{"paper_id":"d43d50ad-4bec-43a5-82d6-9e908c526080","body_text":"Vol.:(0123456789)\nArchives of Gynecology and Obstetrics (2024) 309:2697–2707 \nhttps://doi.org/10.1007/s00404-024-07412-6\nGENERAL GYNECOLOGY\nTotally intracorporeal colorectal anastomosis (TICA) versus classical \nmini‑laparotomy for specimen extraction, after segmental bowel \nresection for deep endometriosis: a single‑center experience\nManuel Maria Ianieri1,2 · Alessandra De Cicco Nardone1 · Pierfrancesco Greco3  · Antonella Carcagnì3,4 · \nFederica Campolo1 · Fabio Pacelli3,5 · Giovanni Scambia1,3 · Francesco Santullo5\nReceived: 20 November 2023 / Accepted: 1 February 2024 / Published online: 21 March 2024 \n© The Author(s) 2024\nAbstract\nPurpose The surgical approach to bowel endometriosis is still unclear. The aim of the study is to compare TICA to con-\nventional specimen extractions and extra-abdominal insertion of the anvil in terms of both complications and functional \noutcomes.\nMethods This is a single-center, observational, retrospective study conducted enrolling symptomatic women underwent \nlaparoscopic excision of deep endometriosis with segmental bowel resection between September 2019 and June 2022. \nWomen who underwent TICA were compared to classical technique (CT) in terms of intra- and postoperative complica-\ntions, moreover, functional outcomes relating to the pelvic organs were assessed using validated questionnaires [Knowles-\nEccersley-Scott-Symptom (KESS) questionnaire and Gastro-Intestinal Quality of Life Index (GIQLI)] for bowel function. \nPain symptoms were assessed using Visual Analogue Scale (VAS) scores.\nResults The sample included 64 women. TICA was performed on 31.2% (n = 20) of the women, whereas CT was used on \n68.8% (n = 44). None of the patients experienced rectovaginal, vesicovaginal, ureteral or vesical fistula, or ureteral stenosis \nand uroperitoneum, and in no cases was it necessary to reoperate. Regarding the two surgical approaches, no significant \ndifference was observed in terms of complications. As concerns pain symptoms at 6-month follow-up evaluations on strati-\nfied data, except for dysuria, all VAS scales reported showed significant reductions between median values, for both surgery \ninterventions. As well, significant improvements were further observed in KESS scores and overall GIQLI. Only the GIQLI \nevaluation was significantly smaller in the TICA group compared to CT after the 6-month follow-up.\nConclusions We did not find any significant differences in terms of intra- or post-operative complications compared TICA \nand CT, but only a slight improvement in the Gastro-Intestinal Quality of Life Index in patients who underwent the CT \ncompared to the TICA technique.\nKeywords Bowel resection · Bowel endometriosis · Intracorporeal anastomosis · Deep endometriosis · Complications · \nMini-laparotomy\n * Pierfrancesco Greco \n p.greco753@gmail.com\n1 Unit of Oncological Gynecology, Women’s Children’s \nand Public Health Department, Fondazione Policlinico \nUniversitario Agostino Gemelli, IRCCS, Rome, Italy\n2 Gynecology and Breast Care Center, Mater Olbia Hospital, \nOlbia, Italy\n3 Catholic University of the Sacred Heart, Rome, Italy\n4 Epidemiology and Biostatistics Research Core Facility, \nGemelli Generator, Fondazione Policlinico Universitario \nAgostino Gemelli IRCCS, Rome, Italy\n5 Surgical Unit of Peritoneum and Retroperitoneum, \nFondazione Policlinico Universitario Agostino Gemelli \nIRCCS, Rome, Italy\n\n2698 Archives of Gynecology and Obstetrics (2024) 309:2697–2707\nWhat does this study add to the clinical work \nThis study shows for the first time the functional \noutcomes and complications of a new surgical tech-\nnique for intestinal resections for deep endometrio-\nsis with completely intracorporeal anastomosis and \ncompares them with those of the classic technique.\nIntroduction\nDeep endometriosis (DE), defined as endometrial glands and \nstroma infiltrating the peritoneum by at least 5 mm, is the most \nsevere form of endometriosis [1]. Within the DE spectrum, \nbowel endometriosis has been estimated to affect between 5 \nand 12% of patients [2]. The rectum and sigmoid are involved \nin up to 90% of all intestinal lesions [3], and a laparoscopic \nor robotic resection of the affected part of the bowel may be \nrequired in cases of either occlusive symptoms or non-respon-\nsive medical pain patients [4–6].\nIn recent years there has been growing interest in the extrac-\ntion of specimens via transnatural orifices [7–12], i.e. through \na transvaginal or transrectal route, thus avoiding the abdomi-\nnal incisions described in classic techniques (mini-laparotomy), \nwhich, though smaller than a laparotomy, can be associated \nwith complications and suboptimal aesthetic results [7, 8].\nCurrently, even though there are no universal guide-\nlines recommending which extraction and anastomosis \ntechnique should be preferred as an alternative to the \nclassic one, a natural orifice specimen extraction (NOSE) \nis the most widely used [9 –12]. In 2021, however, totally \nintracorporeal colorectal anastomosis (TICA) was \ndescribed for the first time by our group [13]. It involves \nthe execution of completely intra-abdominal colorectal \nanastomosis and the extraction of the specimen from the \nincision used for the 12 mm trocar, which is also used \nto insert the linear stapler, without a mini-laparotomy.\nThe aim of this study has been to investigate the impact of \nTICA, compared to conventional specimen extractions and \nextra-abdominal insertion of the anvil in terms of both com-\nplications and functional outcomes, in patients who under -\nwent segmental bowel resection for colorectal endometriosis.\nMaterials and methods\nStudy protocol\nThis is a single-center, observational, retrospective study, \nwhich is reported in accordance with the “Strengthening \nthe Reporting of Observational Studies in Epidemiology” \n(STROBE) guidelines and checklist [14]. We retrieved data \nsets on symptomatic women who underwent laparoscopic \nexcision of DE with segmental bowel resection between \nSeptember 2019 and June 2022 from the electronic data-\nbases and clinical records of the tertiary academic center for \nEndometriosis of the Fondazione Policlinico-Universitario \nAgostino Gemelli IRCCS in Rome (Italy). Patients were \ndivided into two groups according to the surgical technique \nused for anastomosis and the extraction of specimens: either \nthe classic technique (CT) or TICA. Pre-operative and \npost-operative functional outcomes, as well as differences \nbetween pre-operative and post-operative ones, were com-\npared for the two groups.\nEthics statement\nThis study received approval from the Institutional Review \nBoard of the “Dipartimento Universitario Scienze della Vita \ne di Sanità Publica” (IRB protocol number DIPUSVSP-\nPD-07–234) and was carried out in accordance with the Hel-\nsinki Declaration. During pre-operative evaluation, patients \nwere asked in advance to sign a consent form regarding the \nsubsequent use of their anonymized data.\nVariables and procedures\nSegmental bowel resection was performed in cases of \npatients for whom medical therapy had failed to control \nsymptoms (i.e. progestins or estro-progestins), with simul-\ntaneous bowel obstruction or nodule residue > 3 cm after a \nshaving technique, or in cases of multiple bowel nodules. All \nthe women had a histologically confirmed diagnosis of endo-\nmetriosis. We excluded all women aged < 18 years, women \nwho had previous discoid or segmental bowel resection for \nany benign or malignant diseases, or pelvic external beam \nradiotherapy/brachytherapy, or a concomitant diagnosis of \ndiabetic microangiopathy/vasculopathies.\nRetrieved data included medical and surgical history from \nthe pre-operative evaluation. Moreover, all the women were \nsubjected to recto-vaginal examination, dedicated trans-\nvaginal and transabdominal ultrasonography and/or pelvic \nmagnetic resonance imaging. In cases of sub-occlusive \nsymptoms, either a colonoscopy, a double barium enema \nor a virtual colonoscopy was also required to evaluate ste-\nnosis. Along with the above, interviews on pain symptoms \nand questionnaires on gastrointestinal function were also \nconducted.\nSpecifically, we focused on the main demographic, \nanthropometric and clinical data (i.e. age, body mass index, \nand previous surgery), clinical variables (pain and gastroin-\ntestinal symptoms), surgical findings (operating time, esti-\nmated blood loss, any intraoperative complications, length \nof resection, distance of the nodule from anal verge, and the \n\n2699Archives of Gynecology and Obstetrics (2024) 309:2697–2707 \nneed for ileostomy), and peri-operative data (days of hospi-\ntalization, need for self-catheterization, and post-operative \ncomplications).\nPost-operative complications, occurring within 30 days \nafter surgery, were described using the Clavien-Dindo clas-\nsification [15]. Six months after surgery, patients underwent \nrecto-vaginal evaluation and transvaginal and transabdomi-\nnal ultrasonography. Interviews regarding pain symptoms \nand questionnaires were also reassessed (at the six-month \nfollow-up visit). The severity of pain symptoms (dysmen-\norrhea, dysuria, dyschezia, and dyspareunia) was assessed \nusing Visual Analogue Scale (VAS) scores (ranging from 0 \nto 10, i.e. from absence of pain to most severe).\nInformation regarding gastrointestinal functional out-\ncomes was assessed using validated questionnaires: the \nKnowles-Eccersley-Scott-Symptom Questionnaire (KESS) \n[16] and the Gastro-Intestinal Quality of Life Index (GIQLI) \n[17]. The KESS questionnaire was used to assess bowel \nfunction and specifically determine whether the patient suf-\nfered from constipation (0 to 39 points). We used a cut-off  \ncriterion of ≥ 10 points in the total KESS score to define con-\nstipation [17]. The GIQLI was used to describe the health-\nrelated quality of life (QoL) of patients with gastrointestinal \ndisease (0 to 144 points). The questionnaire consists of 36 \nitems and a higher score indicates a better QoL [17]. Uri-\nnary retention was defined as a post-voiding residual volume \nof 100 mL. In these cases, self-catheterization was recom-\nmended until the post-urinary residual volume was < 100 mL \nat three consecutive measurements.\nEndpoints and outcome assessment\nThe primary endpoint of the study was to evaluate surgical \noutcomes, such as intra-operative, peri- and post-operative \ncomplications in women who underwent segmental bowel \nresection using the CT or the TICA technique. As secondary \nendpoints, we looked at gastrointestinal functional outcomes \nassessed using validated questionnaires, and pain symptoms \nboth at baseline and at 6-month follow-up, to highlight \npotential improvements after intervention. Furthermore, we \nevaluated the correlation between functional outcomes at \nfollow-up, by means of KESS and GIQLI questionnaires, \nand surgical, anthropometric and intra-operative findings.\nSurgical technique and post‑operative care\nWhen preparing for surgery, all patients followed a 5-day \nresidue-free diet and received mechanical bowel prepara-\ntion in the form of a 4-L split dose of Macrogol: 2 L 2 days \nbefore surgery and 2 L the day before surgery. Intravenous \ncefuroxime and metronidazole were administered intraop-\neratively as antibiotic prophylaxis [13].\nAll patients were operated on by a multidisciplinary sur-\ngical team highly experienced in the laparoscopic surgical \nexcision of bowel endometriosis, including a gynecologist \nand a colorectal surgeon. The severity of the disease was \nintra-operatively classified using the revised American-\nFertility-Society (r-ASRM) score [18] and the # ENZIAN \nclassification[19].\nIn all cases, a laparoscopic surgical approach for poste-\nrior DE using a nerve-sparing approach was used, as previ-\nously published [20–22]. When DE involved the lateral and/\nor posterior parametrium, a nerve-sparing parametrectomy \nwas performed, as previously described by our group [1 , \n23]. In the case of further ureteral involvement due to the \ndisease, ureterolysis was performed first and, if this failed to \nsolve ureteral infiltration, ureteroneocistostomy was carried \nout [24, 25].\nSegmental bowel resection was performed following \nthe same steps, i.e. a 5 mm trocar was added in the right \nhypochondrium. Then the peritoneum of the mesosigma \nwas opened above the root of the inferior mesenteric artery \n(IMA), as close to the bowel wall as possible. Sigmoid ves-\nsels, which supply the bowel segment to be resected, were \nprogressively identified and selectively coagulated. The \ndissection was carried out until the rectal wall below the \nendometriotic nodule was reached, and then the rectum was \ntransected with a linear stapler, the Echelon Flex™ Endo-\npath® Stapler (EFES) 60 mm (Ethicon, Cincinnati, OH, \nUSA). Colorectal anastomosis was performed by extracting \nthe segment of bowel to be resected through a suprapu-\nbic mini-Pfannenstiel incision (4–5 cm) and following the \nclassic steps [20, 26], or else with a totally intracorporeal \nanastomosis procedure (TICA) [27]. The choice of whether \nto use totally intracorporeal anastomosis (introduced at our \ninstitution in 2021) or a mini-Pfannenstiel incision was \nmade at the discretion of the gynecologist and colorectal \nsurgeon.\nFollowing the TICA technique, before anastomosis, the \nanvil of the circular stapling device (EEA™ circular stapler \nwith Tri-Staple™ technology, 28 mm or 31 mm Medium/\nThick, Covidien, New Haven, CT, USA) was prepared with \na 0 vicryl suture, bound at the hole of the tip (Fig.  1). The \nanvil was brought into the abdominal cavity through the \nopening for the 12 mm port in the right abdominal flank. A \ncolotomy was performed at the colonic wall just proximal \nto the endometriotic nodule, and then the anvil was intro-\nduced into the colon through the colotomy (Fig.  2). The lin-\near stapler was arranged to include the whole colostomy. The \nsuture attached to the rod of the anvil needed to be held from \nthe superior edge of the colotomy, keeping the vicryl suture \n\n2700 Archives of Gynecology and Obstetrics (2024) 309:2697–2707\nout of the linear stapler. The colon was then transected with \na linear stapler (Fig.  3) and the anvil extracted through the \ncolon next to the suture line, pulling on the thread tied to it \n(Fig.  4). Then the circular stapler was introduced in the rec-\ntum and end-to-end anastomosis was performed. The speci-\nmen was extracted through the 12 mm port on the right flank \nor through the vagina in cases of hysterectomy. In case of \nbowel segments with nodules too large to be extracted from \na 12 mm incision, the specimen was partially morcellated \nwith cold scissors in an endobag. At the end of the proce-\ndure, an air leak test was performed to evaluate anastomosis \nintegrity. One drainage was left in place. In the post-opera-\ntive period, at 3 and 5 post-operative days, a white cell count \nand C-reactive protein measurement were performed to look \nat potential early post-operative septic complications. Fast-\ntrack diet resumption was followed for nutrition.\nStatistical analysis\nGiven the retrospective observational nature of the study, it \nwas not essential to resort to a formal determination of the \nsample size. But taking into account the number of patients \nwho underwent surgery in the reference period and who \nstrictly met the inclusion criteria, it was possible to enroll \n64 patients.\nThe sample was described in its clinical and demographic \ncharacteristics using descriptive statistical techniques. Spe-\ncifically, qualitative data sets were expressed as absolute \nand relative percentage frequencies, whereas quantitative \nvariables as either mean and standard deviations (SD) or \nmedian and interquartile ranges (IQR), as appropriate. To \nverify the Gaussian distribution of quantitative variables, \nthe Shapiro–Wilk test was applied.\nPre-post differences in the questionnaires on quality of \nlife were analyzed using the Student’s t-test or the Wilcoxon \nrank-sum test for paired data, as appropriate. Finally, regres-\nsion modeling was used to compare the pre-post differences \nbetween the two intervention techniques (i.e., estimated \n∆-change differences), considering the CT as the reference \npoint. Statistical significance was set at p-value < 0.05. All \nanalyses were conducted using R software version 4.2.0 \n(CRAN ®, R Core 2022).\nResults\nTable  1 shows the general characteristics of the study sample \nat baseline, overall and classified by surgery method (TICA \nvs CT). The sample included 64 women, with a mean age of \n38.5 ± 6.1 years, and a median body mass index of 23.0 kg/\nm2 (IQR 20.4–24.6). TICA was performed on 31.2% (n = 20) \nof the women, whereas CT was used on 68.8% (n = 44). \nOver 32% (n = 21) of the women had previous surgery for \nFig. 1  Anvil, prepared with a 0 vicryl suture, bound at the hole of the \ntip\nFig. 2  Anvil introduced through the colotomy perfomed cranially to \nthe endometriotic nodule\nFig. 3  The stapler include the colotomy leaving the thread outside \nfrom the suture\n\n2701Archives of Gynecology and Obstetrics (2024) 309:2697–2707 \nendometriosis without bowel involvement; specifically, 35% \n(n = 7) in the TICA goup and over 31% (n = 14) in the CT \ngroup.\nMost of patients were classified as stage III and IV \naccording to the American Society for Reproductive Medi-\ncine (ASRM) guidelines for endometriosis, with no signifi-\ncative differences between the two groups. Endometriosis \nwas further mapped using the # Enzian Classification, as \nreported in Table  2.\nInterventions\nTable  3 shows the intervention data, both overall and classi-\nfied by surgery method. The intestinal nodules were mainly \nsingle in both techniques, i.e. 80% n = 16 vs the 20% n = 4 \nthat were multiple in the TICA group and 70.5% n = 31 vs \nthe 29.5% n  = 13 that were multiple in the CT group, with \na mean size of 3.7 cm ± 1.0 (TICA) and 3.5 cm ± 0.7 (CT).\nIn both the groups, the median resected intestinal tract \nwas 8 cm (IQR 6–9) and the parts involved were mainly \nreferred to the rectum (n = 13; 65% for TICA and n = 22; \n50% for CT), though in 24 cases (n = 7 TICA, n = 17 CT) \nthere was further association of the sigmoid.\nColostomy was not performed on any of the patients, \nwhereas temporary ileostomy was needed in 25% (n = 5) of \ncases in TICA groups and in 31.8% (n = 14) of cases in CT \ngroup.\nOnly in a few cases was salpingo-oophorectomy (mon-\nolateral and bilateral) performed. Moreover, ureterolysis was \nperformed in 79.5% (n = 35) of patients in the CT group and \n65% (n = 13) patients in the TICA groups.\nThe mean operative time was 336.4 ± 77.7 and \n353.2 ± 76.7 min for TICA and TC, respectively. A median \nof 6 days of hospitalization were required overall.\nMoreover, during intervention the median Estimated \nBlood Loss (EBL) was 200 mL (IQR 150–300) in the CT \ngroup and 250 (IQR 187–300) in TICA group. Ureteral \nresection or reimplantation was needed in 1 (5.0%) and 2 \n(4.5%) cases in TICA and CT group, respectively.\nIt is notable that posterolateral parametrectomy was \nneeded in 75% (n = 33) of cases of CT and 90% (n = 18) of \nthe TICA group. The 30.0% (n = 6) TICA patients required \na total hysterectomy comparate with the 40.9% (n = 18) \npatients in the CT group. Finally, as concerns associations \nbetween the surgery methods, only the bowel anastomosis \nprovided a significant result (P = 0.011).\nIntra‑ and post‑operative complications\nNext, data on intra- and post-operative complications rates \nare shown in Table 4. All the women had surgery performed \nin laparoscopy and no conversion was required.\nThe rate of intra-operative complications was extremely \nlow (n = 2; 4.5% in CT vs n = 0 in TICA). Of note, none of \nthe patients experienced rectovaginal, vesicovaginal, ureteral \nor vesical fistula, or ureteral stenosis and uroperitoneum. In \none case (2.3%), hemoperitoneum was reported in the CT \ngroup but was treated conservatively. In one case (5.0%), \nintestinal anastomosis leakage was reported in the CT group, \nbut the patient was underwent to protective ileostomy during \nthe surgery, so she not required a reintervention.\nNo cases of reintervention were recorded, while bladder \nvoiding deficit was observed in 10% of cases (n = 2) in the \nTICA group and 6.8% (n = 3) in the CT group. Urinary tract \ninfections were observed in 15% (n = 3) in the TICA group \nand over 11% (n = 5) in the CT group.\nRegarding the two surgical approaches, no significant dif-\nference was observed in terms of complications.\nPost‑operative evaluation and questionnaires\nFinally, as concerns pain symptoms at 6-month follow-up \nevaluations on stratified data, except for dysuria, all VAS \nscales reported showed significant reductions between \nmedian values, with an overall disappearance of symp-\ntom perception for both surgery interventions. As well, \nsignificant improvements were further observed in KESS \nscores and overall GIQLI. All these data sets are reported \nin Table  5.\nTable  6 shows the estimated ∆-change differences (pre-\npost) between the two intervention techniques for each out-\ncome considered. Notably, only the GIQLI evaluation was \nsignificant after the 6-month follow-up (-14.119, P = 0.011).\nFig. 4  The anvil is extracted through the colon next to the suture line, \npulling on the thread tied to it\n\n2702 Archives of Gynecology and Obstetrics (2024) 309:2697–2707\nConcerning the VAS score, dysuria and dyschezia \nrevealed negative differences, in both questionnaire scores.\nDiscussion\nIn our study, we compared two different segmental bowel \nresection techniques for endometriosis. We did not find any \nsignificant differences in terms of intra- or post-operative \ncomplications, but only a slight improvement in the Gastro-\nIntestinal Quality of Life Index in patients who underwent \nthe CT compared to the TICA technique.\nOther authors had previously demonstrated the feasibility \nand safety of the NOSE technique for bowel resection in DE \nusing both the transvaginal and transrectal routes, for the \nextraction of the specimen [ 10, 28, 31]. In agreement with \nthese studies, we also observed no statistically significant \ndifferences in terms of post-operative complications between \nthe TICA technique and the classical one.\nThere were no major III-IV complications according to \nthe Clavien-Dindo scale. Our data sets are comparable to \nthe results reported by other authors ranging from 2.4 to \n13.2% in terms of rectovaginal fistulas, vesicovaginal fistu-\nlas, anastomosis stenosis, ureteral fistulas, and bladder fis-\ntulas [8, 33]. The low rate of recto-vaginal fistulas and low \npost-operative complications is also supported by a recent \nstudy by Spagnolo et al., with 99 patients who, when com-\nparing transvaginal specimen extraction (n  = 23) and the \nclassic technique (n = 76), showed no statistically signifi -\ncant differences in term of post-operative complications and \nrecto-vaginal fistula rates between the groups [12]. Akladios \net al., examining a group of 39 patients undergoing bowel \nresection for DE, observed a post-operative complication \nrate of 12.5% in those to whom the classic technique was \napplied and 20% in those who had the NOSE technique, with \nno statistically significant differences [29].\nMoreover, these findings are also in agreement with \ntwo recent meta-analyses comparing the NOSE technique \nwith the classic bowel resection technique for colorectal \ncancer; they showed that there were no substantial differ -\nences between the two techniques in terms of post-operative \ncomplications [ 8, 33]. These studies show that transvagi -\nnal and transanal NOSE techniques are as safe as the clas-\nsic suprapubic technique when it comes to post-operative \ncomplications.\nOur study, in particular, indicated that, in the TICA \ngroup, leakage of the anastomosis never occurred, in con-\ntrast to the CT group, where it occurred in only one case \n(5%) (patient who had already undergone surgery for DE). \nThe leakage rate is essentially the one indicated in the lit-\nerature, which ranges between 0 and 3% [10, 28, 31, 33, 34]. \nObviously, given the small number of patients, we cannot \nTable 1  General characteristics \nof the study sample at baseline \n(N = 64)\nBMI: Body mass index, ASRM: American Society for Reproductive Medicine, VAS: Visual Analog Scale, \nKESS: Knowles-Eccersley-Scott-Symptom Questionnaire, GIQLI: Gastro-Intestinal Quality of Life Index\nDescriptive statistics are expressed as mean and standard deviations (SD) or medians (interquartile range: \nIQR) for quantitative variables, and as absolute and relative percentage frequencies for qualitative variables\nVariables Overall (n = 64) TICA (n = 20) CT (n = 44) P\nAge (yrs) 38.5 (6.1) 38.0 (5.3) 38.8 (6.5) 0.629\nBMI, kg/m2 23.0 (20.4–24.6) 21.1 (20–23.1) 23.5 (21–25) 0.064\nPrevious surgery for endometriosis 21 (32.8) 7 (35.0) 14 (31.8) 0.802\nASRM endometriosis stage\n  I 2 (3.1) 0 (0.0) 2 (4.5) 0.305\n  II 2 (3.1) 1 (5.0) 1 (2.3)\n  III 27 (42.2) 12 (60.0) 15 (34.1)\n  IV 33 (51.6) 7 (35.0) 26 (59.1)\nVAS Pain Scales\n  Dysuria 0 (0 – 2) 0 (0–3) 0 (0–3)\n  Dysmenorrhea 8 (5–9) 8 (7–8) 8 (4–9)\n  Dyspareunia 6 (3–7) 6 (5–7) 5 (1–7)\n  Dyschezia 3 (0–7) 4 (1–7) 3 (0–7)\nQuestionnaires\n  KESS 19.2 (7.6) 18.4 (6.4) 19.3 (8.1) 0.638\n  GIQLI 57.3 (21.6) 50.8 (18.3) 60.2 (22.6) 0.083\n\n2703Archives of Gynecology and Obstetrics (2024) 309:2697–2707 \ndetermine definitively whether the TICA technique is safer \nin terms of leakage compared to CT (p = 0.683).\nIt is interesting to observe that one of the most frequent \npost-operative complications for both techniques was blad-\nder voiding deficit (10%, 2 patients for TICA vs 6.8%, 3 \npatients for CT). The complication was resolved with the use \nof intermittent self-catheterization within 45 days from sur -\ngery in each of the 5 patients. However, this rate was lower \nthan in other studies on nerve-sparing techniques (0–22%) \n[35]. Nonetheless, this comparison is not reliable, as only a \nfew studies have specified parametrectomy, which is itself \nconsidered a risk factor for post-operative urinary retension-\nism [1, 20].\nWe did not observe any cases of reintervention, as the \nonly anastomotic leak occurred in a patient for whom a \ntemporary ileostomy had previously been performed due to \nthe low distance of anastomosis from the anal margin. As \nsuch, the patient was treated conservatively, maintaining the \nstoma for 70 days, and it then closed without complications; \nperforming a barium enema confirmed the healing of the \nmillimetric colorectal dehiscence.\nBowel function, on the other hand, improved sig-\nnificantly in our series, as confirmed by the consider -\nable enhancement of both KESS (P < 0.001) and GIQLI \n(P < 0.001) after colorectal surgery. Conversely, an other \nstudy have not shown any relief from digestive complaints \nTable 2  # Enzian Classification \n(N = 64)\nDescriptive statistics are expressed as absolute and relative percentage frequencies\n# Enzian Overall (n = 64) TICA (n = 20) CT (n = 44) P\nPeritoneum 18 (28.1) 3 (15.0) 15 (34.1) 0.202\nOvaries\n Absent 35 (54.7) 9 (45.0) 26 (59.1) 0.655\n O1 12 (18.8) 4 (25.0) 8 (18.2)\n O2 14 (21.9) 6 (30.0) 8 (18.2)\n O3 3 (4.7) 1 (5.0) 2 (4.5)\nTubes\n Absent 34 (53.1) 10 (50.0) 24 (54.5) 0.007\n T1 7 (10.9) 4 (20.0) 3 (6.8)\n T2 12 (18.8) 0 (00.0) 12 (27.3)\n T3 11 (17.2) 6 (30.0) 11 (11.4)\nCompartments\nA (rectovaginal septum and vagina)\n Absent 34 (53.1) 11 (55.0) 23 (52.3) 0.691\n A1 4 (6.2) 1 (5.0) 3 (6.8)\n A2 16 (25.0) 5 (25.0) 11 (25.0)\n A3 10 (15.6) 3 (15.0) 7 (15.9)\nB (uterosacral/cardinal ligaments, parametrium, \npelvic sidewalls)\n Absent 24 (37.5) 7 (35.0) 17 (38.6) 0.801\n B1 13 (20.3) 5 (25.0) 8 (18.2)\n B2 21 (32.8) 7 (35.0) 14 (31.8)\n B3 6 (9.4) 1 (5.0) 5 (11.4)\nC (rectum)\n Absent 4 (6.2) 0 (0.0) 4 (9.1) 0.180\n C1 1 (1.6) 0 (0.0) 1 (2.3)\n C2 22 (34.4) 10 (50.0) 12 (27.3)\n C3 37 (57.8) 10 (50.0) 27 (61.4)\nFa (adenomyosis) 46 (71.9) 14 (70.0) 32 (72.7) 0.822\nFb (urinary bladder involvement) 4 (6.2) 1 (5.0) 3 (6.8) 0.780\nFi (other intestinal locations) 4 (6.2) 0 (0) 4 (9.1)\nFu (ureteric involvement with signs of obstruction) 8 (12.5) 2 (10.0) 6 (13.6) 0.683\n\n2704 Archives of Gynecology and Obstetrics (2024) 309:2697–2707\nafter segmental bowel resection for DE [ 36]. Specifically, \nour study showed that the change in GIQLI score, between \nbaseline and follow-up, in the TICA group was smaller \n(p = 0.011) than the same item in CT. This difference is \nprobably due to the fact that the baseline score was slightly \nbetter in the CT group than in the TICA group.\nWhat in our opinion most differentiates the two surgical \ntechniques is essentially the number of staples necessary for \nthe resection. In fact, in the TICA technique, compared to \na potential advantage in reducing laparotomy incisions, the \nuse of an additional stapler is required to resect the cranial \nportion of the bowel segment with DE and fix the anvil, \nwhich instead in the CT is usually inserted manually into \nthe intestinal lumen and blocked with a tobacco pouch. This \nadditional suture on the bowel could theoretically represent \nan additional risk as in the NOSE, but in our series the only \ndehiscence was actually reported using the CT.\nTable 3  Intervention data for \nthe study population (N = 64)\nTICA totally intracorporeal anastomosis, BSO bilateral salpingo-oophorectomy, MSO monoliteral salpingo-\noophorectomy, T-T termino-terminal, L-T latero-terminal, L-L latero-lateral\n*Descriptive statistics are expressed as mean and standard deviations or median and interquartile ranges for \nquantitative variables, and as absolute and relative percentage frequencies for qualitative variables\nSurgery Overall (n =  64) TICA\n(n = 20)\nCT\n(n = 44)\nP\nLaparoscopy 64 (100) 20 (31.2) 44 (68.8)\nNodules\nSingle 47 (73.4) 16 (80.0) 31 (70.5) 0.422\nMultiple 17 (26.6) 4 (20.0) 13 (29.5)\nIntestinal nodule size, cm 3.6 (0.8) 3.7 (1.0) 3.5 (0.7)\nResected intestinal tract, cm 8 (6 – 9) 8 (6–9) 8 (6–9)\nIntestinal tract\nRectum 35 (54.7) 13 (65.0) 22 (50.0) 0.762\nSigmoid 1 (1.6) 0 (0.0) 1 (2.3)\nRectum + Sigmoid 24 (37.7) 7 (35.0) 17 (38.6)\nRectum + Ileum 2 (3.1) 0 (0.0) 2 (4.5)\nRectum + Ileocecal 2 (3.1) 0 (0.0) 2 (4.5)\nBowel anastomosis\nL-L 5 (7.8) 0 (0.0) 5 (11.4) 0.011\nL–T 10 (15.6) 0 (0.0) 10 (22.7)\nT-T 49 (76.6) 20 (100) 29 (65.9)\nDistance from the anal verge, cm 7 (6–8) 7 (6–7.3) 7 (6–9)\nIleostomy 19 (30.0) 5 (25.0) 14 (31.8) 0.580\nColostomy – – – –\nMSO 9 (14.1) 2 (10.0) 7 (15.9) 0.707\nBSO 6 (9.4) 1 (5.0) 5 (11.4) 0.655\nUreterolysis 48 (75.0) 13 (65.0) 35 (79.5) 0.212\nNeurolysis 8 (12.5) 3 (15.0) 5 (11.4) 0.683\nDuration of intervention (minutes) 348 (77.9) 336.4 (77.7) 353.2 (76.7) 0.426\nDays of hospitalization 6 (6–8) 6 (6–7.3) 6 (6–8) 0.597\nEstimated blood loss, cc/mL 200 (150–300) 250 (187–300) 200 (150–300) 0.244\nOther data\nUreteral resection/reimplantation 3 (4.7) 1 (5.0) 2 (4.5) 0.936\nPartial resection of the bladder 4 (6.2) 2 (10.0) 2 (10.0) 0.583\nPartial vaginal resection 13 (20.3) 5 (25.0) 8 (18.2) 0.523\nConversion to laparotomy – – – –\nTotal hysterectomy 24 (37.5) 6 (30.0) 18 (40.9) 0.403\nPosterolateral parametrectomy 51 (79.7) 18 (90.0) 33 (75.0) 0.166\nAnterior parametrectomy 3 (4.7) 2 (10.0) 1 (2.3) 0.472\n\n2705Archives of Gynecology and Obstetrics (2024) 309:2697–2707 \nWe know that our study’s most significant limitation is \nits retrospective nature and the relatively small sample, but \nthe two groups are comparable from the point of view of \nclinical characteristics and intra-operative findings, which \ncould reduce the initial bias. Nonetheless, our study is the \nfirst to compare the TICA technique with the classic one for \nsegmental bowel resection for DE. Therefore we can argue \nthat the TICA technique is as safe and feasible as the CT in \nterms of post-operative complications, and this technique \ncan thus be considered an alternative to the NOSE, espe-\ncially when opening the vagina is not planned.\nTable 4  Intra- and post-\noperative complications rates \n(N = 64)\nDescriptive statistics are expressed as median and interquartile ranges for quantitative variables, and as \nabsolute and relative percentage frequencies for qualitative variables\nComplications Overall\n(n = 64)\nTICA\n(n = 20)\nCT\n(n = 44)\nP\nIntraoperative complications 2 (3.1) 0 (0.0) 2 (4.5) 0.846\nTransfusion 3 (4.7) 1 (5.0) 2 (4.5) 0.936\nFever 11 (17.2) 3 (15.0) 8 (18.2) 0.754\nSubcutaneous hematoma 1 (1.6) 0 (0.0) 1 (2.3) 0.687\nPelvic abscess 3 (4.7) 1 (5.0) 2 (4.5) 0.936\nUroperitoneum – – – –\nHemoperitoneum 1(1.6) 0 (0.0) 1 (2.3) 0.496\nUrinary tract infections 8 (12.5) 3 (15.00) 5 (11.4) 0.683\nBladder voiding deficit 5 (7.8) 2 (10.0) 3 (6.8) 0.660\nIntestinal anastomosis leakage 1 (1.6) 0 (0.0) 1 (5.0) 0.683\nAnastomosis stenosis – – –\nRectovaginal fistula – – –\nVesicovaginal fistula – – –\nUreteral fistula – – –\nUreteral stenosis – – –\nVesical fistula – – –\nReintervention – – –\nClavienDindo maximum grade 0 (0–2) 0 (0–1) 0 (0–1) 0.119\nDays of catheterization 4 (0–45) 22 (13–45) 2 (0–5) 0.603\nTime from surgery to flatus passage 2 (1–4) 2 (2—3) 2 (2–4) 0.113\nTable 5  Pain VAS scale and \nquestionnaire evaluations before \nintervention and at 6-month \nfollow-up (N = 64)\nVAS: Visual Analog Scale, KESS: Knowles-Eccersley-Scott-Symptom Questionnaire, GIQLI: Gastro-\nIntestinal Quality of Life Index, FU: Follow-up\nDescriptive statistics are expressed as mean and standard deviations or median and interquartile ranges\nP-values were computed using either Student’s t test or the Wilcoxon rank-sum test for paired data\nTICA CT\nBaseline 6-month FU p Baseline 6-month FU p\nVAS\n Dysuria 0 (0–3) 0 (0–0) 0.115 0 (0–0.3) 0 (0–0) 0.067\n Dysmenorrhea 8 (7–8) 0 (0–0)  < 0.001 8 (3.8–9) 0 (0–0)  < 0.001\n Dyspareunia 6 (5–7) 0 (0–2)  < 0.001 5 (0.7–7) 0 (0–1)  < 0.001\n Dyschezia 4 (1–7) 0 (0–0)  < 0.001 3 (0–7) 0 (0–0)  < 0.001\nQuestionnaires\n KESS 18.4 (7.6) 12.1 (7.2) 0.002 19.3 (8.1) 13.0 (7.8)  < 0.001\n GIQLI 50.8 (22.1) 73.8 (20.5) 0.003 60.2 (22.6) 90.5(18.2)  < 0.001\n\n2706 Archives of Gynecology and Obstetrics (2024) 309:2697–2707\nAuthors contributions Conceptualization: Manuel Maria Ianieri; \nMethodology: Manuel Maria Ianieri, Formal analysis and investiga-\ntion: Antonella Carcagnì; Writing—original draft preparation: Manuel \nMaria Ianieri, Piefrancesco Greco, Francesco Santullo; Writing—\nreview and editing: Manuel Maria Ianieri, Federica Campolo; Data \nacquisition -Alessandra De Cicco; Supervision: Giovanni Scambia, \nFabio Pacelli.\nFunding Open access funding provided by Università Cattolica del \nSacro Cuore within the CRUI-CARE Agreement.\nData availability The data that support the findings of this study are \navailable from the corresponding author, upon reasonable request.\nDeclarations \nConflict of interest The authors declare that they have no conflicts of \ninterest and nothing to disclose, and they don’t received any funding \nfor the study.\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article’s Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article’s Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a \ncopy of this licence, visit http://creativecommons.org/licenses/by/4.0/.\nReferences\n 1. Ianieri MM, Raimondo D, Rosati A et al (2022) Impact of nerve-\nsparing posterolateral parametrial excision for deep infiltrating \nendometriosis on postoperative bowel, urinary, and sexual func-\ntion. Int J Gynaecol Obstet 159(1):152–159\n 2. Abo C, Moatassim S, Marty N et al (2018) Postoperative com-\nplications after bowel endometriosis surgery by shaving, disc \nexcision, or segmental resection: a three-arm comparative analysis \nof 364 consecutive cases. 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J Psychosom Obstet Gynaecol 43(3):334–339\nPublisher's Note Springer Nature remains neutral with regard to \njurisdictional claims in published maps and institutional affiliations.","source_license":"CC0","license_restricted":false}