{"paper_id":"b405628d-aaa2-46ad-b362-c0bde0f87852","body_text":"ORIGINAL ARTICLE\nIs the presence of endometrioma always associated\nwith more severe disease?\nM. Setälä & P. Härkki & P. Suvitie & J. Fraser &\nJ. Jalkanen & J. Kössi & A. Perheentupa & J. Mäkinen\nReceived: 29 October 2010 / Accepted: 21 December 2010 / Published online: 11 January 2011\n# Springer-V erlag 2011\nAbstract The aim of this prospective study was to estimate\nwhether the presence of endometrioma was associated with\nmore severe disease, and with operative findings that were\nconsidered to make surgery more demanding in patients\nwith deeply infiltrating en dometriosis located in the\nposterior fornix of the vagina. Ninety-eight patients\nscheduled for primary surgery underwent complete excision\nof all visible endometriotic lesions and adhesions by\nlaparoscopy (86 patients, 87.8%) or by laparotomy (12\npatients, 12.2%) in four hospitals specialized in the surgical\ntreatment of endometriosis. Endometrioma was detected in\n46 patients (47.0%). No statistically significant difference\nwas detected between patients with and without an\nendometrioma, in the presence of six studied operative\nfindings: total obstruction of the pouch of Douglas (28%\nvs. 27%, p=0.88), attachment of a posterior deep lesion to\nthe ureter (52% vs. 44%, p=0.43), peritoneal endometriotic\nlesions (80% vs. 75%, p=0.52), other deep lesions (24% vs.\n33%, p=0.34), attachment of bowel to the uterosacral\nligament deep lesion (65% vs. 69%, p=0.71), and attach-\nment of the rectum to a rectovaginal deep lesion (81% vs.\n84%, p>0.99). Endometrioma did not seem to be associated\nwith operative findings that were considered to represent\nmore severe disease, and make surgery more demanding in\npatients with deep endometriotic lesions in the posterior\nfornix of the vagina and with no previous pelvic surgery.\nKeywords Endometriosis . Endometrioma . Deeply\ninfiltrating endometriosis . Surgery\nAbbreviations\nDIE Deeply infiltrating endometriosis\nRVE Rectovaginal endometriosis\nrASRM Revised American Society of Reproductive\nMedicine\nBMI Body mass index\nBackground\nEndometrioma, an ovarian cyst caused by endometriosis, is\none of the most commonly found endometriotic lesions.\nEndometrioma may be present in 30 –40% of surgically\ntreated endometriosis patients [ 1, 2]. It has been estimated\nearlier that endometrioma could be a marker for more\nsevere endometriotic disease [ 1, 3, 4]. Among surgically\ntreated endometriosis patients, its presence has been\nassociated with an increased risk of intestinal and posterior\nM. Setälä\nDepartment of Obstetrics and Gynecology,\nPäijät-Häme Central Hospital,\nLahti, Finland\nM. Setälä ( *)\n: P . Suvitie: A. Perheentupa : J. Mäkinen\nDepartment of Obstetrics and Gynecology,\nTurku University Hospital,\nP0 BOX 52, 20521 Turku, Finland\ne-mail: marjaleena.setala@fimnet.fi\nP . Härkki\n: J. Jalkanen\nDepartment of Obstetrics and Gynecology,\nHelsinki University Hospital,\nHelsinki, Finland\nJ. Fraser\nDepartment of Obstetrics and Gynecology,\nNorth Karelian Central Hospital,\nJoensuu, Finland\nJ. Kössi\nDepartment of Surgery, Päijät-Häme Central Hospital,\nLahti, Finland\nGynecol Surg (2011) 8:299 –304\nDOI 10.1007/s10397-010-0654-4\n\ncul-de-sac involvement [ 1, 3]. In patients with deeply\ninfiltrating disease, the presence of endometrioma has been\nshown to be associated with multifocality of deep lesions and\nincreased risk of intestinal and ureteral involvement [ 4].\nDeeply infiltrating endometriotic (DIE) lesions located\nin the posterior fornix of the vagina, i.e., lesions in the\nuterosacral ligaments and rectovaginal space, represent the\nmost common form of deeply infiltrating endometriotic\ndisease [ 5, 6]. These lesions are among the few endometri-\notic lesions that can be clinically diagnosed before the\noperation [ 7, 8]. Although they are usually quite easy to\ndetect, it is often difficult to know how demanding the\nsurgical procedures will be and how much operating time\nwill be needed to operate on these patients. Isolated deeply\ninfiltrating lesions in the uterosacral ligaments or in the\nposterior fornix of the vagina are not necessary associated\nwith severe adhesion formation and can often be treated\nwith a relatively easy and short surgical procedure [ 9, 10].\nHowever, technically more demanding and time-consuming\nsurgery is needed when lesions infiltrate to the ureters or\nwhen the bowel is adherent to the lesion, causing\nobstruction of the pouch of Douglas, or when the lesion\ninfiltrates to the wall of the bowel, causing a possible need\nfor bowel surgery [ 10–14].\nBetween 23% and 50% of patients with deeply infiltrating\nendometriosis have endometriomas [ 4, 15]. Even though\nendometrioma is often detected in connection with DIE\nlesions, severe cases of deep disease can also be found\nwithout an endometrioma [ 3, 15]. We performed this\nprospective study to find out whether the presence of\nendometrioma is associated with intraoperative findings that\nwere considered to represent more severe endometriotic\ndisease, and make surgery more demanding in patients with\nDIE lesions located in the posterior fornix of the vagina.\nMaterials and methods\nConsecutive premenopausal patients who were scheduled to\nundergo endometriosis surgery for DIE lesions located in\nthe posterior fornix of the vagina were enrolled to this study\nin four Finnish hospitals between January 2005 and\nDecember 2008. This study was performed as a part of a\nlarger prospective multicenter trial investigating the pres-\nence of different types of endometriotic lesions and other\nendometriosis related findings in surgically treated endo-\nmetriosis patients. Patients were considered eligible for this\nstudy if they had not undergone previous endometriosis\nsurgery, oophorectomy, salpingectomy, hysterectomy, tubal\nsterilization, gastrointestinal tract surgery, or urinary tract\nsurgery. All operations were performed by gynecologists\nexperienced in laparoscopic endometriosis surgery. Patients\nrequiring bowel resection were operated by multidisciplin-\nary approach. Patients received written and verbal informa-\ntion on the purpose of the study and were required to give\nsigned informed consent before being enrolled. The study\nwas approved by the ethics committees of all participating\nhospitals.\nPreoperative evaluation included clinical gynecological\nexamination and transvaginal ultrasound examination in all\ncases. Patients completed a questionnaire concerning pain\nsymptoms, fertility history, and medical treatment before\nthe surgery. During the operation, location and size of all\nendometriotic lesions (DIE lesions, endometrioma, and\nperitoneal lesions), location of adhesions, and attachment\nof DIE lesions to the ureters were recorded in the study\ndatabase. DIE was defined as an endometriotic nodule\n≥0.5 cm of size that infiltrated to the retroperitoneal space\n[16]. The size of the lesion was visually detected after\nlesion was excised. The infiltration of endometriosis was\nconfirmed histologically. Uterosacral ligament DIE was\ndefined as a lesion infiltrating to one or both uterosacral\nligaments. Rectovaginal endometriosis (RVE) was defined\nas a nodular lesion that was located in the posterior fornix\nof the vagina and that had infiltrated through the vaginal\nwall to the retroperitone al space. The stage of the\nendometriosis was classified according to the revised\nclassification of the American Society of Reproductive\nMedicine (rASRM) [ 17]. Only patients with histologically\nconfirmed diagnosis of deeply infiltrating endometriosis\nand endometrioma were included.\nThe presence of six operative findings that were\nconsidered to represent more severe disease and make\nsurgery more demanding: (1) total obstruction of the pouch\nof Douglas, (2) attachment of a DIE lesion to the ureter, (3)\npresence of peritoneal lesions, (4) presence of other DIE\nlesions, (5) attachment of bowel to uterosacral ligament\nDIE lesion (with or without infiltration of endometriosis to\nthe bowel wall), and (6) attachment of the rectum to a RVE\nlesion (with or without infiltration of endometriosis to the\nbowel wall) was compared between patients with and\nwithout an endometrioma. Categorical variables were\nanalyzed using chi-square test or Fisher ’s exact test, as\nappropriate. These associations were further quantified by\nodds ratios (OR) with 95% confidence intervals (CI).\nDifferences in means of continuous variables were com-\npared using the independent-samples t test. Statistical\nanalyses were performed using SAS for Windows version\n9.2 (SAS Institute Inc., Cary, NC, USA). Differences were\nconsidered statistically significant if the p value was <0.05.\nFindings\nA total of 205 premenopausal patients with no previous\npelvic surgery were operated on suspected endometriosis in\n300 Gynecol Surg (2011) 8:299 –304\n\nfour study hospitals during the recruitment time. Of these,\n98 patients (47.8%) had DIE lesions located in the posterior\nfornix of the vagina. All patients participated to this study.\nIndication for surgery was pain in 69 patients (70.4%),\npain and infertility in 26 patients (26.5%), and infertility in\nthree patients (3.1%). At the time of surgery, 27 patients\n(27.6%) were using contraceptive pills, two patients (2.0%)\nwere using progestins, and two patients (2.0%) had\nlevonorgestrel-releasing intrauterine device. Surgical pro-\ncedures performed on study patients are presented in\nTable 1.\nUterosacral ligament DIE lesions were detected in 88\npatients (89.8%), and 47 patients (48.0%) had rectovaginal\nDIE lesions. Thirty-seven patients (37.8%) had both\nrectovaginal and uterosacral ligament DIE lesions. The\nmean of the largest diameter of the uterosacral ligament\nDIE lesions and of the RVE lesions was 1.4 cm (SD 1.4,\nrange 0.5 –4.0) and 2.4 cm (SD 1.0, range 0.8 –4.0),\nrespectively.\nEndometrioma was detected in 46 patients (47.0%).\nComparison of clinical characteristics, rASRM scores, and\nsurgical characteristics, between patients with and without\nan endometrioma is presented in Table 2. Of 46 patients\nwith an endometrioma, 16 patients (35%) had bilateral\nendometriomas, 22 patients (48%) had endometrioma on\nthe left ovary, and eight patients (17%) on the right ovary.\nFive patients had more than one endometrioma per ovary.\nThe mean of the largest diameter of the endometriomas was\n3.6 cm (SD 2.4, range 0.5 –10 cm).\nPeritoneal lesions were detected in 76 patients (78%).\nTwenty-eight patients (28.6%) had 36 other DIE lesions: 19\npatients (19%) in the sigmoid colon, seven patients (7%) in\nthe appendix, seven patients (7%) in the urinary bladder,\nand three patients (3%) in the cecum. The mean number of\nDIE lesions per patient was 2.0 (SD 1.1, range 1 –5) in\npatients with an endometrioma, and 2.2 (SD 1.1, range 1 –5)\nin patients without an endometrioma ( p =0.33). The\nassociation between the presence of endometrioma, and\nthe total obstruction of the pouch of Douglas, the\nattachment of posterior DIE lesion to the ureter, and the\npresence of other endometriotic lesions is presented in\nTable 3.\nOf 88 patients with uterosacral DIE lesions, 43\npatients (49%) had an endometrioma. Bowel was\nattached to the uterosacral ligament DIE lesion in 28 of\n43 patients (65%) with an endometrioma and in 31 of 45\npatients (69%) without an endometrioma ( p=0.71, OR\n0.83, CI 0.35 –2.05).\nOf 47 patients with RVE lesions, 16 patients (34%) had\nan endometrioma. The rectum was attached to the RVE\nlesion in 13 of 16 patients (81%) with an endometrioma and\nin 26 of 31 patients (84%) without an endometrioma ( p>\n0.99, OR 0.83, CI 0.17 –4.14).\nDiscussion\nEndometriosis, and especially deeply infiltrating endome-\ntriosis, is a disease with very different clinical presenta-\ntions, and it is often difficult to know how demanding\nsurgical procedures will be needed when operating patients\nwith suspected endometriosis. Any preoperative marker\nassociated with the severity of the disease would be helpful\nin clinical practice.\nCurrent data suggests that endometrioma could be a\nmarker for more severe disease [ 1, 3, 4]. It seems to be a\ncommon finding in patients with DIE lesions located in the\nposterior fornix of the vagina, as 47% of our study patients\nhad an endometrioma. However, although mean total\nrASRM score was significantly higher in patients with an\nendometrioma, our results revealed no statistically signifi-\ncant association between the presence of endometrioma and\nthe six studied operative findings.\nThese six operative findings were chosen because they\nwere considered to represent more severe disease and make\nsurgery more demanding. The presence of other endometri-\nTable 1 Surgical procedures performed on 98 study patients\nSurgical procedure Number of patients\nDivision of adhesions 97\nExcision of peritoneal endometriosis 76\nResection of uterosacral ligament, unilateral 48\nResection of uterosacral ligament, bilateral 40\nV aginal resection 40\nRectal resection 28\nExtirpation of endometrioma, unilateral 27\nRectal shaving 19\nHysterectomy 15\nSalpingectomy, unilateral 14\nAppendectomy 13\nExtirpation of endometrioma, bilateral 9\nSalpingectomy, bilateral 8\nBladder resection 7\nOophorectomy, unilateral 7\nOophorectomy, bilateral 6\nSigmoid resection 5\nExtirpation of benign ovarian tumor 4\nIleocecal resection 3\nEnucleation of myoma 2\nCecal resection 1\nDisk excision of rectum 1\nUreteroneocystostomy, unilateral 1\nUreteral resection and reanastomosis, bilateral 1\nGynecol Surg (2011) 8:299 –304 301\n\notic lesions was considered to represent the overall severity\nof the disease. The goal of contemporary endometriosis\nsurgery is to remove all endometriosis which can be very\ncomplex especially in cases with multiple deep lesions.\nTotally obstructed pouch of Douglas, attachment of bowel\nto the DIE lesion and attachment of DIE lesion to the ureter\nare often detected in patients with posterior DIE lesions, but\nnot all gynecologists are used to perform demanding\nadhesiolysis or ureterolysis needed in these cases. If it\ncould be demonstrated that the presence of endometrioma is\nassociated with this kind of findings and surgery, it could\nhelp gynecologists to decide, where and by whom these\npatients should be operated.\nIn previous studies, patients with superficial ovarian\nendometriosis and endometriomas had more pelvic areas\ninvolved by endometriosis, and endometrioma was a good\npreoperative marker for pouch of Douglas obliteration [ 1,\n3]. Furthermore, the presence of endometrioma was\nassociated with multifocality, and ureteral involvement of\nthe deeply infiltrating lesions [ 4]. We also did expect to find\nout that endometrioma would be associated with studied\nfindings, but although patients with an endometrioma had\nsignificantly more adnexal adhesions compared to the\npatients without an endometrioma, no other significant\nassociation was detected.\nThe most important factor influencing our results is\nprobably the fact that we included only patients with no\nprevious pelvic surgery. For that, we had two reasons.\nFirstly, postoperative adhesions are often difficult to\ndifferentiate from adhesions caused by endometriosis,\nwhich would probably greatly alter the detected results.\nWe now observed, that the presence of totally obstructed\npouch of Douglas was not very frequent finding in patients\nwithout previous pelvic surgery. It was detected in 28% of\nthe patients with an endometrioma and in 27% without an\nendometrioma.\nSecond reason to include only patients without previous\npelvic surgery was the knowledge that the probability of\nrecurrence seems to differ according to the type of operated\nendometriotic lesion. The recurrence of DIE lesions seems\nto be very rare if complete excision has been performed in\nthe first operation, while the recurrence of endometrioma\nseems to be quite common, even after complete excision of\nthe capsule [ 18–22]. If patients with previous endometriosis\nsurgery had been included, the detected findings would\nhave been largely dependent on the type of previous\nsurgery.\nThere is very little previous knowledge of the prevalence\nof these six studied operative findings in patients with no\nprevious pelvic surgery. Based on our findings, it seems\nthat in general, DIE lesions in the posterior fornix of the\nvagina have a considerable ability to provoke adhesion\nformation by themselves, although the total obstruction of\nthe pouch of Douglas was not very frequent finding. Even\nwithout an endometrioma, bowel was attached to the\nuterosacral ligament DIE lesion in 69%, and to the\nrectovaginal lesion in 84% of the patients. Associated\nendometrioma probably does not have a significant addi-\nTable 2 Comparison of clinical characteristics, rASRM scores, and surgical characteristics between patients with and without an endometrioma\nPatients with endometrioma ( n=46) Patients without endometrioma ( n=52)\nMean SD Range Mean SD Range p V alue\nAge (years) 33.5 6.9 20 –52 29.5 5.6 19 –43 0.002\nBMI 23.7 5.0 15.6 –40.6 23.7 3.5 17.5 –34.2 0.97\nTotal rASRM score 60 31 9 –128 24 26 3 –114 <0.001\nrASRM adnexal adhesion score 17 15 0 –64 6 14 0 –64 <0.001\nTotal operating time (min) 157 85 40 –520 160 102 30 –450 0.85\nLaparoscopya 41 (89%) 45 (87%) 0.69\na Data presented as n (%)\nTable 3 Four studied operative findings in patients with and without an endometrioma\nOperative finding Endometrioma ( n=46) No endometrioma ( n=52)\nn % n % p V alue OR 95% CI\nTotal obstruction of the pouch of Douglas 13 28 14 27 0.88 1.1 0.44 –2.60\nAttachment of DIE lesion to the ureter 24 52 23 44 0.43 1.4 0.62 –3.05\nPresence of peritoneal lesions 37 80 39 75 0.52 1.4 0.52 –3.58\nPresence of other DIE lesions 11 24 17 33 0.34 0.6 0.26 –1.58\n302 Gynecol Surg (2011) 8:299 –304\n\ntional effect on adhesion formation in these patients. The\nattachment of DIE lesion to the ureter was also a common\nfinding, as it was detected in 48% of the patients.\nAdditionally, 29% had other DIE lesions located in the\nbladder, or in the intestine. When present, these findings\nrepresent the most severe forms of the endometriotic\ndisease, and gynecologists who operate these patients,\nshould have the technical skills to perform needed surgical\nprocedures. We believe that the knowledge of the preva-\nlence of these findings could help to plan surgical\ntreatment.\nThe fact that we included only patients with no previous\nsurgery is also a reflection of the small number of study\npatients. A large number of endometriosis patients undergo\nrepeated surgery for endometriosis, and therefore it is very\ndifficult to obtain a large enough study population,\nespecially if only certain types of endometriosis patients\nare studied. Due to the relatively small sample size, our\nresult needs to be interpreted with caution. The nonsignif-\nicant p values could reflect either the fact that the true effect\nis nil or the fact that our study had low power. A larger\nprospective study with a proper power calculation based on\nthe prevalence of these operative findings in patients with\nno previous pelvic surgery would be needed to confirm our\nresults.\nConclusions\nIt would be very useful if it could be demonstrated that\nendometrioma is also a practical marker for more severe\ndisease in patients with posterior DIE lesions, as that would\nenable more individually tailored planning of surgical\ntreatment and more detailed patient counseling. However,\nat least in this cohort of patients with DIE lesions in the\nposterior fornix of the vagina and with no previous pelvic\nsurgery, the presence of endometrioma did not seem to be\nassociated with operative findings that were considered to\nmake surgery more demanding.\nAcknowledgments This study was supported by a grant from the\nResearch Fund of The Joint Authority for Päijät-Häme Social and\nHealth Care. We would wish to thank statistician Jaakko Matomäki for\nexpert help with the statistical analysis, and study nurse Minna Tuuri\nfor her assistance in this study.\nDeclaration of interest The authors report no conflicts of interest. The\nauthors alone are responsible for the content and writing of the paper.\nReferences\n1. Redwine DB (1999) Ovarian endometriosis: a marker for more\nextensive pelvic and intestinal disease. Fertil Steril 72(2):310 –\n315\n2. 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