Surgical Treatment of Deep Infiltrating Endometriosis | Article

This chapter should be cited as follows:
Raimondo D, Maletta M, et al, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.420703

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 8

Gynecological endoscopy

Volume Editors: Professor Alberto Mattei, Director Maternal and Child Department, USL Toscana Centro, Italy
Dr Federica Perelli, Obstetrics and Gynecology Unit, Ospedale Santa Maria Annunziata, USL Toscana Centro, Florence, Italy

Chapter

Surgical Treatment of Deep Infiltrating Endometriosis

First published: August 2024

AUTHORS

Diego Raimondo, MD, PhD

IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy; Advisory Board Member of European Society for Gynaecological Endoscopy (ESGE) ESGE SIG member in Robotics

Manuela Maletta, MD

Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, DIMEC, University of Bologna, Bologna, Italy

Stefano Ferla, MD

Antonio Raffone, MD

Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy

Francesca Govoni, MD

Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy

Renato Seracchioli, MD

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INTRODUCTION

Deep infiltrating endometriosis (DIE), the most severe form of endometriosis, can be defined as endometrial-like glands and stroma infiltrating the peritoneum by at least 5 mm in depth or as the infiltration of organ walls or retroperitoneal structures (regardless the depth of infiltration).¹ DIE can affect several structures and organs, including uterosacral ligaments, pelvic sidewall, rectovaginal septum, vagina, bowel, bladder, ureter and lateral parametrium.

Indications for surgical treatment of DIE are severe pelvic pain in patients with a poor response or contraindications to hormonal therapies and/or severe impairment of pelvic organ function, such as critical bowel or urinary stenosis.²^,³^,⁴ Complete surgical removal of macroscopic endometriotic lesions significantly improves endometriosis associated pain and quality of life in women with DIE.³ However, surgery for DIE can be challenging due to the inflammatory process which causes important distortion of pelvic anatomy. As DIE surgery can be associated with significant intraoperative and postoperative complications, it should be performed as a tailored surgical treatment, based on patient and disease characteristics (e.g., age, desire for future pregnancy, symptoms, quality of life), in a high-volume center with an expert multidisciplinary surgical team, after informing patients of potential surgical risks and expected benefits.³ A balance between radicality and conservativity is crucial for surgical management of DIE in order to avoid further surgical procedures and surgical-related morbidity.

The role of surgery in infertile women with DIE and its timing (i.e., before or after failure of assisted reproductive technology cycles) is still unclear.³

SURGICAL INSIGHTS: LAPAROSCOPIC SET-UP, RETROPERITONEAL DISSECTION, AND NERVE-SPARING SURGERY

Surgery for DIE is routinely performed through a laparoscopic approach.⁵ After creation of pneumoperitoneum, the trocars’ scheme can be set-up: a 10 mm trocar is introduced at the level of the umbilicus and three trocars of 5 mm are located lateral to the inferior epigastric arteries, just above the level of the anterior superior iliac spine, with one above the pubis. The use of a uterine manipulator can be useful to achieve better visualization of pelvic anatomy and adequate traction on the tissues. First, diagnostic laparoscopy is always performed in a systematic way: due to the multifocal occurrence of endometriosis, the visible bowel tract (appendix, small bowel, cecum, and ileocecal valve) and the diaphragm should always be inspected. Suspension of ovaries or of the bowel can also be considered to improve the visualization of the surgical field.

A standardized and reproducible surgical technique for DIE treatment, should include some general steps: identification, isolation of the nodule (in order to preserve the “noble” structures attracted by fibrosis) and its safe removal. Dealing with anatomical distortion and retroperitoneal fibrosis caused by DIE requires extensive knowledge and adequate exposure of the retroperitoneum. First, we recommend identifying anatomical landmarks and finding the avascular spaces, separating progressively different anatomical layers (“onion-like” technique) (Figure 1).⁶ The peritoneal and retroperitoneal anatomical distortion surrounding the DIE nodule may limit the identification of pelvic landmarks; thus, it is essential to start the dissection from distant healthy tissue. To perform adequate retroperitoneal dissection, we recommend:

applying traction-counter traction and make a controlled thinning out of connective tissues to reveal structures within
using CO₂ dissection, surfing into the spider-web structures of the connective tissue
keeping the surgical field clean and dry, avoiding bleeding or unnecessary irrigation.

Laparoscopic overview: inspection of the pelvis and identification of the anatomic landmarks covered by the peritoneum. Sacral promontory, right hypogastric nerve, right ureter, right iliac vessels, sigmoid-colon and pouch of Douglas.

According to the site of DIE, embryological issues and the need to avoid iatrogenic trauma on surrounding structures, we have to use precise entry points and pathways between fasciae along virtual and avascular anatomical spaces⁶ to isolate DIE nodules.

Surgery for the posterior compartment is performed by developing pararectal and retrorectal spaces following the principles of nerve-sparing surgery.⁷ The pararectal spaces are two bilateral spaces, which lie laterally to the rectum and medially to the anterior trunk of internal iliac vessels. Ureter and mesoureter (a dependence of presacral fascia) divides the pararectal space into two further spaces, the medial pararectal space (Okabayashi space) and the lateral pararectal space (Latzko space) (Figure 2). The rectum is surrounded by the mesorectum, which is then surrounded by the fascia propria recti (or mesorectal fascia), which lies ventrally to the presacral fascia. The median space between these mesorectal and presacral fasciae is an avascular space of loose areolar tissue along the sacral bone, named the retrorectal space (or “holy plane of Heald”).⁸ The mesorectal fascia is connected to the parietal pelvic fascia by the two-lateral rectal ‘ligaments’ (or rectal wings), containing inconsistently middle rectal vessels, and by the recto-sacral fascia.⁹ The medial pararectal space communicates medially with the retrorectal space, while the lateral pararectal space communicates with the presacral space. Nerve-sparing surgery aims to identify and spare hypogastric nerves and inferior hypogastric plexuses bilaterally, to avoid accidental autonomic nervous injury which may cause urinary, anorectal, and sexual dysfunctions.¹⁰ The superior hypogastric plexus is a reticular structure located over the sacral promontory containing predominantly sympathetic fibers and forming hypogastric nerves. The pelvic splanchnic nerves arise from S2–S4 ventral sacral roots, lie below the deep uterine vein and follow the middle rectal artery to join the inferior hypogastric plexus. the pelvic plexus (or inferior hypogastric plexus) is located antero-laterally to the rectum and is formed by the conjunction of sympathetic (hypogastric nerves) and parasympathetic fibers of pelvic splanchnic nerves (“erigens nerves''). Nerve-sparing technique can be performed considering the ureters and uterosacral ligaments as anatomic landmarks and using "interfascial" dissection between the pre-hypogastric fascia and the fascia propria recti. Hypogastric nerves run approximately 5–20 mm below the course of the pelvic ureter along the dorsolateral part of the uterosacral ligaments. In particular, the right hypogastric nerve is significantly farther to the ureter than the left one, and closer to the midsagittal plane on the right side than on the left side.¹¹

Pararectal spaces.

BOWEL ENDOMETRIOSIS

Bowel endometriosis occurs in 8–12% of patients with endometriosis. The rectum and sigmoid colon account for up to 90% of all cases of bowel endometriosis.¹² The involvement of the lower gastrointestinal tract may cause chronic pelvic pain, dyspareunia and digestive symptoms, such as diarrhea, constipation and dyschezia.¹²

Although several surgical techniques for rectosigmoid DIE have been described, there is no consensus regarding the best technique to adopt.⁶ Regarding short-term surgical outcomes, a lower postoperative complication rate was significantly reported in the shaving group (5.4%) compared with in the discoid excision (9.1%) and segmental resection (17.7%) groups.⁶ In a recent meta-analysis, the shaving group showed a lower risk of rectovaginal fistula and anastomotic leakage compared to discoid excision and segmental resection groups, while no difference was found between these latter groups.¹³ Moreover, risk of anastomotic stenosis was found to be lower in the discoid excision group than in the segmental resection one.¹³ No significant difference in functional gastrointestinal or urinary outcomes was reported among the three surgical procedures; it is noteworthy that functional outcomes seem to be influenced mostly by the need of parametrial resection.¹⁴^,¹⁵ Regarding the risk of histologically proven recurrence, it was reported to be significantly higher after shaving procedure than after full-thickness procedures, while no significant difference was observed between the discoid excision and segmental resection groups.¹⁶

Some clinical characteristics (e.g., per rectum bleeding, subocclusive symptoms) and rectal nodule features (e.g., grade of bowel infiltration, distance from anal verge, number and size of the lesion) may help to stratify the pre-operative risk of radical surgery,⁶^,¹⁷ guiding the counseling with the patient before the operation and the need for general surgeon or urologist consultation in the operating room.

Surgical technique

In order to minimize fecal soiling into the abdomen in women scheduled for rectosigmoid surgical treatment, preoperative bowel preparation on the day before surgery can be adopted, despite there existing no good evidence on its effectiveness.¹⁸^,¹⁹

Intraoperatively, the surgeons must carefully evaluate the rectosigmoid endometriotic tract and decide which technique is more appropriate to remove the lesion.

Shaving

Shaving consists of careful dissection of the endometriotic by nodule peeling it off the bowel wall (Figure 3).¹⁸ In case of a partial muscular wall defect, sutures must be applied in one layer with absorbable stitches starting from the healthy margins. In case of a full thickness defect with opening of the mucosa, a two-layer technique or a conversion to disc excision must be performed.¹⁸

Shaving technique.

Discoid resection (or nodulectomy)

Discoid excision can be performed using different techniques, such as the use of a semi-circular transanal stapler (Rouen technique), circular transanal stapler or linear transperitoneal stapler. Before discoid excision, preliminary rectal shaving should be considered to reduce the thickness of the rectal nodule, facilitating the excision (Figure 4).¹⁸

Discoid resection.

Segmental resection

In case of segmental resection, mobilization of the rectum is performed just above and below the rectal nodule margins (“economic resection”).¹⁸ Preservation of the inferior mesenteric artery and superior rectal artery should be preferred in order to spare intestinal vascularization and improve functional postoperative outcomes.²⁰ After bowel mobilization using a nerve-sparing approach, the rectosigmoid colon is resected using a mechanical linear stapler. Segmental resection is considered low and ultra-low when the distance of caudal bowel transection from the anal verge is between 5 and 8 cm or ≤5 cm, respectively.² With a small incision (3 cm) on the abdominal wall, the affected bowel tract can be exteriorized outside the abdomen and then removed (Figure 5). A circular running suture is inserted around the proximal segment of sigmoid, and the head of a circular stapler is positioned on the margin of the resection (Knight-Griffen technique). An end-to-end or end-to-side anastomosis is created using a transanal circular stapler via laparoscopic approach, paying attention to avoid tension and rotation of the proximal stump.²¹ Recently, totally intracorporeal colorectal anastomosis has been proposed in order to avoid a wider mobilization of the colon to pull it outside the abdomen and the need of the 3-cm abdominal incision.²⁰^,²² Protective ileostomy can be performed when the risk of anastomotic leakage and/or rectovaginal fistula after segmental resection for DIE is high, such as in case of ultra-low rectal resection, associated posterior colpotomy, associated ureteroneocystostomy, or positive Michelin test.¹²

Segmental resection.

Schematically, segmental bowel resection should be performed when endometriotic nodules are ≥3 cm in diameter with deep muscular infiltration, or involving >50% of the circumference, or affecting the sigma, or in case of multifocal endometriotic nodules; a discoid excision using a circular transanal stapler should be executed in case of a single implant smaller than 3 cm, on the ventral surface of the rectum and within 15 cm from the anal verge; finally, shaving should be considered when an endometriotic lesion is located on the bowel serosa with initial infiltration of the muscular layer.⁶

At the end of our surgery, the integrity of the bowel must be tested by filling the pelvic cavity with warm saline solution and insufflating air or injecting methylene blue per rectum. Near infrared-indocyanine green imaging (NIR-ICG) using intravenous injection of the dye (fluorescence angiography) can provide a more objective bowel perfusion assessment after rectosigmoid surgery, in order to improve surgical outcomes of patients with deep Infiltrating endometriosis.² A drainage catheter can be left in the pouch of Douglas until resumption of bowel function.

Antibiotic therapy is given for at least 6 days after surgery. During the postoperative course, serum CRP can be measured from postoperative day 3 and every 48 hours to monitor clinical status.¹⁴^,²³ After removal of the bladder catheter, the postvoid residual volume is evaluated in all patients to check for any urinary dysfunction. Since surgery for DIE may lead to complications such as ureteral lesion, pelvic abscess, rectovaginal fistula, and bowel perforation, in case of signs or symptoms of acute abdomen or sepsis, a clinical examination, blood and/or urinary exams and eventual abdominopelvic ultrasound and/or CT scan should be performed.²³

URINARY TRACT ENDOMETRIOSIS

Urinary tract endometriosis is diagnosed in 1–5.5% of all women with endometriosis, involving the bladder in 70–85% and the ureter in 9–23% of cases. Urethral and kidney involvement by the disease are very rare.²⁴

Ureteral endometriosis

Ureteral endometriosis consists of compression or distortion of the normal ureteral anatomy caused by endometriosis or its associated fibrosis.²⁵ In most cases, ureteral endometriosis is unilateral and occurs more commonly on the left side with the distal segment as the most affected (Figure 6).²⁶

Ureteral endometriosis.

Two types of ureteral endometriosis can be distinguished according to the site of the endometriotic implant: extrinsic ureteral endometriosis, i.e., compression of the ureter by external endometriotic nodule or fibrosis, or intrinsic ureteral endometriosis, i.e., infiltration of the ureteral muscular layer with or without reaching the lumen. No specific symptoms characterize ureteral endometriosis. Preoperatively, ureteral involvement can be easily suspected when ureteral dilatation is visualized on preoperative imaging, but in cases of extrinsic compression without stenosis, the preoperative diagnosis can be challenging. Surgical treatment is mandatory in patients with ureteral obstruction because of the risk of progression of ureteral stenosis and hydronephrosis which can lead to loss of renal function.

Ureteral involvement has to be suspected when DIE lesions are close to the ureter (such as uterosacral ligament, rectovaginal septum, lateral parametrium).²⁶ For this reason, in all cases of DIE surgery, intraoperative retroperitoneal identification and inspection of both ureters is recommended. Surgical treatment of ureteral endometriosis ranges from conservative ureterolysis to radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy.

In case of extrinsic ureteral endometriosis, ureterolysis with any removal of (peri-) ureteral endometriosis nodules should be performed as the first attempt: starting from the healthy tissue, the ureter is isolated and freed from the surrounding fibrotic tissue.¹⁸

Ureteral endometriosis can be aggressive and indolent. Hormonal therapy improves endometriosis symptoms but does not always control the urinary tract involvement especially in cases of intrinsic ureteral endometriosis. In such cases, if conservative ureterolosysis is not able to restore a proper ureteral anatomy, more radical procedures must be taken into account. In case of an affected ureteral segment distant from the bladder, a ureteral resection with end-to-end anastomosis is performed. The ureter is first mobilized, the stenotic part of the ureter is removed and an anastomosis with interrupted sutures (e.g., 4–0 to 5–0, with monofilament material) is created. Conversely, ureteral reimplantation (or ureteroneocystostomy) is performed when ureteral lesions are near to the vesico-ureteral junction.¹⁸^,²⁷ A tension-free direct anastomosis can be performed in case of a short gap due to the ureteral defect, whereas larger distances need a psoas hitch procedure (fixing the posterior bladder wall to the psoas tendon) or a Boari bladder flap (tubularization of bladder to substitute the distal ureter).¹⁸^,²⁷

Near-infrared indocyanine green-enhanced fluorescence (NIR-ICG) after surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess residual ureteral perfusion and guide surgical decision, together with other visual cues at white light.²⁸

After ureteral surgery, patients should be monitored by kidney ultrasound every 6 months in order to avoid overlooking silent hydronephrosis.¹⁸ Selective preoperative placement of a ureteral stent in women with urinary bladder trigone involvement and/or radiological diagnosis of moderate-severe hydronephrosis can be useful in order to reduce perioperative ureteral complications.²⁹

Bladder endometriosis

Patients with bladder nodules can complain of dysuria, hematuria, and, less frequently, bladder pain and urgency. These symptoms can worsen during menses.³⁰ An endometriotic nodule of the bladder more commonly involves the detrusor muscle and rarely infiltrates mucosa (Figure 7). Eradication of the endometriosis nodule is performed with a partial cystectomy with or without opening of the bladder cavity. The dissection starts in the healthy tissues adjacent to the nodule: prevesical, paravesical and vesico-uterine spaces, following a lateral to medial approach. The bladder is mobilized to ensure subsequent suturing without tension. When the nodule is isolated, and the bladder mobilized, the nodule is grasped with traction and excised with macroscopically free margins. It may be worth trying to excise the nodule from the detrusor muscle, respecting the mucosa if the latter is not involved; however, this is possible only in the minority of cases. On the other hand, it is easier to control the dissection with an open bladder as the definition of the resection margins from both in- and outside is comfortable for the surgeon. Also, the trigone can be directly visualized to avoid ureteral damage in this manner. After resection, the bladder defect can be closed horizontally with a running suture using absorbable material. If possible, only the detrusor should be sutured, avoiding the mucosal layer. After suturing, the leak tightness of the bladder is checked by filling it with 100–200 ml sodium chloride and blue dye. Leakages are commonly managed by placing reinforcing stitches. Retrograde cystography can be recommended before the removal of the urinary catheter.

Bladder endometriosis (opened).

PARAMETRIAL ENDOMETRIOSIS

Posterolateral parametrium is a frequent site of DIE lesions (Figure 8).¹⁰ In detail, we distinguish a posterior parametrium (i.e., uterosacral ligaments, rectovaginal pillars and lateral ligaments of the rectum) and a lateral parametrium (i.e., retroperitoneal connective areolar tissue from the uterus and vagina to the pelvic sidewall, containing utero-vaginal vessels, lymphatic structures and nerves of inferior hypogastric plexus).³¹ Posterior parametrial endometriosis is involved in 50–70% of patients with DIE, while lateral parametrial endometriosis is found intraoperatively in 17% of cases. Lateral parametrial endometriosis has been associated with more severe dysmenorrhea, ureteral stenosis and preoperative voiding dysfunctions. Lateral parametrial endometriosis can be preoperatively suspected during the clinical examination and with preoperative diagnostic imaging; however, retroperitoneal surgical dissection remains the gold standard for its diagnosis.⁶ Some clinical and sonographic factors can be used to counsel the patient before the operation in order to plan the surgical approach.⁹^,²⁴ Radical surgery for DIE of posterolateral parametrial endometriosis can injure the autonomic nerves of the inferior hypogastric plexus, causing bladder dysfunction, particularly in cases of infiltration of both lateral parametrium.⁶ As the surgical risk is not negligible, in some cases it is advisable to leave the parametrial disease or to choose the most affected side to treat in cases of bilateral parametrial involvement. Surgical treatment of lateral and/or posterior parametrial DIE should consist of a nerve-sparing parametrectomy, if it is feasible. The retroperitoneal dissection is performed according to the principles of the nerve-sparing surgery previously reported. Regarding posterior parametrial DIE, after development of the rectovaginal space and medial pararectal space, posterolateral parametrium is identified and isolated, saving nerves running into rectal wings and ‘hypogastric’ fascia. However, if grossly involved by the disease, rectal wings and/or rectovaginal ligaments and/or uterosacral ligaments must be resected. Regarding lateral parametrial DIE, after development of medial and lateral pararectal spaces, the uterine artery is isolated from its origin to the ureteral tunnel. When possible, the uterine artery should be spared, and the deep uterine vein is used as a landmark to distinguish the vascular portion of the paracervix from its neural portion, which has to be preserved as much as possible.¹⁰

Parametrial endometriosis.

PRACTICE RECOMMENDATIONS

Deep infiltrating endometriosis is the most severe form of endometriosis and can affect several structures and organs, including uterosacral ligaments, pelvic sidewall, rectovaginal septum, vagina, bowel, bladder, ureter and lateral parametrium.
Complete surgical removal significantly improves endometriosis-associated pain and quality of life in women with deep infiltrating endometriosis.
Surgery should be performed as a tailored treatment, based on patient and disease characteristics, in a high-volume center with an expert multidisciplinary surgical team, after informing patients of the potential surgical risks and expected benefits.
A standardized and reproducible surgical technique for deep infiltrating endometriosis treatment, should include some general steps: identification, isolation of the nodule and its safe removal.
Dealing with anatomical distortion and retroperitoneal fibrosis caused by deep infiltrating endometriosis requires extensive knowledge and adequate exposure of the retroperitoneum.
Despite there being no consensus regarding the best technique to adopt in recto-sigmoid endometriosis, conservative techniques are preferred as a first attempt.
Ureteral involvement has to be suspected when deep endometriotic lesions are close to the ureter (such as the uterosacral ligament, rectovaginal septum, and lateral parametrium).
After ureteral surgery for both intrinsic and extrinsic endometriosis, patients should be monitored by kidney ultrasound every 6 months in order to avoid overlooking silent hydronephrosis.
Endometriotic nodule of the bladder more commonly involves the detrusor muscle and rarely infiltrates mucosa.
Eradication of the bladder nodule is performed with a partial cystectomy with or without opening of the bladder cavity.
At the end of surgery, the integrity of the bowel and/or bladder must be tested regularly.
Radical surgery for DIE of postero-lateral parametrial endometriosis can injure the autonomic nerves of the inferior hypogastric plexus, causing bladder dysfunction, particularly in cases of infiltration of both lateral parametrium.
As the surgical risk is not negligible, in some cases it is advisable to leave the parametrial disease or to choose the side to treat in cases of bilateral parametrial involvement.

CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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REFERENCES

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