Surgical Therapy of Endometriosis: Challenges and Controversies

! Endometriosis is one of the most common gynae- cological disorders but also one of the greatest challenges facing gynaecological surgeons [1]. A guideline-oriented approach [2], extensive expe- rience of surgical techniques and interdisciplinary cooperation [3] are the prerequisites for success- ful treatment. A detailed history of individual symptoms, ade- quate diagnostics and special surgical skills are in- dispensable for diagnosing endometriosis and for preoperative planning and surgery [4]. It is also important that the surgeon and patient take the time to consider the “difficult”, in some instances, controversial, and potentially risky aspects of pos- sible surgical interventions. Factors to consider include individual risks, such as the risk of recurrence, as well as factors intrin- sic to the disease and the risks associated with the surgical technique. This paper discusses several such combinations which deserve particular con- sideration due to their prevalence and potentially serious consequences.

! Endometriosis is one of the most common disor- ders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgi- cal intervention, the extent of information pro- vided to patients and the interdisciplinary coordi- nation make it a challenging intervention. Com- plete resection of all visible foci of disease offers the best control of symptoms. However, the possi- bility of achieving this goal is limited by the diffi- culty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a signifi- cant impairment of ovarian function, while dam- age to nerve structures during resection of the uterosacral ligaments, the parametrium, the rec- tovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore neces- sary, and patients must be treated using an indi- vidual approach. Zusammenfassung ! Die Endometriose gehört zu den häufigsten Krankheitsbildern in der operativen Gynäkologie mit erheblichen Herausforderungen an die lapa- roskopische Technik, aber auch die OP-Planung, Patientinnenaufklärung und Interdisziplinarität. Ziel im Hinblick auf eine bestmögliche Symptom- kontrolle ist die vollständige Entfernung der er- kennbaren Krankheitsherde, die aber limitiert wird durch nachweisliche Grenzen der Detektier- barkeit und die Risiken radikaler Operationsstra- tegien. So kann die Exzision ovarieller Endome- triome zu einer signifikanten Beeinträchtigung der Ovarialfunktion, die Läsion nervaler Struktu- ren bei der Resektion tief-infiltrierender Endo- metriose der Sakrouterinligamente, der Parame- trien, des Septum rectovaginale und des Vaginal- pols zu schwerwiegenden Funtionsbeeinträchti- gungen wie Blasenentleerungsstörungen führen. Eine gründliche Nutzen-Risiko-Abwägung muss daher symptomorientiert erfolgen und in einem individualisierten Vorgehen resultieren. Surgical Therapy of Endometriosis: Challenges and Controversies Herausforderungen und Kontroversen bei der operativen Therapie der Endometriose Authors S. Rimbach 1, U. Ulrich 2, K. W. Schweppe 3 Affiliations 1 Gynäkologie und Geburtshilfe, Landeskrankenhaus Feldkirch, Feldkirch, Austria 2 Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin 3 Endometriose-Zentrum Ammerland, Westerstede Key words l" reproductive medicine l" dyspareunia l" endometriosis l" gynaecology l" infertility l" ovary Schlüsselwörter l" Reproduktionsmedizin l" Dyspareunie l" Endometriose l" Gynäkologie l" Infertilität l" Ovar received 4. 8. 2013 revised 4. 9. 2013 accepted 4. 9. 2013

DOI http://dx.doi.org/ 10.1055/s-0033-1350890 Geburtsh Frauenheilk 2013; 73: 918–923 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0016‑5751 Correspondence Priv.-Doz. Dr. Stefan Rimbach Landeskrankenhaus Feldkirch Gynäkologie und Geburtshilfe Carinagasse 47 6800 Feldkirch Österreich [email protected] 918 Rimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923 GebFra Science Extent of Surgery and Dealing with Unexpected Findings ! Both from the surgeon ʼs and the patient ʼs point of view, the ex- tent of the actual manifestation of disease and the associated ex- tent of the planned surgery are the most important preoperative considerations, but these are also the factors which are most dif- ficult to assess preoperatively. Frequently, the extent of surgery will only become clear intraoperatively. The lines of resection are primarily determined by the extent of disease spread. The goal of surgery is complete resection, which can include resection of parts of the intestine and involve the ureters and bladder [5 –11]. In addition to the necessary surgical experience, a good interdis- ciplinary cooperation and close involvement of the patient are important during the planning stage. Despite adequate diagnos- tics, it may be necessary to broaden the scope of the primary in- tervention. This may also be unexpectedly necessary during sur- gery, for example, if there is intestinal involvement beyond the rectovaginal septum or non-obstructive involvement of the ure- ter (l " Fig. 1 a and b). This not untypical constellation represents a considerable chal- lenge as regards the information routinely provided to the pa- tient preoperatively and for surgical logistics. The problem is commonly tackled using one of two approaches: either a flexible surgical strategy with the patient given a maximum of informa- tion about all eventualities or a two-stage approach compatible with the disease constellation. It is important in every individual case to weigh up the psychological burden for the patient which may be affected by the amount of information given (which may be far too extensive) and, depending on the structure of the hos- pital department, the possibly unnecessary allocation of operat- ing room capacity and interdisciplinary personnel resources against the disadvantages of a second operation. In each case, clear positioning during preoperative planning is recommended to guard against surprises. In addition to the extent of endometriosis, secondary factors such as the presence of adhesions or, in the case of the retroperitoneal space, the presence of fibrotic lesions also have a significant im- pact on surgery. These factors can change the anatomy to such an extent that extensive dissection is necessary for reconstruction. Intestinal adhesiolysis and extensive ureterolysis may be re- quired to reach the endometriotic lesion and to avoid iatrogenic injury to structures close to the margins of the endometriotic le- sion. At the same time, dissection is also associated with an in- trinsic risk of injury. Injuries are by no means rare; in fact, they are fairly common, particularly when treating deep infiltrating endometriosis, and require awareness and appropriate discussion preoperatively. Limits of Detectability of Endometriotic Lesions and Differentiation from Healthy Tissue ! The detection and differentiation of endometriotic lesions from healthy tissue is a challenge ( l" Fig. 2), particularly in cases of re- currence. Out of a total of 39 patients with persistence of complaints after excision or ablation of histologically verified endometriosis, re- peat laparoscopy found peritoneal recurrence in 37 %. Recurrence occurred significantly more frequently in previously operated (RR 2.54; 95 % confidence interval [CI]: 1.63 –3.97) or immediate- ly adjacent (RR 1.29; 95 % CI: 0.84 –2.0) areas compared to areas distant to the original localisation, which supports the hypothesis that primary resection was probably incomplete [12]. The reason for this could be that endometriotic lesions in the peritoneum can extend far beyond the visible foci, as has been shown in ex- aminations using scanning electron microscopy [13]. The pres- ence of residual foci of endometriosis in a number of patients could also explain the success of a combined approach using sur- gery and hormone therapy. This interpretation is supported by the results of a prospective randomised study in 450 patients which compared outcomes after surgery, hormone therapy or combined surgery and hormone therapy. The combined ap- proach had significantly better results, with a 60 % success rate as measured by the clinical parameters “dysmenorrhea” and “dyspareunia” and findings at second-look laparoscopy, com- Fig. 1 a and ba Involvement of the left ureter in a case with rectosigmoid endometriosis. b After ureterolysis and rectosigmoid resection. Fig. 2 Peritoneal endometriosis with unclear extent and spread: red le- sions with typical vascular patterns next to fibrotic peritoneal defects. 919 Rimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923 DGGG Review pared to rates of 55 % for exclusively hormone therapy and 50 % for exclusively surgical treatment [14]. Radical Dissection: Opportunities and Risks ! Peritoneal endometriosis Exclusively endocrine therapy has been shown to have results comparable to the outcomes after surgery, at least for peritoneal endometriosis. Given the existing uncertainty about detecting the extent of endometriotic lesions and the potential use of ex- clusively endocrine therapy as an alternative to surgery [15, 16], it is important in individual cases to weigh the extent of the po- tential excision against the risk of overtreatment. Ovarian endometriosis After peritoneal endometriosis, the ovaries are the second most common site for endometriosis. But although surgery to treat ovarian endometriomas is assumed to be a routine procedure, it involves particular challenges for the surgeon. As the reported rate of recurrence ranges from 9.6 –45.5 % [17, 18], the surgeon must weigh the necessity for adequate excision against the potential iatrogenic decrease in ovarian reserve. Anal- ysis of anti-Müllerian hormone (AMH) levels showed that sur- gery for ovarian endometriosis was associated with a significant decrease in AMH concentrations [19 –21]. AMH levels decreased by 24 % after unilateral surgery and by up to 67 % after bilateral surgery [22, 23]. Meticulous dissection to expose the correct cleavage plane (l " Fig. 3) by an experienced surgeon taking special care to pre- serve the ovarian hilum is recommended as the optimal surgical technique [24–26]. The benefits of excision as opposed to electro- surgical ablation have been demonstrated and confirmed in an extensive meta-analysis [27 –29]. The analysis by Dan and Limin [29] compared the data of seven studies and found that, com- pared to ablation, excision was associated with a significantly re- duced risk of symptom recurrence (RR 0.29; 95 % CI: 0.15 –0.55; p < 0.001) and a significantly reduced rate of recurrence (RR 0.50; 95 % CI: 0.26–0.97; p = 0.04). Recurrence rates after excision were also lower compared to laser vaporisation (RR 0.33; 95 % CI: 0.12–0.88; p = 0.03). The achieved pregnancy rates after excision were also significantly better compared to electrosurgical coagu- lation (RR: 2.64; 95 % CI: 1.49 –4.69; p < 0.001), but not compared to laser vaporisation (RR: 0.92; 95 % CI: 0.30 –2.80; p = 0.89). Data on ovarian reserve was not analysed in this meta-analysis. One study postulated that impairment of ovarian function could be prevented by replacing bipolar coagulation with a haemostatic suture [30], but this could not be confirmed in a prospective ran- domised study; instead, it was found that AMH levels decreased, irrespective of the technique used [31]. The indication for surgery requires the potential benefits of bet- ter pain management or better access to growing follicles in IVF, which would otherwise be obscured by endometrioma, to be weighed against a potentially significant impairment of ovarian reserve [32]. It is, of course, obvious that unclear ovarian masses need to be identified histologically. Deep infiltrating endometriosis The indication for surgery for deep infiltrating endometriosis is usually severe pain. Complete excision may require expanding the procedure to include the vagina, intestines and ureters, but complete surgery has been shown to control symptoms and re- duce the rate of recurrence [7, 33–35]. The majority of procedures can be carried successfully using laparoscopy; the rate of conver- sion to laparotomy is between 1.6 and 12 % [36 –38]. In addition to the demanding surgical technique which requires a high degree of specialisation, other major challenges are plan- ning and correctly determining the extent of surgery. A risk-ben- efit analysis weighing the benefits of pathological and anatomical radicality against benefits and risks of more limited procedures may be necessary. The question whether limited surgery could potentially not increase the rate of recurrence if the remnants left in situ in the intestine or vagina were asymptomatic preopera- tively is still discussed controversially [39], but can obviously not always be estimated properly. For specialised centres, the reported complication rates in the immediate postoperative period are 2 –4 % [8, 9], the overall rate of serious complications is 7 –9 % [36–38, 44] and the rate of re- currence is 8 –13 % [38, 40–42]. In view of the complexity of the intervention, these rates appear to be within “acceptable” ranges. However, the potentially serious nature of early and late compli- cations and unwanted side-effects and outcomes may make the final result after surgery almost insupportable for individual pa- tients. Factors which need to be taken into account range from the gen- eral risks which depend on the extent of the intervention to the specific risks of surgery for endometriosis. General risks can be irrespective of the diagnosis of endometrio- sis. For example, observational studies have reported a causal as- sociation between lengthy surgical procedures with the patient in the lithotomy position and serious lower limb compartment syndrome [43, 44]. Colorectal surgery is a common endometriosis-specific risk. In one case series, revision surgery after segmental resection was required in the first week after primary surgery in 4.1 % of cases [9]. Anastomotic insufficiency was reported in 0.7 –3 % of cases [36, 45]. A protective ileostomy is done in 3 –14.5 % of cases. One study re- ported the regular creation of a protective ileostomy during sur- gery in 95.2 % of cases [36, 38, 45, 46]. From a surgical point of view, this is not a complication but a necessary measure to avoid complications, but for a young woman with endometriosis this frequently constitutes a barrier against intervention when taking the decision to undergo surgery. Another study reported late functional impairments which took the form of either severe constipation or pathologically increased frequency of daily stools in 52 % of patients who had segmental Fig. 3 Meticulous dissection to expose the cleavage plane in right-sided ovarian endometriosis. 920 Rimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923 GebFra Science resection, and in 19 % of patients who had nodule resection [47]. When surgery is adapted intraoperatively, the goal is to reduce the radicality of the procedure as far as possible. Less radical sur- gical techniques include the so-called shaving technique to pre- serve the intestinal wall [42] and discoid resection instead of seg- mental resection to preserve bowel continuity [48, 49]. Unfortu- nately there are no comparative prospective studies for these techniques. But adequate complete resection of the endometri- otic nodule must be ensured, as otherwise there is an increased risk of recurrence. In the study of Brouwer and Woods, the recur- rence rates of 2.19 % after segmental rectal resection and 5.17 % after full-thickness excision of the anterior rectal wall rose signif- icantly to 22.2 % after what was probably incomplete dissection off the rectal wall [45]. Another study reported severe urological complications such as hydronephrosis in 4.8 %, urinary fistulas in 3 % and bladder void- ing dysfunction in 28.9 % after colorectal resection with partial colpectomy [50]. Voiding dysfunction rates after resection are reported to be 15 – 30 %, but voiding dysfunction is likely to affect the majority of all patients in a mild and transient form after complex resection of deep infiltrating endometriosis and can even result in a perma- nent need for self-catheterisation. The cause of voiding dysfunc- tion is autonomic nerve damage, particularly iatrogenic injury to the inferior hypogastric plexus at the proximal portion of the uterosacral ligament during resection of the uterosacral liga- ments, of the parametrium, the deep rectum and the vaginal cuff [51–53] (l " Fig. 4 a und b). Postoperative rates of urinary dysfunc- tion could be reduced if nerve structures are identified and spared intraoperatively [54, 55]. If hydronephrosis is present, ureteral involvement must always be considered; however, ureteral involvement may be silent and completely asymptomatic [56]. In one study of patients with ret- rocervical endometriosis in the vicinity of the uterosacral liga- ments, ureteral involvement was present in 17.9 % of cases with nodules ≥ 3 cm compared to 1.6 % of cases with nodules < 3 cm [57]. Ureterolysis was reported to be successful in the majority of cases (53.8–73.3 %) [56, 58, 59], but complication rates were be- tween 23 and 31.4 % [58, 59]. Special Situations: Adolescence and Recurrence ! Both situations, although completely dissimilar, confront the sur- geon with the same necessity to weigh the benefits against the risks of an invasive or repeat invasive procedure. In adolescence, qualms about the invasiveness of laparoscopy may result in a delay in diagnosis of several years [60]. Further systematic reviews will be necessary to confirm the data of one study which reported the prevalence of endometriosis to be 70 – 75 % in girls with therapy-resistant, chronic, pelvic pain and dys- menorrhea [61]. The limited data available on treatment out- comes is controversial. One study came to the conclusion, based on the data for re-interventions, that early laparoscopic excision had the potential to eradicate disease [62]. Another study of 57 women ≤ 21 years who underwent laparoscopy for endometrio- sis reported an unusually high rate of 56 % of patients suspicious for recurrence and a constant increase in recurrence rates over the 5-year follow-up period and concluded, based on these data, that early surgical intervention was associated with a particularly high risk of recurrence [63]. Caution is advised with regard to re-operations of patients with symptomatic recurrence, particularly patients who have had re- petitive surgical interventions for endometriosis. The cumulative probability for further surgical interventions was found to be at least 15 –20 %, although the authors of the study surmised that publication bias meant that these data were probably an under- estimate [64]. Re-operation for recurrence and pelvic pain was as efficacious as primary surgery and had comparable limitations [65]; however, with regard to the desire for conception, preg- nancy rates after re-operation were only half of those achieved after primary operation.

! The aim of this overview was to discuss controversial aspects and challenges in the surgical treatment of endometriosis. This dis- cussion has made it clear that significant challenges still remain with regard to preoperative diagnosis and decision-making, the provision of information to patients and surgical techniques to treat endometriosis. Conflict of Interest ! None. Fig. 4 a and ba Endometriotic nodules with infiltration of the vaginal cuff; the fibres of the right inferior hypogastric plexus are immediately lat- eral to the nodules. b Resection of vaginal endometriosis preserving the inferior hypogastric plexus. 921 Rimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923 DGGG Review

1 Deguara CS, Pepas L, Davis C. Does minimally invasive surgery for endo- metriosis improve pelvic symptoms and quality of life? Curr Opin Ob- stet Gynecol 2012; 24: 241 –244 2 AWMF. Diagnostik und Therapie der Endometriose. AWMF Leitlinien Register 015/045. awmf.org/leitlinien/detail/ll/015-045.html 3 Wattiez A, Puga M, Albornoz J et al. Surgical strategy in endometriosis. Best Pract Res Clin Obstet Gynaecol 2013; 27: 381 –392 4 Kondo W, Bourdel N, Zomer MT et al. Surgery for deep infiltrating endo- metriosis: technique and rationale. Front Biosci (Elite Ed) 2013; 5: 316–332 5 Berkes E, Bokor A, Rigó jr. J. Current treatment of endometriosis with laparoscopic surgery. Orv Hetil 2010; 151: 1137 –1144 6 Fritzer N, Tammaa A, Salzer H et al. Effects of surgical excision of endo- metriosis regarding quality of life and psychological well-being: a re- view. Womens Health (Lond Engl) 2012; 8: 427 –435 7 Koninckx PR, Ussia A, Adamyan L et al. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 2012; 98: 564 –571 8 Pandis GK, Saridogan E, Windsor AC et al. Short-term outcome of fertil- ity-sparing laparoscopic excision of deeply infiltrating pelvic endome- triosis performed in a tertiary referral center. Fertil Steril 2010; 93: 39– 45 9 Minelli L, Ceccaroni M, Ruffo G et al. Laparoscopic conservative surgery for stage IV symptomatic endometriosis: short-term surgical compli- cations. Fertil Steril 2010; 94: 1218 –1222 10 Schonman R, Dotan Z, Weintraub AY et al. Deep endometriosis inflicting the bladder: long-term outcomes of surgical management. Arch Gyne- col Obstet 2013; DOI: 10.1007/s00404-013-2917-6 11 Kovoor E, Nassif J, Miranda-Mendoza I et al. Endometriosis of bladder: outcomes after laparoscopic surgery. J Minim Invasive Gynecol 2010; 17: 600–604 12 Taylor E, Williams C. Surgical treatment of endometriosis: location and patterns of disease at reoperation. Fertil Steril 2010; 93: 57 –61 13 Lessey BA, Higdon HL 3rd, Miller SE et al. Intraoperative detection of subtle endometriosis: a novel paradigm for detection and treatment of pelvic pain associated with the loss of peritoneal integrity. J Vis Exp 2012; DOI: 10.3791/4313 14 Alkatout I, Mettler L, Beteta C et al. Combined surgical and hormone therapy for endometriosis is the most effective treatment: prospective, randomized, controlled trial. J Minim Invasive Gynecol 2013; 20: 473 – 481 15 Vercellini P, Somigliana E, Consonni D et al. Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Ef- fect on pain during intercourse and patient satisfaction. Hum Reprod 2012; 27: 3450 –3459 16 Vercellini P, Frattaruolo MP, Somigliana E et al. Surgical versus low-dose progestin treatment for endometriosis-associated severe deep dyspa- reunia II: effect on sexual functioning, psychological status and health-related quality of life. Hum Reprod 2013; 28: 1221 –1230 17 Porpora MG, Pallante D, Ferro A et al. Pain and ovarian endometrioma recurrence after laparoscopic treatment of endometriosis: a long-term prospective study. Fertil Steril 2010; 93: 716 –721 18 Hayasaka S, Ugajin T, Fujii O et al. Risk factors for recurrence and re-re- currence of ovarian endometriomas after laparoscopic excision. J Obstet Gynaecol Res 2011; 37: 581 – 585 19 Uncu G, Kasapoglu I, Ozerkan K et al. Prospective assessment of the im- pact of endometriomas and their removal on ovarian reserve and de- terminants of the rate of decline in ovarian reserve. Hum Reprod 2013; 28: 2140–2145 20 Raffi F, Metwally M, Amer S. The impact of excision of ovarian endome- trioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012; 97: 3146 –3154 21 Streuli I, de Ziegler D, Gayet V et al. In women with endometriosis anti- Müllerian hormone levels are decreased only in those with previous endometrioma surgery. Hum Reprod 2012; 27: 3294 –3303 22 Urman B, Alper E, Yakin K et al. Removal of unilateral endometriomas is associated with immediate and sustained reduction in ovarian reserve. Reprod Biomed Online 2013; 27: 212 –216 23 Celik HG, Dogan E, Okyay E et al. Effect of laparoscopic excision of endo- metriomas on ovarian reserve: serial changes in the serum antimüller- ian hormone levels. Fertil Steril 2012; 97: 1472 –1478 24 Canis M, Kondo W, Botchorishvili R et al. Surgical arrows should be identified on the cyst wall. Fertil Steril 2013; 99: e7 25 Donnez J, Squifflet J, Jadoul P et al. Fertility preservation in women with ovarian endometriosis. Front Biosci (Elite Ed) 2012; 4: 1654 –1662 26 Bourdel N, Roman H, Mage G et al. Surgery for the management of ovar- ian endometriomas: from the physiopathology to the pre-, peri- and postoperative treatment. Gynecol Obstet Fertil 2011; 39: 709 –721 27 Somigliana E, Benaglia L, Viganoʼ Pe ta l .Surgical measures for endome- triosis-related infertility: a plea for research. Placenta 2011; 32 (Suppl. 3): S238–S242 28 Hart RJ, Hickey M, Maouris P et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008; 2: CD004992 29 Dan H, Limin F. Laparoscopic ovarian cystectomy versus fenestration/ coagulation or laser vaporization for the treatment of endometriomas: a meta-analysis of randomized controlled trials. Gynecol Obstet Invest 2013; 76: 75 –82 30 Litta P, DʼAgostino G, Conte L et al. Anti-Müllerian hormone trend after laparoscopic surgery in women with ovarian endometrioma. Gynecol Endocrinol 2013; 29: 452 –454 31 Ferrero S, Venturini PL, Gillott DJ et al. Hemostasis by bipolar coagula- tion versus suture after surgical stripping of bilateral ovarian endome- triomas: a randomized controlled trial. J Minim Invasive Gynecol 2012; 19: 722–730 32 Ruiz-Flores FJ, Garcia-Velasco JA. Is there a benefit for surgery in endo- metrioma-associated infertility? Curr Opin Obstet Gynecol 2012; 24: 136–140 33 Kössi J, Setälä M, Mäkinen J et al. Quality of life and sexual function 1 year after laparoscopic rectosigmoid resection for endometriosis. Colo- rectal Dis 2013; 15: 102 –108 34 Setälä M, Härkki P, Matomäki J et al. Sexual functioning, quality of life and pelvic pain 12 months after endometriosis surgery including vagi- nal resection. Acta Obstet Gynecol Scand 2012; 91: 692 –698 35 Bassi MA, Podgaec S, Dias jr. JA et al. Quality of life after segmental re- section of the rectosigmoid by laparoscopy in patients with deep infil- trating endometriosis with bowel involvement. J Minim Invasive Gyne- col 2011; 18: 730 –733 36 Ruffo G, Sartori A, Crippa S et al. Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative re- sults. Surg Endosc 2012; 26: 1035 –1040 37 Maytham GD, Dowson HM, Levy B et al. Laparoscopic excision of recto- vaginal endometriosis: report of a prospective study and review of the literature. Colorectal Dis 2010; 12: 1105 –1112 38 Koh CE, Juszczyk K, Cooper MJ et al. Management of deeply infiltrating endometriosis involving the rectum. Dis Colon Rectum 2012; 55: 925 – 931 39 Borghese B, Santulli P, Streuli I et al. [Recurrence of pain after surgery for deeply infiltrating endometriosis: How does it happen? How to manage?]. J Gynecol Obstet Biol Reprod (Paris) 2012; DOI: 10.1016/j. jgyn.2012.11.009 40 Meuleman C, Tomassetti C, Wolthuis A et al. Clinical outcome after rad- ical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg 2013; Apr 10 [Epub ahead of print]; PMID: 23579578 41 Dubuisson J, Pont M, Roy P et al. Female sexuality after surgical treat- ment of symptomatic deep pelvic endometriosis. Gynecol Obstet Fertil 2013; 41: 38 –44 42 Donnez J, Squifflet J. Complications, pregnancy and recurrence in a pro- spective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 2010; 25: 1949–1958 43 Boesgaard-Kjer DH, Boesgaard-Kjer D, Kjer JJ. Well-leg compartment syndrome after gynecological laparoscopic surgery. Acta Obstet Gyne- col Scand 2013; 92: 598 –600 44 Tomassetti C, Meuleman C, Vanacker B et al. Lower limb compartment syndrome as a complication of laparoscopic laser surgery for severe endometriosis. Fertil Steril 2009; 92: 2038.e9 –2038.e12 45 Brouwer R, Woods RJ. Rectal endometriosis: results of radical excision and review of published work. ANZ J Surg 2007; 77: 562 –571 46 Canon B, Collinet P, Piessen G et al. Segmentary rectal resection and rec- tal shaving by laparoscopy for endometriosis: peri-operative morbid- ity. Gynecol Obstet Fertil 2013; 41: 275 –281 47 Roman H, Loisel C, Resch B et al. Delayed functional outcomes associ- ated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice. Hum Re- prod 2010; 25: 890 –899 48 Daraï E, Touboul C, Chéreau E et al. Segmental resection for colorectal endometriosis: are there alternatives? Gynecol Obstet Fertil 2012; 40: 116–120 922 Rimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923 GebFra Science 49 Roman H, Vassilieff M, Gourcerol G et al. Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom- guided approach. Hum Reprod 2011; 26: 274 –281 50 Zilberman S, Ballester M, Touboul C et al. Partial colpectomy is a risk fac- tor for urologic complications of colorectal resection for endometrio- sis. J Minim Invasive Gynecol 2013; 20: 49 –55 51 Deffieux X, Raibaut P, Hubeaux K et al. Voiding dysfunction after surgi- cal resection of deeply infiltrating endometriosis: pathophysiology and management. Gynecol Obstet Fertil 2007; 35 (Suppl. 1): S8 –S13 52 Dubernard G, Rouzier R, Piketty M et al. Assessment of the urinary side effects after surgery for deep pelvic endometriosis. Gynecol Obstet Fer- til 2007; 35 (Suppl. 1): S1 –S7 53 Ceccaroni M, Clarizia R, Roviglione G et al. Neuro-anatomy of the poste- rior parametrium and surgical considerations for a nerve-sparing ap- proach in radical pelvic surgery. Surg Endosc 2013; DOI: 10.1007/ s00464-013-3043-2 54 Possover M, Chiantera V, Baekelandt J. Anatomy of the sacral roots and the pelvic splanchnic nerves in women using the LANN technique. Surg Laparosc Endosc Percutan Tech 2007; 17: 508 –510 55 Ceccaroni M, Clarizia R, Bruni F et al. Nerve-sparing laparoscopic erad- ication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical tri- al. Surg Endosc 2012; 26: 2029 –2045 56 Seracchioli R, Mabrouk M, Manuzzi L et al. Importance of retroperitone- al ureteric evaluation in cases of deep infiltrating endometriosis. J Minim Invasive Gynecol 2008; 15: 435 –439 57 Kondo W, Branco AW, Trippia CH et al. Retrocervical deep infiltrating endometriotic lesions larger than thirty millimeters are associated with an increased rate of ureteral involvement. J Minim Invasive Gyne- col 2013; 20: 100 –103 58 Mereu L, Gagliardi ML, Clarizia R et al. Laparoscopic management of ureteral endometriosis in case of moderate-severe hydroureterone- phrosis. Fertil Steril 2010; 93: 46 –51 59 Miranda-Mendoza I, Kovoor E, Nassif J et al. Laparoscopic surgery for se- vere ureteric endometriosis. Eur J Obstet Gynecol Reprod Biol 2012; 165: 275–279 60 Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hid- den, progressive and severe disease that deserves attention, not just compassion. Hum Reprod 2013; 28: 2026 –2031 61 Janssen EB, Rijkers AC, Hoppenbrouwers K et al. Prevalence of endome- triosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update 2013; 19: 570–582 62 Yeung jr. P, Sinervo K, Winer W et al. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? Fertil Steril 2011; 95: 1909 –1912, 1912.e1 63 Tandoi I, Somigliana E, Riparini J et al. High rate of endometriosis recur- rence in young women. J Pediatr Adolesc Gynecol 2011; 24: 376 –379 64 Vercellini P, Barbara G, Abbiati A et al. Repetitive surgery for recurrent symptomatic endometriosis: what to do? Eur J Obstet Gynecol Reprod Biol 2009; 146: 15 –21 65 Berlanda N, Vercellini P, Fedele L. The outcomes of repeat surgery for re- current symptomatic endometriosis. Curr Opin Obstet Gynecol 2010; 22: 320–325 Deutschsprachige Zusatzinformationen online abrufbar unter: www.thieme-connect.de/ejournals/toc/gebfra. 923 Rimbach S et al. Surgical Therapy of … Geburtsh Frauenheilk 2013; 73: 918 –923 DGGG Review