Surgical Management of Gastrointestinal and Genitourinary Endometriosis

Endometriosis is the presence of endometrium-like tissue outside the uterus and can take many forms that include superficial peritoneal lesions, cysts in the ovaries known as endometriomas, and deep endometriosis penetrating at least 5 mm into surrounding tissue (1). This last type of endometriosis is accompanied by fibrosis and adhesions leading to distorted anatomical planes that commonly manifest as an obliterated posterior cul-de-sac. Deep endometriosis is overall rare, and its prevalence is estimated to be 1%–2% of the population (2). However, deep endometriosis presents a surgical challenge, given extensive scarring as well as the involvement of other organ systems. These systems include the gastrointestinal tract – most commonly, the rectum, rectosigmoid, or sigmoid colon – as well as the genitourinary tract – most commonly, the bladder (80% of cases) or the ureters (14% of cases) (3). Given the involvement of other organ systems in addition to distorted surgical planes and fibrotic tissue, surgery for deep endometriosis can be associated with a high complication rate. One retrospective cohort study including 165 patients at a tertiary referral center for patients with deep endometriosis found that the overall rate of postoperative complications was 16.2%, with severe postoperative complications of 2.42% (4). As such, it is imperative for all gynecologic surgeons to be aware of the surgical principles to follow when encountering advanced deep endometriosis. This chapter will focus on deep endometriosis affecting the gastrointestinal and genitourinary systems (Figure 24.1).