:16 –24\n36. V ercellini P , Pietropaolo G, De Giorgi O, Daguati R, Pasin R,\nCrosignani PG (2006) Reproductive performance in infertile\nwomen with rectovaginal endometriosis: is surgery worthwhile?\nAm J Obstet Gynecol 195:1303 –1310\n37. Brouwer R, Woods RJ (2007) Rectal endometriosis: results of\nradical excision and review of published work. ANZ J Surg\n77:562–571\n276 Gynecol Surg (2011) 8:269 –277\n\n38. Maytham GD, Dowson HM, Levy B, Kent A, Rockall TA (2009)\nLaparoscopic excision of rectovaginal endometriosis: report of a\nprospective study and review of the literature. Colorectal Dis Jul 3\n(Epub ahead of print)\n39. Fanfani F, Fagotti A, Gagliardi ML, Ruffo G, Ceccaroni M,\nScanbia G, Minelli L (2010) Discoid or segmental rectosigmoid\nresection for deep infiltrating endometriosis: a case-control study.\nFertil Steril 94:444 –449\n40. Redwine DB, Wright JT (2001) Laparoscopic treatment of\ncomplete obliteration of the cul-de-sac associated with endometriosis:\nlong-term follow-up of en bloc resection. Fertil Steril 76:358–365\n41. Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotsch F (2004)\nLong term follow up after conservative surgery for rectovaginal\nendometriosis. Am J Obstet Gynecol 190:1020 –1024\n42. Ford J, English J, Miles W A, Giannopoulos T (2004) Pain, quality\nof life and complications following the radical resection of\nrectovaginal endometriosis. BJOG 111:353 –356\n43. Thomassin I, Bazot M, Detchev R, Barranger E, Cortez A, Darai\nE (2004) Symptoms before and after surgical removal of\ncolorectal endometriosis that are assessed by magnetic resonance\nimaging and rectal endoscopic sonography. Am J Obstet Gynecol\n190:1264–1271\n44. Darai E, Marpeau O, Thomassin I, Dubernard G, Barranger E,\nBazot M (2005) Fertility after laparoscopic colorectal resec-\ntion for endometriosis: preliminary results. Fertil Steril\n84:945–950\n45. Darai E, Thomassin I, Barranger E, Detchev R, Cortez A, Houry\nS, Bazot M (2005) Feasibility and clinical outcome of laparo-\nscopic colorectal resection for endometriosis. Am J Obstet\nGynecol 192:394 –400\n46. Fleisch MC, Xafis D, De Bruyne F, Hucke J, Bender HG, Dall P\n(2005) Radical resection of invasive endometriosis with bowel or\nbladder involvement —long-term results. Eur J Obstet Gynecol\nReprod Biol 123:224 –229\n47. Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E\n(2006) Quality of life after laparoscopic colorectal resection for\nendometriosis. Hum Reprod 21:1243 –1247\n48. Lyons SD, Chew SS, Thomson AJ, Lenart M, Camaris C,\nV ancaillie TG et al (2006) Clinical and quality-of-life outcomes\nafter fertility-sparing laparoscopic surgery with bowel resection\nfor severe endometriosis. J Minim Invasive Gynecol 13:436 –441\n49. Ribeiro PA, Rodrigues FC, Kehdi IP , Rossini L, Abdalla HS,\nDonadio N et al (2006) Laparoscopic resection of intestinal\nendometriosis: a 5-year experience. J Minim Invasive Gynecol\n13:442–446\n50. Langebrekke A, Istre O, Busund B, Johannessen HO, Qvigstad E\n(2006) Endoscopic treatment of deep infiltrating endometriosis\n(DIE) involving the bladder and rectosigmoid colon. Acta Obstet\nGynecol Scand 85:712 –715\n51. Seracchioli R, Poggioli G, Pierangeli F, Manuzzi L, Gualerzi B,\nSavelli L et al (2007) Surgical outcome and long-term follow up\nafter laparoscopic rectosigmoid resection in women with deep\ninfiltrating endometriosis. BJOG 114:889 –895\n52. Mereu L, Ruffo G, Landi S, Barbieri F, Zaccoletti R, Fiaccavento\nA et al (2007) Laparoscopic treatment of deep endometriosis with\nsegmental colorectal resection: short-term morbidity. J Minim\nInvasive Gynecol 14:463 –469\n53. Zanetti-Dällenbach R, Bartley J, Müller C, Schneider A, Köhler C\n(2008) Combined vaginal –laparoscopic–abdominal approach for\nthe surgical treatment of rectovaginal endometriosis with bowel\nresection: a comparison of this new technique with various\nestablished approaches by laparoscopy and laparotomy. Surg\nEndosc 22:995 –1001\n54. Pereira RM, Zanatta A, Preti CD, de Paula FJ, da Motta EL,\nSerafini PC (2009) Should the gynecologist perform laparoscopic\nbowel resection to treat endometriosis? Results over 7 years in\n168 patients. J Minim Invasive Gynecol 16:472 –479\n55. Stepniewska A, Pomini P , Scioscia M, Mereu L, Ruffo G, Minelli\nL (2010) Fertility and clinical outcome after bowel resection in\ninfertile women with endometriosis. Reprod Biomed Online\n20:602–609\n56. Ruffo G, Scopelliti F, Scioscia M, Ceccaroni M, Mainardi P ,\nMinelli L (2010) Laparoscopic colorectal resection for deep\ninfiltrating endometriosis: analysis of 436 cases. Surg Endosc\n24:63–67\n57. Chapron C, Jacob S, Dubuisson JB, Vieira M, Liaras E,\nFauconnier A (2001) Laparoscopically assisted vaginal manage-\nment of deep endometriosis infiltrating the rectovaginal septum.\nActa Obstet Gynecol Scand 80:349 –354\n58. Hollett-Caines J, Vilos GA, Penava DA (2003) Laparoscopic\nmobilization of the rectosigmoid and excision of the obliterated\ncul-de-sac. J Am Assoc Gynecol Laparosc 10:190 –194\n59. Remorgida V , Ragni N, Ferrero S, Anserini P , Torelli P , Fulcheri E\n(2005) How complete is full thickness disc resection of bowel\nendometriotic lesions? A prospective surgical and histological\nstudy. Hum Reprod 20:2317 –2320\n60. Angioni S, Peiretti M, Zirone M, Palomba M, Mais V , Gomel V et\nal (2006) Laparoscopic excision of posterior vaginal fornix in the\ntreatment of patients with deep endometriosis without rectum\ninvolvement: surgical treatment and long-term follow-up. Hum\nReprod 21:1629 –1634\n61. Kristensen J, Kjer JJ (2007) Laparoscopic laser resection of\nrectovaginal pouch and rectovaginal septum endometriosis: the\nimpact on pelvic pain and quality of life. Acta Obstet Gynecol\nScand 86:1467 –1471\n62. Matsuzaki S, Houlle C, Botchorishvili R, Pouly JL, Mage G, Canis\nM (2009) Excision of the posterior vaginal fornix is necessary to\nensure complete resection of rectovaginal endometriotic nodules of\nmore than 2 cm in size. Fertil Steril 91(4 Suppl):1314 –1315\n63. Donnez J, Squifflet J (2010) Complications, pregnancy and\nrecurrence in a prospective series of 500 patients operated on by\nthe shaving technique for deep rectovaginal endometriotic\nnodules. Hum Reprod 25:1949 –1958\n64. Reich H, McGlynn F, Salvat J (1991) Laparoscopic treatment of\ncul-de-sac obliteration secondary to retrocervical deep fibrotic\nendometriosis. J Reprod Med 36:516 –522\n65. Donnez J, Nisolle M, Casanas-Roux F, Bassil S, Anaf V (1995)\nRectovaginal septum, endometriosis or adenomyosis: laparoscopic\nmanagement in a series of 231 patients. Hum Reprod 10:630 –635\n66. Crosignani PG, V ercellini P , Biffignandi F, Costantini W, Cortesi\nI, Imparato E (1996) Laparoscopy versus laparotomy in conser-\nvative surgical treatment for severe endometriosis. Fertil Steril\n66:706–711\n67. Donnez J, Nisolle M, Gillerot S, Smets M, Bassil S, Casanas-Roux F\n(1997) Rectovaginal septum adenomyotic nodules: a series of 500\ncases. Br J Obstet Gynaecol 104:1014–1018\n68. Bailey HR (1992) Colorectal endometriosis. Perspect Colon\nRectal Surg 5:251 –259\n69. Roman H, Puscasiu L, Kouteich K, Gromez A, Resch B,\nMarouteau-Pasquier N, Hochain P , Tuech JJ, Scotte M, Marpeau\nL (2007) Laparoscopic management of deep endometriosis with\nrectal affect. Chirurgia 102:421 –428\n70. Anaf V , El Nakadi I, De Moor V , Coppens E, Zalcman M, Noel\nJC (2009) Anatomic significance of a positive barium enema in\ndeep infiltrating endometriosis of the large bowel. World J Surg\n33:822–827\nGynecol Surg (2011) 8:269 –277 277","source_license":"CC0","license_restricted":false}