Surgery for Deep Endometriosis: A Pathogenesis-Oriented Approach

Abstract

Background: Deep endometriosis is usually associated with severe symptoms and constitutes a complex treatment challenge. Methods: The available evidence has been revisited with the aim of defining an effective diagnostic workup and a safe surgical strategy based on pathogenetic findings. Results: Vaginal, rectal, and bladder detrusor endometriosis appear to be caused by intraperitoneal seeding of regurgitated endometrial cells which implant in the posterior and anterior cul-de-sac and trigger an inflammatory process leading to adhesion of contiguous organs. Excision of posterior deep lesions implies removal of a fibrotic cast of the Douglas’s pouch which may involve the posterior vaginal fornix and the rectal muscular layer, with a not negligible risk of major complications. Removal of full-thickness bladder detrusor endometriosis entails excision of the bladder dome or posterior wall, generally well above the trigone. Transurethral resection is contraindicated. A radical approach to obstructive uropathy is suggested, with resection of the stenotic ureteral tract and reimplantation with antireflux vesicoureteral plasty. Conclusion: Infiltrating endometriotic lesions appear to originate intraperitoneally sharing common pathogenetic mechanisms. Involvement of the intestinal and urologic apparatuses should be identified before surgery, in order to schedule intraoperative consultation and to inform the woman about the type of intervention required and its potential sequelae.

Th1 and Th2 immune responses related to pelvic endometriosis

“…Particularly, in more aggressive, infiltrating forms of the disease, there appears to be a predominant action of cell immunity, with cells, enzymes and cytokines provoking adhesion, infiltration and maintenance of the foci of ectopic endometrial tissue. Deeply infiltrating endometriosis is a major issue in several studies related to this disease, including etiopathogenesis, clinical data, imaging methods and an intense clinical and surgical treatment debate 16,17,18,19,20,21 . There are still some topics that have no consensus, such as the best imaging method for diagnosis of deep lesions (mainly bowel endometriosis) 18,19 and the best option for treatment of these lesions, due to the complication risk related to the more advanced surgical procedures 20,21 .…”

Atypical Endometriosis of the Urinary Bladder: Review of the Literature and a Clinical Case

“…При поражении внутреннего слоя пузыря цистоскопию рекомендуется выполнять непосредственно перед или во время менструации, когда эндометриоидные гетеротопии несколько увеличены в размерах. Цистоскопия позволяет оценить расстояние между устьями мочеточников и границами эндометриоидных очагов для планирования объема хирургического вмешательства [8].…”

Experience with multidisciplinary laparoscopic surgery in patients with deep infiltrating colorectal endometriosis

“…Az intraoperatív szövődmények közé sorolható az ureterperforáció, amely klinikánkon 2%-ban fordult elő, ami hasonló arányban fi gyelhető meg (0,5-1%) Vercellini és mtsai tanulmányában [26]. Az intraoperatív komplikációk közül megemlítendő még az arteria epigastrica inferior sérülése, amely szintén egy esetben fordult elő (2%).…”

“…Az egyik leggyakoribb, az alsó gastrointestinalis traktust érintő korai posztoperatív szövőd-mény a rectovaginalis fi stula. Klinikánkon mindössze egy esetben (2%) alakult ki, míg más vizsgálatok magasabb arányú, 8,4%-os [20] és 2-10%-os [26] előfordulási gyakoriságról számoltak be. Kialakulását jelentős mér-tékben csökkenti a tehermentesítő colostoma vagy a kisebb oldalirányú hőhatással rendelkező ultrahangos vágókészülék, illetve a CO 2 -lézer használata [20].…”

“…Kismedencei tályog kialakulásáról 4,2%-ban [20] és 1-2%-ban [26] számoltak be, amely betegeinkben nem fordult elő.…”