{"paper_id":"aeef927e-cd8d-487c-bf4b-9e2ea7375324","body_text":"Submit Manuscript | http://medcraveonline.com\nThe symptoms of endometriosis are very much dependent on the \nlocation of the disease however dysmenorrheal, chronic pelvic pain, \ndeep dyspareunia, fatigue, and sub fertility continue to be the leading \nsymptoms.4 DIE involving the RVS is generally associated with \nmore severe forms of dyschezia and dyspareunia 5 and DIE involving \nthe urinary tract can present with frequency, nocturia, bladder \nspasms and haematuria. 6 Delay in the diagnosis of endometriosis \nstill remains a problem, with a reported mean time from initial \ncomplaint to diagnosis varying from 7.96 to 11.73years. 7 A variety \nof diagnostic methods have been evaluated over the past few decades \nin diagnosing DIE, such as transvaginal ultrasound (TVS), magnetic \nresonance imaging (MRI), transrectal ultrasound, barium enema and \ncolonoscopy, however definitive diagnosis is still often only made at \nlaparoscopy.8–12 There is a wide variety of treatment options available \nranging from ovarian suppression using hormonal agents to radical \nsurgery. In DIE the efficacy of medical treatment is often suboptimal, \nwith high recurrence rates on cessation of treatment 13,14 and in such \ncases many advocate the use of more radical surgical excision. Debate \nand controversy still exists as to how radical surgery should be when \nexcising DIE and its long-term benefits and complications. This aim \nof this article is to appraise the current evidence for the diagnosis of \nDIE as well as the various different surgical options available and to \ndiscuss their benefits, risks and limitations. \nRole of BSGE/tertiary referral centres\nAll cases where DIE has been previously diagnosed or there is a \nstrong diagnostic suspicion should be referred to a tertiary referral \ncentre for assessment. The laparoscopic management of such cases can \nbe technically challenging and assessment by a multidisciplinary team \nwith the necessary skills, expertise and experience to manage such \ncomplex cases is essential. Ideally the multidisciplinary team should \ninclude gynecological, colorectal and urological surgeons, as well as a \nspecialist pain management team and a specialist endometriosis nurse.\nPre-operative assessment\nThorough assessment and preoperative planning is essential \nin these complex cases. Firstly full staging is imperative to allow \nthorough patient counseling as to the extent of the radical surgery \nand potential short-term and long-term complications. Secondly \nit is essential to ensure adequate surgical time is allocated and the \ncorrect expertise is available especially with regards to colorectal \nand urological input. Historically staging by means of “first look” \nlaparoscopy often combined with cystoscopy and sigmoidoscopy were \nconsidered to be the gold standard to fully assess bladder and bowel \ninvolvement and plan further radical surgery. However in cases of an \nobliterated pelvis, laparoscopic visualization may be suboptimal and \nthe depth of invasion and full extent of the disease may be difficult to \nassess. The diagnosis of endometriosis on laparoscopy is also highly \ndependent on the experience and skill of the surgeon performing \nthe procedure; the depth of infiltration of endometrial deposits can \noften be misjudged and retroperitoneal and vaginal endometriosis \noften missed4 (Figure1). Both TVS and MRI have been found to be \nhighly sensitive in diagnosing and assessing the extent of DIE. 9,10 \nWith regards to bowel endometriosis, a systematic review assessing \nthe diagnostic value of TVS as a pre-surgical tool to detect bowel \nendometriosis was undertaken by Hudelist et al.32 and 91% sensitivity \nand 98% specificity was reported. 9 Thus TVS is a very useful and \nreadily available tool in identifying or ruling out bowel endometriosis \nand assessing the extent of invasion pre-operatively. However it is \nvery much operator dependent and should only be performed by \nhighly experienced clinicians. 4 The use of MRI to stage DIE pre-\noperatively is also widely under taken and studies have demonstrated \na high accuracy in predicting bowel endometriosis with a sensitivity \nand specificity of 88% and 98% respectively. 10,15 MRI has also been \nshown to be useful in detecting DIE involving the USL, vagina, RVS \nand bladder.15 MRI is less operator-dependent, however is slightly \nless sensitive in detecting bowel endometriosis and overall is a more \nexpensive and less readily available tool when compared to TVS. \nBarium enema has also been evaluated in the assessment of bowel \nendometriosis and has shown to be useful with a sensitivity of 88% and \nspecificity of 93%,16 however when compared to TVS appears to be \ninferior,17 but may be useful in selected cases such as those with high \nrecto-sigmoid or sigmoid lesions. Trans-rectal ultrasonography has \nalso been found to be useful in assessing recto-vaginal endometriosis \nwith a sensitivity and specificity of 96% and 100% respectively, \nhowever this technique is less useful in assessing more distal lesions \nsuch as USL involvement. 12 Colonoscopy is also only useful in a \nselect group of patients, as it is often negative in cases of small bowel \nnodules, and only in rare cases of very large nodules with significant \nbowel obstruction will a colonoscopy be positive. 11 In all cases of \nsevere endometriosis it is also prudent to fully assess the urinary tract. \nMOJ Surg. 2017;4(5):107‒112. 107\n© 2017 Mallick. This is an open access article distributed under the terms of the Creative Commons Attribution License , which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nThe diagnosis and management of severe \nendometriosis\nVolume 4 Issue 5 - 2017\nRebecca Mallick\nWestern Sussex Hospital, NHS Foundation Trust, UK\nCorrespondence: Rebecca Mallick, Western Sussex Hospital, \nNHS Foundation Trust, St Richards Hospital, Chichester, UK, T el \n074-116-171-43, Email rmallick@doctors.org.uk\nReceived: March 05, 2017 | Published: August 03, 2017\nMOJ Surgery\nReview Article\n Open Access\nIntroduction\nEndometriosis is a common gynecological condition predominantly \naffecting women in their reproductive years. Estimated prevalence \nrates are approximately 10%, but in cases of sub fertility can be as \nhigh as 25-40%. 1 Symptoms vary, but for many women it can be a \ndebilitating condition with a significant impact on their quality of \nlife.2 Endometriosis is defined as the presence of endometriotic glands \nand stroma out-with the uterine cavity. Three types of endometriosis \nare generally described: peritoneal, ovarian and deep infiltrating \nendometriosis (DIE), with the latter being defined as the infiltration \nof endometrial deposits of ≥5mm into surrounding tissue. 3 The areas \nmost commonly affected include the uterosacral ligaments (USL), \nrecto-sigmoid colon, recto-vaginal septum (RVS), vagina and bladder. \n\nThe diagnosis and management of severe endometriosis\n108\nCopyright:\n©2017 Mallick\nCitation: Mallick R. The diagnosis and management of severe endometriosis. MOJ Surg. 2017;4(5):107‒112. DOI: 10.15406/mojs.2017.04.00087\nBladder endometriosis can be diagnosed by TVS, ideally while the \npatient has a full bladder to facilitate the detection of the more discrete \nnodules in the bladder wall.18 TVS is reported to have a high accuracy \n(91-95%) in the detection of bladder nodules. 18,19 MRI is also useful \nparticularly for smaller bladder lesions. 20 Cystoscopy can also be \nbeneficial to preoperatively assess the size/position of a bladder nodule \nand it relationship to the ureteric orifices and if indicated a biopsy can \nbe taken for histological diagnosis4 (Figure 2). Renal ultrasound, MRI \nor computerized tomography (CT) urogram is the investigations of \nchoice to assess endometriosis affecting the ureter and the presence \nof hydronephrosis. In the presence of hydronephrosis, consideration \nshould be given to performing a radioisotope (MAG3 or DMSA) \nscan to assess renal function. Pre-operatively it is thus recommended \nthat all patients with suspected DIE should have detailed imaging, \nwhether TVS or MRI and renal ultrasound, to assess bowel, ureter and \nbladder involvement to fully prepare for further management. Further \ninvestigations such as barium enema, colonoscopy and radioisotope \nscans may be required in selected patients. The decision on the type \nof imaging should be decided by local protocols and expertise, but \nideally the approach should be multidisciplinary between surgeons \nand radiologists. \nFigure 1 Misjudged and retroperitoneal and vaginal endometriosis.\nFigure 2 Preoperatively assess the size/position of a bladder nodule.\nBladder and ureteric endometriosis \nDIE involving the urinary tract is uncommon; however its exact \nprevalence is not entirely know. It is thought to occur in approximately \n1-2% of patients with endometriosis and involves the bladder in \n90% of these cases. 18,21 Bladder endometriosis can be described as \nsuperficial or deep depending on the degree of invasion. Deep bladder \nendometriosis involves invasion of the muscular is and symptoms can \ninclude dysuria, frequency, nocturia, bladder spasms, suprapubic pain \nand haematuria.18 Superficial endometriosis describes endometriosis \non the peritoneal surface overlying the bladder.\nEndometriosis involving the ureter can either be described as \nintrinsic or extrinsic, with the latter the more prevalent. In extrinsic \ncases, the ureter is compressed by the surrounding endometriotic \ntissue, with resultant fibrosis, hydronephrosis and impaired renal \nfunction in up to 30% of cases 6 (Figure 3). Intrinsic involvement, \ndefined as endometriotic tissue infiltrating into the ureteral muscular \nis a rare occurrence. Prior to surgery involving the urinary tract, many \nsurgeons advocate the prophylactic insertion of ureteric catheters/\nstents. There is limited evidence in the literature to suggest that stenting \nactually reduces ureteric injury, 22 but the use of stents undoubtedly \nimprove visualization of the ureters and hence may make dissection \ntechnically easier. They are also particularly useful in duplex urinary \nsystems, where unusual anatomy may increase the risk of injury. \nSize 6F Stamey catheters may be inserted pre-operatively using an \noperating cystoscopy and removed at the end of the procedure without \nthe need for radiographic image intensification. The postoperative \ninsertion of double J stents is indicated if the ureter has been opened \nand re-anastomosed or re-implanted into the bladder or if there has \nbeen extensive ureteriolysis and a potential risk of devascularisation. \nAlternatively some advocate the primary insertion of double J stents; \nagain this is generally surgeon’s preference rather than evidence \nbased. If double J stents are inserted, they should generally be \nremoved 6 weeks later with a check urogram performed after removal \nto exclude ureteric leaks. In cases of superficial bladder disease it is \noften possible to shave the disease off the peritoneal surface of the \nbladder. However in cases of deep infiltration of the bladder wall \nfull excision is indicated. The bladder should be mobilised first, by \nopening the uterovesical fold and the dome of the bladder then opened \nto reveal the extent of the nodule, assessing carefully its relationship \nto the ureteric orifices. The nodule should then be excised in its \nentirety and consideration should be given to inserting prophylactic \ndouble J stents particularly if the distance between the border of the \nlesion and the ureteric orifice is <2cm 14 (Figure 4). The bladder is \nclosed using a double layer (although many advocate the use of one \nlayer) of interrupted or continuous absorbable sutures such as 2/0 \npolyglactin and closure checked using methylene blue dye. A free \ndraining catheter should be left in for at least 7days, ideally with a \ncheck cystogram to ensure there is no leak prior to removal of the \ncatheter. Laparoscopic partial cystectomy has been found to be a \nsafe and effective treatment for bladder endometriosis in multiple \nstudies with symptomatic improvement in 95-100% of patient, few \ncomplications noted and low recurrence rates.14,21,23\nWith regards to ureteric disease, surgical management of \nsuch cases is dependent on numerous factors including patient \nsymptoms, the type of ureteric involvement and also the presence \nof hydronephrosis/significant strictures In the vast majority of \ncases the conservative approach with ureteriolysis to mobilize and \nfree the ureterand resection of the surrounding endometriotic tissue \nand fibrosis may be sufficient. In rare cases where the muscular is \ninvolved and or there is significant stenosis, resection of a portion \nof the ureter with either end-to-end anastomosis or re-implantation \nwith/without a poses hitch may be necessary (Figure 5). Choice of \ntechnique is dependent of the location and size of the resected ureteric \nsegment,6 however both techniques have been successfully described \n\n\nThe diagnosis and management of severe endometriosis\n109\nCopyright:\n©2017 Mallick\nCitation: Mallick R. The diagnosis and management of severe endometriosis. MOJ Surg. 2017;4(5):107‒112. DOI: 10.15406/mojs.2017.04.00087\nin the literature with significant improvement in symptoms and low \ncomplication and recurrence rates.21,24 In very rare cases renal function \ncan be significantly reduced in the presence of severe hydronephrosis \nand in such cases consideration should be given to nephrectomy due \nto the risks of recurrent infection and vascular hypertension. This can \nbe performed laparoscopically in a multidisciplinary setting at the \ntime of the primary surgery for endometriosis.25,26\nFigure 3 Resultant fibrosis, hydronephrosis and impaired renal function.\nFigure 4 Distance between the border of the lesion and the ureteric orifice is \n<2cm.\nFigure 5  End-to-end anastomosis or re-implantation with/without a poses \nhitch.\nFigure 6 Rectal shaving is performed by excising a serosal disc of endometriosis \noff the rectal wall and overlying sutures placed to reinforce the excised area.\nBowel endometriosis \nThe exact prevalence of bowel endometriosis is unknown, although \nit is estimated that 5-12% of women with endometriosis will have \nbowel involvement, equating to 150,000 to 300,000 women in the \nUK.27,28 The rectum and recto-sigmoid tend to account for up to 93% \nof bowel lesions followed by the ileum, appendix and caecum. 29 The \ndepth of involvement can range from serosal to mucosal and lesions \ncan be solitary or multiple. Symptoms vary, but most commonly \ninclude dyschezia, constipation, diarrhoea, bloating, passing of mucus \nper rectum and cyclical rectal bleeding. The management of disease \ninvolving the bowel remains a highly controversial and contentious \nissue. Medical treatment has been found to be largely inadequate \nfor rectal disease. 30,31 Surgical treatment and the complete excision \nof endometriosis appears to offer good long term symptomatic \nrelief,32–34 however this may involve significant bowel surgery and the \npotential for major complications. Conversely less invasive surgery is \nassociated with fewer complications, but incomplete resection carries \na higher risk of disease recurrence and generally does not confer the \nlong-term symptomatic benefits seen with complete resection. 27 Two \nsurgical approaches are generally employed, the more radical approach \ninvolving segmental bowel resection or the more conservative \napproach involving either rectal shaving or disc resection. Rectal \nshaving is performed by excising a serosal disc of endometriosis off \nthe rectal wall and overlying sutures placed to reinforce the excised \narea (Figure 6). Disc resection involves removal of the endometriotic \nnodule by resecting a full thickness “disc” of bowel; this can be done \nusing a circular stapler or excising the area and suturing the defect \nlaparoscopically. The reported outcomes in the literature following \ndisc resection are positive and a prospective analysis of 500 cases \nreported high conception rates following surgery with low major \ncomplication and recurrence rates.35 However there are limitations to \nthis technique; it tends to be more suitable for lesions on the anterior \nsurface of the bowel and small nodules involving less than 50% of \nthe circumference of the rectal wall. 28 The technique is generally not \nsuitable for large rectal nodules (>3cm) and in cases where there are \nmultiple bowel lesions. In cases where large nodules are “shaved” \nthere is invariably some residual disease left behind. Remordiga et \nal.36 demonstrated that at least one third of patients undergoing disc \n\n\nThe diagnosis and management of severe endometriosis\n110\nCopyright:\n©2017 Mallick\nCitation: Mallick R. The diagnosis and management of severe endometriosis. MOJ Surg. 2017;4(5):107‒112. DOI: 10.15406/mojs.2017.04.00087\nresection have persistent disease 36 however controversy exists as to \nwhether this is symptomatically significant. The current literature \nsuggests recurrence rates are significantly higher for disc excision \nwhen compared to segmental resection. 37 Segmental bowel resection \ninvolves resection of the pelvic endometriosis leaving the residual \ndisease attached to the rectum and mobilisation of the rectal tube \ninvolving lateral and anterior retroperitoneal dissection. The bowel \nis then transected below the level of disease and to a clear margin \nabove the proximal end of the disease. Primary anastomosis is then \nperformed using a circular anastomosis gun and the integrity of the \nanastomosis checked by filling the pelvis with fluid and distending \nthe rectum with air insufflated via a rigid sigmoidoscopy. If an air \nleak is visible, the anastomosis is inadequate and a defunctioning \nstoma is performed. Over the past 10 years, a large number of studies \nhave shown significant improvements in pain and overall quality of \nlife following radical surgery.32–34 However it can be associated with \nsignificant complications. Both minor and major complications have \nbeen reported following radical surgery including fistula formation \n(0-14%),27,32 anastomotic leaks (2.2-8%)hemorrhage (1-11%), 38 \ninfection (1-3%),38 ureteric injury (4.1%)32 and long term bladder (1-\n71%) and bowel dysfunction (1-15%). 38 Kondo et al. reported a total \nmajor complication rate of 4.6% of patients undergoing any form of \nbowel surgery and 24, 17.6 and 6.7% for those undergoing segmental \nresection, disc resection and shaving respectively. 27 Darai et al. 15 \nreported a 12.6% major complication rate following laparoscopic \nsegmental bowel resection. 39 Long-term bladder and bowel \ndysfunction (urinary retention, tenesmus, frequency of defecation) \nare often the most disabling long-term complications encountered by \npatients following radical surgery. Rectal shaving certainly avoids \nthe need for deep lateral rectal dissection and hence preserves the \npelvic autonomic nerves and thus as expected fewer bladder and \nbowel complications are reported post-operatively, 35 however once \nagain this must be balanced again the risk of residual disease and \nrecurrence. More recently nerve sparing rectal resection techniques \nhave been described in the literature with identification and sparing \nof the hypo gastric and pelvic splanchnic nerves. This technique \nwhen compared to the standard technique appears to be associated \nwith significantly less bladder/bowel and sexual dysfunction.40,41 Thus \nthere is still no definitive consensus on which approach is the “best” \ntechnique to treat bowel endometriosis; ultimately the aim of treating \nDIE affecting the bowel should focus on the long-term resolution of \nbowel symptoms with the fewest complications. Detailed counseling \nand a multidisciplinary approach is key. Ultimately the surgical \ntechnique employed should be tailored to patient’s symptoms, pre-\noperative assessment and surgical findings. A balance must be made \nagainst suboptimal resection and symptom recurrence, and extensive \nsurgical excision and the potential for major complications\nUse of robotic surgery for the treatment of \nDIE\nRecently the use of robotic surgery has increased in the treatment \nof DIE, however most of these studies are from outside the UK and \nthe current recommendation from NICE is that a surgical robot should \nonly be used in gynecology in a research setting. Almost all of the \nstudies are observational case series with the largest published being \na retrospective review of 164patients with stage 4 endometriosis. 42 \nThis study described a lower conversion to laparotomy rate with \nthe robotic approach (0.6% vs. 10%). Another study by Dulemba et \nal. compared operative time (77 vs. 72min), blood loss (29 vs. 25mL) \nand complication rates (1.1% vs. 0%) in robot-assisted and standard \nlaparoscopy43 and found no significant differences. However they \ndid note that the number of biopsies confirming endometriosis was \nhigher in the robotic group (80%vs 56.8% P<0.001) and hypothesised \nthat robotic surgery, with its improved visual acuity, may have the \nability to excise endometriosis more precisely. In the absence of any \nrandomized case-control studies, it is difficult to recommend its usage \nin routine practice, however as its use becomes more prevalent in the \nUK there is a definite need for larger multi-centre trials.\nFertility sparing surgery\nWomen with confirmed endometriosis, who desire to conceive, \nshould be referred to secondary care specialist services. Hormonal \ntreatment is not an option in this group as this does not improve fertility \nand may cause further delays in surgical and assisted reproductive \ntreatments that are known to potentially improve fertility.4 The benefit \nof surgical treatment to improve fertility in patients with endometriosis \nis well established in the literature by three Cochrane reviews 44–46 \nand the European Society of Human Reproduction and Embryology \n(ESHRE) guidelines on endometriosis.4\nIn women with minimal to mild endometriosis, there is evidence that \noperative laparoscopy significantly improves chances of conception.45 \nIt is suggested that where possible this could be done at the time of \ninitial laparoscopy. What remains unclear to date is the comparative \nsurgical effectiveness of the various treatment techniques. There is \nalso evidence that laparoscopic surgical excision of moderate to severe \nendometriosis and adhesiolysis improves spontaneous pregnancy rates \nby as much as 57-69% (moderate endometriosis) and 52–68% (severe \nendometriosis).47,48 With no treatment spontaneous conception rates \ncan remain as low as 0% in severe endometriosis and 30% in moderate \nendometriosis cases.49 For patients with endometriomas, excision of \nthe endometrioma results in higher pregnancy rates when compared \nto drainage and electro-coagulation of the cyst. Both the techniques \nare known to deplete the ovarian reserves 44 and this should be kept \nin mind and discussed with the patient before surgery, especially in \ncases of recurrent endometriomas. With the improvements in egg \nfreezing technology, this might be a possible option for this group of \npatients in the future. For patients with rectovaginal disease complete \nexcision of the disease including bowel resection and anastomosis \nmay have higher spontaneous pregnancy rates when compared to \nlimited excision of endometriosis without bowel resection,49 however \nthe severity of symptoms rather than fertility should be the deciding \nfactor when it comes to extensive resection. \nConclusion\nSevere endometriosis is a complex condition requiring a \nmultidisciplinary approach in a tertiary referral centre and early \nreferral is essential. Full pre-operative planning including detailed \nimaging is vital to assess the full extent of the disease, give thorough \ncounseling and plan appropriate surgical management. Radical \nexcision of DIE involving both bladder and bowel appears to have \ngood success rates with significant improvements in quality of life, \nimproved fertility and low recurrence rates. However such extensive \nprocedures carry both short and long-term risks that patients must be \nfully aware of before embarking down the aggressive surgical route.\n\nThe diagnosis and management of severe endometriosis\n111\nCopyright:\n©2017 Mallick\nCitation: Mallick R. The diagnosis and management of severe endometriosis. MOJ Surg. 2017;4(5):107‒112. DOI: 10.15406/mojs.2017.04.00087\nAcknowledgements\nNone.\nConflict of interest\nThe author declares no conflict of interest.\nReferences\n1. Ozkan S, Murk W, Arici A. Endometriosis and infertility: epidemiology \nand evidence-based treatments. Ann N Y Acad Sci. 2008;1127:92–100.\n2. Culley L, Law C, Hudson N, et al. The social and psychological impact of \nendometriosis on women’s lives: a critical narrative review. Hum Reprod \nUpdate. 2013;19(6):625–639.\n3. Koninckx PR, Meuleman C, Demeyere S, et al. 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