Retroperitoneal Anatomy during Excision of Pelvic Side Wall Endometriosis

Abstract

Surgical management of endometriosis has been shown to improve dysmenorrhea at all disease stages and is recommended in severe disease for treatment of infertility. Deeply infiltrating endometriosis (DIE) produces thick inflammatory tissue that precludes visualization of anatomical landmarks and distorts normal anatomy. Excision of DIE poses several technical and surgical challenges that mandate a clear understanding of the anatomy of the pelvic sidewall. This review details relevant surgical anatomy and addresses the principles of safe retroperitoneal entry, ureterolysis and excision of endometriotic lesions. Proper use of these techniques should facilitate safe and successful surgery for management of DIE.

Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial

“…The higher failure rate in the UL group than the OR group reinforces the concept that the UA closure at the origin is more reproducible than closing at the isthmus, which is not always feasible 21 . Notably, the failure to close UAs at the UL was significantly associated with the intraoperative identification of endometriosis and the need for parametrectomy and ureterolysis 21–23 . In these cases, developing the paravesical and pararectal spaces is necessary 22–24 .…”

“…[21][22][23] In these cases, developing the paravesical and pararectal spaces is necessary. [22][23][24] Consequently, the UA occlusion at the origin appears to be a safer and more reproducible maneuver to complete hysterectomy. 21 Moreover, we observed two (2.2%) cases of ureteral duplication in the OR group.…”

“…21 Notably, the failure to close UAs at the UL was significantly associated with the intraoperative identification of endometriosis and the need for parametrectomy and ureterolysis. [21][22][23] In these cases, developing the paravesical and pararectal spaces is necessary. [22][23][24] Consequently, the UA occlusion at the origin appears to be a safer and more reproducible maneuver to complete hysterectomy.…”

Pelvic Sidewall Anatomy in Gynecologic Oncology—New Insights into a Potential Avascular Space

“…Depending on the stage and histology of a tumor, a lymph node dissection is often performed in gynecologic oncology [ 2 ]. In cases of bulky metastatic lymph nodes, gynecological tumors or recurrences located near the pelvic sidewall, oncogynecologists should dissect tissues in that region [ 3 , 4 ]. Moreover, surgery of deep infiltrating endometriosis, e.g., within the sacral plexus, or oncological procedures, such as a laterally extended endoplevic resection (LEER) or a laterally extended parametrectomy (LEP), often require a dissection of the pelvic sidewall (PSW) [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ].…”

“…In cases of bulky metastatic lymph nodes, gynecological tumors or recurrences located near the pelvic sidewall, oncogynecologists should dissect tissues in that region [ 3 , 4 ]. Moreover, surgery of deep infiltrating endometriosis, e.g., within the sacral plexus, or oncological procedures, such as a laterally extended endoplevic resection (LEER) or a laterally extended parametrectomy (LEP), often require a dissection of the pelvic sidewall (PSW) [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ]. Extraperitoneal internal iliac artery ligation can also be necessary for patients with locally advanced cervical cancer and severe genital bleeding.…”