Uterine rupture following laparoscopic excision of deeply invasive rectovaginal endometriosis: Is it the song or the singer?

Deeply infiltrating endometriosis (DIE) is characterized by penetration of endometriosis more than 5 mm into the affected tissue, commonly involving the uterosacral ligaments, rectovaginal septum, and rectosigmoid colon, with partial or complete posterior cul-de-sac obliteration. It is suspected in women reporting dysmenorrhea, deep dyspareunia, chronic pain, and/or dyschezia (1Nezhat C. Li A. Falik R. Copeland D. Razavi G. Shakib A. et al.Bowel endometriosis: diagnosis and management.Am J Obstet Gynecol. 2018; 218: 549-562Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar). Fertility-enhancing surgical management of endometriosis is recommended for symptomatic patients who have failed medical therapy, or in whom medical therapy is not indicated, to avoid inherited potential complications (1Nezhat C. Li A. Falik R. Copeland D. Razavi G. Shakib A. et al.Bowel endometriosis: diagnosis and management.Am J Obstet Gynecol. 2018; 218: 549-562Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 2Mohr C. Nezhat F. Nezhat C. Seidman D. Nezhat C. Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.JSLS. 2005; 9: 16-24PubMed Google Scholar). In this issue, Ziadeh et al. reported a multicenter case series of seven patients who underwent video laparoscopic resection of posterior DIE (3Zeadeh H. Panel P. Lethoic A. Canis M. Amari S. Gauthier T. et al.Resection of deep infiltrating endometriosis (DIE) could be a risk factor for uterine rupture: a case series with review of the literature.F S Rep. 2020; 1: 213-218Google Scholar). Six of the patients presented with an endometriotic nodule involving the rectovaginal septum; three patients had rectal shaving; two patients had segmental bowel resection; and one patient underwent both procedures. The seventh patient had a nodule involving the uterosacral ligament and underwent an extensive adhesiolysis and excision procedure. In all cases, ultrasonic dissection was the primary energy source. Six of these patients incurred uterine rupture during labor, and the seventh patient was diagnosed with a large posterior wall defect. The site of uterine rupture involved the posterior corpus and isthmus in five patients, and the fundus in the remaining patient. The authors concluded that resection of posterior DIE should be considered a potential risk factor for uterine rupture during labor. Uterine rupture is a grave obstetric complication with significant maternal and fetal morbidity and mortality. Given the large number of reproductive-aged women requiring surgical management of rectovaginal DIE, understanding whether it actually predisposes these patients to uterine rupture warrants exploration. Because of the variable manifestations of DIE, diversity of surgical approaches available, as well as rarity of uterine rupture, development of meaningful prospective or randomized studies will not be practical. The literature describing uterine rupture in the setting of endometriosis is heterogeneous; some occurred in patients with adenomyosis, in most instances after prior adenomyomectomy. There are also several isolated case reports describing rupture of either the uterine artery or vein during labor in patients in women with endometriosis involving the parametrium. More specifically, there have been seven cases of uterine rupture following laparoscopic resection of rectovaginal DIE reported between 1999 and 2019 (3Zeadeh H. Panel P. Lethoic A. Canis M. Amari S. Gauthier T. et al.Resection of deep infiltrating endometriosis (DIE) could be a risk factor for uterine rupture: a case series with review of the literature.F S Rep. 2020; 1: 213-218Google Scholar). In two of these cases, described by Fetterback et al. (4Fettback P.B. Pereira R.M. Domingues T.S. Zacharias K.G. Chamié L.P. Serafini P.C. Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion.Int J Gynecol Obstet. 2015; 129: 268-270Crossref PubMed Scopus (8) Google Scholar), uterine rupture involved the cornual region of the uterus. Both patients had DIE lesions invading into the myometrium at the posterior uterine wall. To achieve resection and hemostasis, extensive electrocoagulation into the myometrium was required, leading to visible thinning of the uterine wall in one patient and use of sutures to reapproximate a portion of the uterine wall in the other. Both achieved pregnancy by in vitro fertilization (IVF) 5 and 9 months after the laparoscopic resection procedure. Uterine rupture occurred prior to the onset of labor at 32 and 33 weeks of gestation, respectively (4Fettback P.B. Pereira R.M. Domingues T.S. Zacharias K.G. Chamié L.P. Serafini P.C. Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion.Int J Gynecol Obstet. 2015; 129: 268-270Crossref PubMed Scopus (8) Google Scholar). For the remaining five cases reported in the literature, uterine rupture occurred intrapartum and involved the lower posterior uterine segment (3Zeadeh H. Panel P. Lethoic A. Canis M. Amari S. Gauthier T. et al.Resection of deep infiltrating endometriosis (DIE) could be a risk factor for uterine rupture: a case series with review of the literature.F S Rep. 2020; 1: 213-218Google Scholar). All five patients had undergone laparoscopic resection of extensive rectovaginal endometriosis. The amount of electrocautery used, the extent of dissection into the myometrium, as well as the degree of posterior uterine wall involvement were presumed to be the causes. Interestingly, a recent case-control study of 62 pregnant women with previously excised posterior DIE matched to 186 pregnant controls without endometriosis examined pregnancy complications following surgery (5Nirgianakis K. Gasparri M.L. Radan A.P. Villiger A. McKinnon B. Mosimann B. et al.Obstetric complications after laparoscopic excision of posterior deep infiltrating endometriosis: a case-control study.Fertil Steril. 2018; 110: 459-466Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar). There was no incidence of uterine rupture, and the likelihood of a successful vaginal delivery was similar for both groups (5Nirgianakis K. Gasparri M.L. Radan A.P. Villiger A. McKinnon B. Mosimann B. et al.Obstetric complications after laparoscopic excision of posterior deep infiltrating endometriosis: a case-control study.Fertil Steril. 2018; 110: 459-466Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar). These findings, the heterogeneity in the literature, as well as the paucity of case reports and use of doubtful techniques leads us to question whether it is rectovaginal DIE itself (the song) or rather the surgical technique (the singer) that leads to this complication. There are the challenges surrounding the surgical management of DIE involving the rectovaginal area. However, certain principles and techniques may guide surgeons to perform the most effective and least harmful procedure. In most of the reported cases with uterine rupture, extensive use of energy such as monopolar and bipolar electrosurgery or ultrasonic for dissection of recto-vaginal septum is reported (3Zeadeh H. Panel P. Lethoic A. Canis M. Amari S. Gauthier T. et al.Resection of deep infiltrating endometriosis (DIE) could be a risk factor for uterine rupture: a case series with review of the literature.F S Rep. 2020; 1: 213-218Google Scholar, 4Fettback P.B. Pereira R.M. Domingues T.S. Zacharias K.G. Chamié L.P. Serafini P.C. Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion.Int J Gynecol Obstet. 2015; 129: 268-270Crossref PubMed Scopus (8) Google Scholar). Extensive use of energy may devascularize tissue and predispose to poor tissue healing. Regardless of the type of energy source, creating the correct anatomical plane by lateral dissection and avoiding myometrium, minimizing thermal injury, and preserving healthy tissue are critical for promoting wound healing and maintaining tissue integrity. It is doubtful that the short procedure-to-pregnancy intervals of 5 and 9 months allowed adequate time for tissue repair (4Fettback P.B. Pereira R.M. Domingues T.S. Zacharias K.G. Chamié L.P. Serafini P.C. Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion.Int J Gynecol Obstet. 2015; 129: 268-270Crossref PubMed Scopus (8) Google Scholar). Similarly, three of the seven patients described by Ziadeh et al. also conceived within 1 year of the laparoscopic resection procedure (3Zeadeh H. Panel P. Lethoic A. Canis M. Amari S. Gauthier T. et al.Resection of deep infiltrating endometriosis (DIE) could be a risk factor for uterine rupture: a case series with review of the literature.F S Rep. 2020; 1: 213-218Google Scholar). Another important technical consideration is appropriate procedure selection. A more conservative approach avoids the need for extensive dissection, minimizing nerve and vascular injury. The depth of excision must be minimized with an attempt made to delineate the healthy from the diseased tissue. This is particularly important for lesions involving rectovaginal septum or uterine corpus. Resection of endometriosis into the myometrial tissue and extensive use of an energy source in this area may compromise uterine wall integrity. Infertility is not an indication for aggressive resection or bowel surgery (1Nezhat C. Li A. Falik R. Copeland D. Razavi G. Shakib A. et al.Bowel endometriosis: diagnosis and management.Am J Obstet Gynecol. 2018; 218: 549-562Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar). Three patients in the series described by Ziadeh et al. had extensive bowel resection procedures. A more conservative approach may have minimized the extent of dissection required. In fact, in patients with severe disease who are interested in fertility, successful pregnancies with less aggressive treatment, even in the presence of a bowel stricture, have been reported (2Mohr C. Nezhat F. Nezhat C. Seidman D. Nezhat C. Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.JSLS. 2005; 9: 16-24PubMed Google Scholar). In caring for reproductive-aged patients, we must proceed with caution. If resection of posterior DIE is truly believed to be an independent risk factor for uterine rupture, a conservative approach, even by leaving some disease behind, would be preferred in patients with a desire for fertility. Otherwise, cesarean delivery will be required because of the risks associated with labor and vaginal delivery. This mode of delivery comes with significantly increased risks of intraoperative and postoperative complications, especially for patients with extensive endometriosis and previous surgeries. We must not subject our patients to any increased risk without first understanding the nature of the complications. The current publications describing uterine rupture following resection of DIE are confined to case reports and small series (3Zeadeh H. Panel P. Lethoic A. Canis M. Amari S. Gauthier T. et al.Resection of deep infiltrating endometriosis (DIE) could be a risk factor for uterine rupture: a case series with review of the literature.F S Rep. 2020; 1: 213-218Google Scholar, 4Fettback P.B. Pereira R.M. Domingues T.S. Zacharias K.G. Chamié L.P. Serafini P.C. Uterine rupture before the onset of labor following extensive resection of deeply infiltrating endometriosis with myometrial invasion.Int J Gynecol Obstet. 2015; 129: 268-270Crossref PubMed Scopus (8) Google Scholar). They reflect different disease presentations, surgeons, surgical techniques, as well as selection biases. Treatment of DIE can be challenging, as it is multi-focal and involves different organs. Just as a highly trained and skilled singer is needed to bring out the emotional depth and beauty of a song, a skilled surgeon with knowledge of the disease, anatomy, and the devices should undertake surgical management of complex DIE. Hitting the right notes, by use of proper technique, appropriate procedure selection, meticulous dissection, preservation of healthy tissue, and limited use of energy devices, may prevent these types of complications. Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literatureF&S ReportsVol. 1Issue 3PreviewTo highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture. Full-Text PDF Open Access