Prise en charge chirurgicale des nodules endométriosiques de la cloison recto-vaginale. A propos d'une série continue de 40 cas

L'examen clinique en période cataméniale est essentiel pour évoquer le diagnostic. La réalisation pré-opératoire d'une IRM permet d'établir une cartographie complète des lésions sous-péritonéales (cloison recto-vaginale, ligaments utéro-sacrés, vessie et uretères) et péritonéales (endométriomes, implants péritonéaux) et l'EESAR permet le diagnostic d'une infiltration de la paroi rectale de façon fiable et confirme la présence d'un nodule de la cloison rectovaginale. Les données de ces deux examens permettent au chirurgien de prévoir les gestes nécessaires au traitement complet, en particulier les exérèses digestives, et d'en informer la patiente pour qu'elle puisse assumer sa décision d'être opérée. Le traitement chirurgical est sûr dans une équipe habituée à cette prise en charge. Les complications per-opératoires sont rares mais sont à mettre en parallèle avec la complexité et la diversité des gestes à réaliser (exérèse de ligaments utéro-sacrés, résections digestives…) ainsi que l'expérience des opérateurs ayant effectué ces gestes, justifiant la prise en charge dans des centres spécialisés. Les complications post-opératoires sont peu fréquentes mais très sévères et leurs conséquences sur la fertilité de ces femmes jeunes désireuses de grossesse sont méconnues. Les résultats fonctionnels sont, en balance à ces complications, très satisfaisants et justifient la prise en charge chirurgicale de cette pathologie.

Clinical examination during a catamenial period is essential in order to evoke the diagnosis. A pre-operative MRI yields a complete map of the sub-peritoneal (rectovaginal septum, uterosacral ligaments, bladder and ureters) and peritoneal (endometrioma, peritoneal implants) lesions, and ARES allows for the diagnosis of an infiltration of the rectal wall in a reliable fashion and confirms the presence of a nodule of the rectovaginal septum. The data collected from these two examination procedures allow the surgeon to foresee the series of acts required for a complete cure, in particular the digestive resections, and to inform the patient of those acts so that she can give her informed consent to be operated on. The surgical treatment is usually safe with a team used to managing such cases. 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