{"paper_id":"d4522f6f-8386-4f69-84fe-618c3f4211f3","body_text":"Ulrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nVolume 8 | Issue 2\nDOI: 10.23937/2377-9004/1410196\nCitation: Ulrich A, Arabkahzaeli M, Dellacerra G, Malcher F, Lerner V (2021) A Multidisciplinary Approach to \nthe Patient with Deep Infiltrating Endometriosis. Obstet Gynecol Cases Rev 8:196. doi.org/10.23937/2377-\n9004/1410196\nAccepted: April 03, 2021: Published: April 05, 2021\nCopyright: © 2021 Ulrich A, et al. This is an open-access article distributed under the terms of the \nCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction \nin any medium, provided the original author and source are credited.\n• Page 1 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nOpen Access\nISSN: 2377-9004\nObstetrics and\nGynaecology Cases - Reviews\nA Multidisciplinary Approach to the Patient with Deep \nInfiltrating Endometriosis\nUlrich, Amanda, MD 1*, Arabkhazaeli, Moona, MD 2, Dellacerra, Gary, DO 3, Malcher, \nFlavio, MD4 and Lerner, Veronica, MD2\n1Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Connecticut \nHealth Center, Connecticut, USA\n2Department of Obstetrics & Gynecology and Womens Health, Albert Einstein College of Medicine/Montefiore Medical \nCenter, New York, USA\n3Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, New York, USA\n4Department of Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, New York, USA\nCAse RepORt\nAbstract\nEndometriosis is a prevalent condition that affects women’s \nhealth-related quality of life worldwide and deep infiltrating \nendometriosis represents a subset of these patients who are \nmost severely affected. Due to the complex nature of deep \ninfiltrating endometriosis (DIE) a preoperative suspicion for \nthe condition allows for coordination of a multidisciplinary \napproach to surgical planning, a key to successful surgical \nresection. We describe three patient cases to highlight the \nimportance of preoperative planning and the added benefit \nof imaging with an MRI protocol specific for DIE that includes \nvaginal and rectal contrast. Additionally, we emphasize the \nimportance of appropriate referral to surgical subspecialists \nto allow for coordination of care during pre-operative plan -\nning to improve outcomes of patients with deep infiltrating \nendometriosis.\nKeywords\nChronic pelvic pain, Deep infiltrating endometriosis, Appro-\npriate imaging evaluation MRI\nAbbreviations\nDIE: Deep infiltrating endometriosis; EBL: Estimated blood \nloss; LEEP: Loop electrode excisional procedure; IUD: Intra-\nuterine device; MRI: Magnetic resonance imaging; UTI: Uri-\nnary tract infection; TVUS: Transvaginal ultrasound; RES: \nRectal endoscopic sonography\nCheck for\nupdates\nIntroduction\nEndometriosis is a prevalent condition that affects \nwomen’s health-related quality of life worldwide. Deep \ninfiltrating endometriosis (DIE) represents a subset of \nthese patients, estimated to affect up to 20% of en-\ndometriosis patients [1]. DIE is defined as lesions pen-\netrating at least 5 mm deep to the peritoneal surface \nand could have genital or extragenital manifestations, \nincluding involvement of the uterosacral ligaments, the \nrectosigmoid colon, the vagina, the bladder, and the \nsmall and large bowel [2, 3]. In advanced cases, large \nfull-thickness lesions need to be resected from the va-\ngina, bowel, bladder and ureters, resulting in extensive \nsurgeries. For this reason, it can have a profound clinical \nimpact and diagnosis and treatment can be challenging. \nWhile patient symptoms and anatomic sites of DIE do \ncorrelate, physical exam has limited value in assessing \nthe extent of the disease which frequently requires im-\naging by ultrasound or MRI, as well as multidisciplinary \nconsultations [4]. The complex nature of DIE mandates \ntaking preoperative suspicion seriously in surgical plan -\nning and patient counseling [5,6].\nBeyond a thorough pelvic examination, imaging is \nthe modality to fully assess the extent of disease in or-\n*Corresponding author:  Ulrich, Amanda, MD, Division of Minimally Invasive Gynecologic Surgery, Department of \nObstetrics and Gynecology, University of Connecticut Health Center, Connecticut, USA\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410196\n• Page 2 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nlaparoscopic resection of endometriosis seven years \nprior, with operative report describing stage 4 endome-\ntriosis and significant bowel adhesions. Moreover, she \nwas noted to have biopsy proven endometriosis adja -\ncent to and possibly involving the rectal lesion which \nwas not resected as it was not anticipated pre-opera-\ntively and as a result, surgical back up for a colorectal \nsurgeon was not arranged. Her symptoms transiently \nimproved after her first surgery but returned several \nyears later and were not responsive to medical manage-\nment with combined oral contraceptives. Limited exam \nin the office due discomfort demonstrated a 14-week \nglobular uterus adherent to the anterior abdominal wall \nwith no other significant findings. Pre-operative MRI \nwith intravenous contrast demonstrated bilateral en-\ndometriomas as well as T1-hyperintense implants along \nthe surface of the uterus, cervix, and posterior to the \nbladder (Figure 1).\nThe MRI did not show evidence of intestinal endo -\nmetriosis, nor did a subsequent colonoscopy when per-\nformed pre-operatively. Despite this negative gastro-\nintestinal work up, given the patient’s complaints and \nthe report of possible bowel involvement in her last \nsurgery, an outpatient general surgical consultation was \nobtained, and patient was consented for possible recto-\nsigmoid resection. Finally, pre-operative cystoscopy was \nperformed due to persistent urinary complaints, which \nwas negative for evidence of endometriosis. The patient \nwas extensively counseled, and the plan was made to \nperform robotic assisted total laparoscopic hysterecto -\nmy with bilateral salpingo-oophorectomy and resection \nof endometriosis.\nExam under anesthesia demonstrated a fixed rectum \nand uterosacral ligaments. Digital rectal exam was no -\ntable for a palpable 2-centimeter lesion on the upper \nrectum. Inspection of the vagina identified a 2-centime-\nter nodule in the posterior fornix and a 1 cm anterior \nvaginal wall nodule halfway between the introitus and \napex. Intraoperatively, presence of bilateral endometri-\nder to prepare for surgical resection. Sensitivity of ultra-\nsound in detecting DIE with bowel preparation is esti-\nmated to be 75-98% [5], however, it is operator depen-\ndent and in practices where adequate expertise is not \navailable, detection rates might be lower. The role of \nMRI is evolving and can be helpful in cases where there \nis a clinical suspicion of involvement of extragenital or-\ngans [7]. Bazot, et al. compared imaging modalities for \nDIE and concluded that MRI performs similarly to rectal \nendoscopic sonography (RES) for the diagnosis of intes-\ntinal endometriosis, however has higher sensitivity for \nuterosacral ligament and vaginal endometriosis. The \nsensitivity of MRI was 84.8% vs. RES 45.6% for detect -\ning uterosacral endometriosis, MRI 77.7% vs. RES 7.4% \nfor detecting vaginal endometriosis, and MRI 88.3% \nand RES 90% for detecting colorectal endometriosis [8]. \nMRI is often used for imaging because it is not operator \ndependent like TVUS, it can pick up peritoneal disease \nwhich ultrasound misses, and it helps to determine if \nvisceral involvement, importantly gastrointestinal or \ngenitourinary, is noted. If identified, appropriate refer -\nral to specialists can be initiated to assure that surgeons \nfrom different specialties are present during surgery, so \nthat all resectable disease is removed to avoid the need \nfor subsequent and repeated surgeries and to improve \nthe patient’s quality of life. Given the complex nature \nof DIE, optimizing outcomes requires extensive preop-\nerative planning and multidisciplinary coordination. In \nthis manuscript, we present the cases of three patients \nwith DIE, to demonstrate the importance of preopera -\ntive diagnosis, preoperative planning, and involvement \nof a multidisciplinary team of surgeons.\nCase Description\nCase 1\nThe patient is a 35-year-old G2P0 with chronic pelvic \npain, failed IVF cycles, and biopsy-proven endometriosis \nfrom her prior laparoscopy who presented with wors-\nening pelvic pain and dyschezia. Patient had undergone \n          \nFigure 1(A,B,C): Axial, sagittal, and coronal T2-weighted MR images demonstrate an enlarged uterus with a markedly thickened \njunctional zone and subcentimeter T2 hyperintense foci throughout the myometrium; findings consistent with adenomyosis. \nEvaluation of the rectouterine space demonstrates infiltrative T2 hypointense signal abnormality which is inseparable from the \nanterior rectum, representing DIE with rectal involvement (yellow arrows).\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410196\n• Page 3 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nthe vagina and the rectosigmoid. The biopsy of the small \nbowel, also was positive for endometriosis. The appen -\ndix contained subserosal fibrosis with hemosiderin-lad -\nen macrophages but no overt endometrial glands and \nstroma was reported. In light of the bowel involvement \nthat was not described on imaging preoperatively, the \nMRI images was re-reviewed with radiology, and rectal \ninvolvement was retrospectively appreciated (Figure 2).\nCase 2\n41-year-old G4P0040 with a 15-year history of chron-\nic pelvic pain with symptoms of dysmenorrhea, dysche-\nzia, constipation, dysuria, and abnormal uterine bleed-\ning failed previous management with hormonal sup -\npression. Her history was significant for irritable bowel \nsyndrome, depression, alcoholism, and a prior laparo -\nscopic excision of endometriosis and appendectomy. \nGiven her bladder and bowel symptoms, pre-operative-\nly the patient was seen by both urology and general sur-\ngery. Colonoscopy noted a 3-centimeter non-obstruct -\ning lesion protruding into but not all the way through \nmucosa with negative mucosal biopsies. Pre-operative \ncystoscopy was negative.\nOn exam in the office, she was noted to have a 10-\nweek sized uterus with mobility limited by posterior cul-\nde-sac lesion with a 2-centimeter posterior fornix lesion \ntethered to a rectal lesion. The MRI, which this time was \nperformed with intravenous, oral, rectal, and vaginal \ncontrast, reported deep pelvic endometriosis with mass \nlike T2-hypointense process in the rectovaginal septum, \nwith gross invasion into the anterior rectal wall. The \nendometrial mass appeared to invade full thickness of \nthe rectal wall, extending into the rectal lumen (Figure 3 \nand Figure 4). MRI also demonstrated adenomyosis and \nthickening of the right fallopian tube and right proximal \nround ligament.\nPre-operatively, both general surgery and gynecol-\nogy surgeons had extensive discussions with the pa-\nomas was confirmed (10 centimeters on the left and 3 \ncentimeters on the right). A “frozen pelvis” was noted \nwith dense pelvic adhesions and an obliterated posteri-\nor cul-de-sac. Finally, nodules typical for DIE were seen \non the rectosigmoid, correlating with exam, as well as \non the terminal ileum, and the appendix.\nExtensive dissection was performed as follows: the \nretroperitoneum was entered bilaterally via lateral \napproach to the sidewalls, pararectal spaces were de-\nveloped, and bilateral ureterolysis performed. Lysis of \nadhesions of the uterus and adnexa was performed to \nmobilize the uterus and adnexa and to separate it from \nthe sidewall and vital structures. Extensive fibrosis was \nnoted, making it difficult to identify individual peritone-\nal implants. At the conclusion of the hysterectomy, an \nupper partial vaginectomy was performed to remove \nvaginal endometriosis lesions seen on exam. Next, ap-\npendectomy as well as a discoid resection of the rec -\ntosigmoid lesion, located at approximately 11 cm from \nanal verge, were performed by the general surgeon. An \nanterior and lateral mobilization of the rectum was per-\nformed and superficial lesions of the mesorectum were \nexcised. A few small fibrotic areas were noted on the \ncolon and terminal ileum and biopsies were performed. \nA nerve-sparing approach was taken throughout the \nabove dissection with identification of the hypogastric \nplexus.\nTotal surgical time for the surgery was 461 minutes. \nEstimated blood loss (EBL) was 500 milliliters. Post-op -\nerative course was complicated by acute blood loss ane-\nmia for which the patient received 3 units of packed red \nblood cells with subsequent stabilization of hematocrit. \nPost-operative course otherwise uneventful and after \nthe patient was discharged home on postoperative day \n2. Patient did well clinically and was pain free at her \n6-week post-operative visit.\nPathology review of specimens confirmed the pres-\nence of endometriosis within the resected portions of \n          \n \nFigure 2(A,B,C): Axial and sagittal fat-suppressed, T1-weighted MR images demonstrate bilateral T1 hyperintense ovarian \nmasses consistent with endometriomas (blue arrows). The sagittal images show numerous sub-centimeter T1 hyperintense \nfoci along the periphery of the uterus, representing endometrial implants (yellow arrows). Some of these foci are noted along \nthe serosa of the rectum in the location of DIE identified on the T2 images (orange arrow).\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410196\n• Page 4 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nPost-operative course was complicated by post-op -\nerative urinary retention, presumably secondary to dis -\nruption of the parasympathetic plexus during the deep \nendometriosis resection for which she required inter-\nmittent catheterization with timed voids.\nCase 3\nCase 3 is a 33-year-old G1P1001 with past history \nsignificant for a cesarean section, LEEP, history of chla -\nmydia, and CopperT IUD in place. She had presented \nas a referral from urology for chronic pelvic pain and \nan endometriosis bladder lesion that was seen on out -\npatient cystoscopy. The plan was for a combined pro-\ncedure. The patient complained of dysmenorrhea and \nchronic pelvic pain with urinary symptoms; bladder irri-\ntation, dysuria, urinary frequency, and frequent urgent \nvisits for UTI symptoms with negative urine cultures. \nHer chronic pelvic pain was cyclical. Exam in the office \nwas unremarkable. Pre-operative office cystoscopy \ndemonstrated no stones or diverticula but identified a \nblue hue endometrial nodule covered with bladder mu-\ncosa pushing into the bladder posteriorly in the midline. \nBilateral ureteral orifices visualized with clear efflux of \ntient regarding etiology, treatment options and surgi-\ncal options. She did not desire childbearing but desired \novarian conservation to avoid premature menopause. \nShe then underwent a robotically-assisted total laparo -\nscopic hysterectomy, bilateral salpingectomy, cystosco-\npy, bilateral ureterolysis, lysis of adhesions, segmental \nrectosigmoidectomy and anastomosis, partial vaginec-\ntomy, and flexible sigmoidoscopy. EBL for the case was \n500 cc. Findings at the time of surgery were notable for \na 2-centimeter mid-upper vaginal posterior fornix nod -\nule with blue-brown hue consistent with transmural \nvaginal endometriosis nodule, 12-week sized globular \nuterus consistent with adenomyosis, normal adnexa \nbilaterally, DIE endometriosis lesions limited to recto -\nsigmoid (5 × 3 centimeters), upper vagina (3 × 3 centi-\nmeters), bilateral uterosacral ligaments, 10 centimeters \nin aggregate, not noted in other areas. Dense adhesions \nand obliterated posterior cul-de-sac were noted in the \npelvis. At conclusion of the procedure, all grossly visible \nendometriosis had been completely resected. Patholo -\ngy was consistent with endometriosis in all specimens \nobserved during surgery and the uterus was consistent \nwith adenomyosis and leiomyomata.\n          \n \nFigure 3(A,B,C): Axial and sagittal T2-weighted MR images show a large mass of intermediate signal intensity involving the \nupper rectovaginal septum and invading the rectum (arrows). Hypointense spiculation within the surrounding fat corresponds \nto fibrotic reaction. Of note, the rectum and vagina are distended with gel per exam protocol.\n          \n \nFigure 4(A,B): Axial and sagittal fat-suppressed, T1-weighted MR images demonstrate scattered T1 hyperintense foci within \nthe pelvis, including within the rectal mass (orange arrows); findings are consistent with DIE.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410196\n• Page 5 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nno vaginal involvement. The bladder defect was closed \nand confirmed to be water-tight, right ureteral stent \nwas removed but the left ureteral stent was left in place \ndue to its proximity to the suture line. Final pelvic and \nabdominal survey confirmed little to no residual disease \nwith adequate hemostasis and an EBL 150 cc (Figure \n7). Post-operative course was complicated by a urinary \ntract infection which responded to antibiotics. Patholo-\ngy confirmed histologic evidence of endometriosis in all \nexcised tissue. Two weeks post-operative, the patient \nhad normal CT cystogram and office cystoscopy and the \nleft ureteral stent was removed without difficulty.\nConclusions\nThese three cases highlight the importance of exten-\nsive preoperative planning by a multidisciplinary surgi-\ncal team to achieve optimal surgical resection of DIE. \nEach case demonstrates the value of appropriate pre-\noperative imaging, subspecialty consultation, coordina-\ntion of care, and an individualized comprehensive work \nup including colonoscopy or cystoscopy.\nWhile transvaginal ultrasound, cystoscopy, and rec -\ntosigmoidoscopy, have been studied and used for the \npreoperative evaluation of symptomatic endometriosis, \nMRI may provide an added benefit of mapping deep le-\nurine. MRI urogram was done in order to delineate col -\nlecting system due to concern with potential ureteral \ninvolvement and/or obstruction, which demonstrated \na small bilateral T1 markedly hyperintense ovarian cys-\ntic structures suspicious for endometriomas and small \nfilling of the bladder posteriorly with contrast without \ngross visible defect (Figure 5 and Figure 6). Based on \nthe patient’s clinical picture a combined procedure was \nplanned with urology. She wanted to preserve her fer -\ntility for future childbearing. On exam under anesthesia, \na small mobile retroverted uterus with bilateral adnexal \nfullness was noted with no rectovaginal nodules. Cop -\nper T IUD was removed and replaced by Levonorgestrel \nIUD to reduce recurrence of endometriosis. After cys-\ntoscopy with bilateral ureteral stent insertion, roboti -\ncally-assisted laparoscopy was performed with lysis of \nadhesions, resection of endometriosis and left ovarian \ncystectomy, for a 1.5-centimeter ovarian endometrio-\nma. The urology team resected a transmural 3 × 3-cen-\ntimeter bladder DIE lesion with adequate margins and \n         \n \nFigure 5(A,B): Coronal T2-weighted images reveal focal soft tissue thickening of the posterior bladder dome, just to the left \nof midline, with a T2 hyperintense cystic focus (blue arrow) and adjacent infiltrative T2 hypointense signal abnormality within \nthe vesico uterine space (orange arrow).\n          \nFigure 6: Coronal fat-suppressed, T1-weighted MR image \ndemonstrates small bilateral T1 hyperintense ovarian \nmasses consistent with endometriomas (blue arrows). T1 \nhyperintense foci are also identified within the posterior \nbladder dome (orange arrow). Findings represent DIE \ninvolving the urinary bladder.\n         \n \nFigure 7: Finding of bladder endometriosis on cystoscopy.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410196\n• Page 6 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\ntosigmoid lesion was smaller and therefore amenable \nto a discoid resection. A collaborative relationship with \njoint meetings to review patient cases was created with \ngeneral surgery, radiology, and minimally invasive gyne-\ncology to improve patient care. As a result, recognition \nin the community was established and increased refer -\nrals were seen, giving us reassurance that patients have \nbetter access to comprehensive surgical teams and are \navoiding incomplete surgical debulking’s.\nThese three cases highlight the importance of thor-\nough preoperative planning and the added benefit of \nMRI in preoperative planning with a protocol that in -\ncludes vaginal and rectal contrast. In addition, we em -\nphasize the importance of referral to subspeciality sur-\ngeons to allow for coordination of a multidisciplinary \napproach to surgical planning to improve treatment and \noutcomes of patients with deep infiltrating endometrio-\nsis. Finally, patients with deep infiltrating endometriosis \nwould benefit from a center with multispecialty provid-\ners that can work in conjunction to coordinate patient \ncare and surgical planning.\nFinancial Disclosures\nThe authors did not report any potential conflicts of \ninterest.\nEach author has confirmed compliance with the \njournal’s requirements for authorship.\nFunding\nThis work was completed without any external \nsource of funding.\nStatement of Equal Authors’ Contribution\nWe acknowledge that all the authors have contribut-\ned to this paper.\nReferences\n1. Koninckx PR, Martin D (1994) Treatment of deeply infiltrat-\ning endometriosis. Curr Opin Obstet Gynecol 6: 231-241.\n2. Graham A, Chen S, Skancke M, Moawad G, Obias V \n(2019) A review of deep infiltrative colorectal endometriosis \ntreated robotically at a single institution. Int J Med Robot \n15: e2001.\n3. Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR \n(1990) Deeply infiltrating pelvic endometriosis: Histology \nand clinical significance. Fertil Steril 53: 978-983.\n4. Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, et al. \n(2004) Deep pelvic endometriosis: MR imaging for diagno -\nsis and prediction of extension of disease. Radiology 232: \n379-389.\n5. Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, et \nal. (2015) Deep endometriosis infiltrating the recto-sigmoid: \nCritical factors to consider before management. Hum Re-\nprod Update 21: 329-339.\n6. Piessens S, Edwards A (2020) Sonographic evaluation for \nendometriosis in routine pelvic ultrasound. J Minim Invasive \nGynecol 27: 265-266.\n7. Hsu AL, Khachikyan I, Stratton P (2010) Invasive and non-\nsions with greater accuracy than other modalities [9]. \nBazot, et al. demonstrated that MRI had a sensitivity \nof 90.3% and NPV of 89% for DIE which appeared as a \nhyperintense foci and/or hypointense areas on T1- and \nT2-weighted MR images, respectively. Similarly, Hottat, \net al. reported a sensitivity of 96.3% and NPV of 93.3% \n[4,9,10]. The use of T1 and T2 weight sequences in \nmapping lesions has become an integral step in surgi-\ncal planning for DIE as was demonstrated in the above \ncases. More importantly, the cases above support the \nutility of adding vaginal and rectal contrast to the pro-\ntocol for MRI when evaluating for DIE. Chasong, et al. \ndemonstrated that opacification of the vagina and rec -\ntum with ultrasound gel improved the sensitivity of MRI \nfor the detection of DIE and allowed for improved visu -\nalization and delineation of the vagina and rectovaginal \nseptum, allowing for better delineation of the pelvic or-\ngans [11]. Endometriotic lesions have an MRI signal in -\ntensity similar to their surrounding fibromuscular struc-\ntures, since they are fibromuscular structures. Vaginal \nand rectal distension and opacification with ultrasound \ngel can help to delineate the cervix, vaginal fornices, \nvaginal wall, rectum, and rectosigmoid colon junction \n[12]. Endelarae, et al. was also in favor of using vaginal \nand rectal distension to detect and localize, with better \naccuracy, endometriotic lesions, and to identify condi -\ntions either developing inside the lumen of cavities or \ncoming from the outside [13]. For our case 1, DIE dis -\ncovered intra-op was not seen pre-operatively by MRI \nmost likely because of the lack of vaginal and rectal con-\ntrast when obtaining this MRI. After this case the vag -\ninal and rectal contrast was added to the protocol. In \ncase 2, where vaginal and rectal contrast was used for \nthe MRI protocol, DIE was seen involving the rectovagi -\nnal septum, with gross invasion into the anterior rectal \nwall. This allowed for preoperative planning with gener-\nal surgery and plan for segmental rectosigmoidectomy \nand anastomosis. These cases prompted the develop-\nment of a collaborative relationship with radiology and \nthe establishment of formalized reporting system and \nendometriosis-specific MRI protocol when evaluating \nfor DIE, allowing clinicians to order correct studies and \nfor radiologists to report their findings in a standardized \nfashion. The inclusion of a radiologist that specializes in \nMRI is crucial to the multidisciplinary team approach.\nWhen approaching bowel endometriosis, Abrao, \net al. describes several considerations critical to surgi-\ncal planning: The number of DIE lesions, multifocality, \nlesion size (with lesions over 3 centimeters typically \nrequiring a segmental resection while smaller lesions \nare often amenable to discoid resections), the extent \nof bowel surface involvement, and lesion depth [14]. \nIn case 2, the general surgery team identified a great -\ner then 5 centimeters lesion on the upper and medial \nrectum. Given its size, the lesion was not amenable to \nshaving or a discoid resection, but rather demanded a \nsegmental resection. In comparison, in case 1 the rec -\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410196\n• Page 7 of 7 •\nUlrich et al. Obstet Gynecol Cases Rev 2021, 8:196\nToullalan O, et al. 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(2007) Accuracy of magnetic resonance imaging and \nrectal endoscopic sonography for the prediction of location \nof deep pelvic endometriosis. Hum Reprod 22: 1457-1463.\n9. Ito TE, Abi Khalil ED, Taffel M, Moawad GN (2017) Magnet-\nic resonance imaging correlation to intraoperative findings \nof deeply infiltrative endometriosis. Fertil Steril 107: e11-e2.\n10. Hottat N, Larrousse C, Anaf V, Noel JC, Matos C, et al. \n(2009) Endometriosis: contribution of 3.0-T pelvic MR im-\naging in preoperative assessment--initial results. Radiology \n253: 126-134.\n11. Chassang M, Novellas S, Bloch-Marcotte C, Delotte J,","source_license":"CC0","license_restricted":false}