Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis †‡¶

Abstract

STUDY QUESTION How should surgery for endometriosis be performed? SUMMARY ANSWER This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age. WHAT IS KNOWN ALREADY Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe. STUDY DESIGN, SIZE, DURATION A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis. PARTICIPANTS/MATERIALS, SETTING, METHODS This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery. MAIN RESULTS AND THE ROLE OF CHANCE The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis. LIMITATIONS, REASONS FOR CAUTION Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added. WIDER IMPLICATIONS OF THE FINDINGS These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma. STUDY FUNDING/COMPETING INTEREST(S) The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose. TRIAL REGISTRATION NUMBER na

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

“…Because of the risk of urinary and bowel complications [ 6 , 7 ] an experienced multidisciplinary team should perform the surgery. The latest guidelines on the practical aspects of surgery for the treatment of deep infiltrating endometriosis were elaborated by a clinical expert consensus panel [ 8 ] and efforts to identify and preserve autonomic pelvic nerves whenever possible are recommended [ 9 ].…”

Nerve-Sparing Modified Radical Hysterectomy for Severe Endometriosis and Complex Pelvic Pathology

“…In cases of endometriosis and other complex pelvic pathology such as large uterine fibroids, ovarian cysts, and/or severe adhesive disease, laparoscopy is often necessary for thorough evaluation and treatment of the etiology of pelvic pain. Laparoscopy allows for improved anatomical visualization and more thorough treatment of various pathologies in the abdomen and pelvis, including treatment of extragenital endometriosis [7].…”

Classification of endometriosis

“…More recently, the European Society of Human Reproduction and Embryology (ESHRE) published recommendations for the surgical treatment of DIE [ 28 ]. A working group of the European Society for Gynaecological Endoscopy, ESHRE and World Endometriosis Society (WES) collaborated to make recommendations for surgical treatment of DIE.…”