Surgical Techniques for the Treatment of Rectal Endometriosis: A Systematic Review of Randomized Controlled Trials and Observational Studies

Abstract

BACKGROUND Endometriosis is a common disease in reproductive-age women and it is estimated to occur in up to 50% of those with infertility. Intestinal involvement is reported in up to a third of the cases. This condition is related to chronic pain and loss of quality of life, resulting in emotional, social and economic costs. Treatment consists of hormonal block and surgical resection, with variable side effects and efficacy. The best choice for surgical treatment for rectal endometriosis is a matter of discussion regarding the indication and the best technique to be employed. OBJECTIVE To summarize data on indications, results and complications of surgical techniques for the treatment of rectal endometriosis. METHODS: This comprehensive systematic review is a compilation of the available literature and discussion, carried out by a team with experience in the surgical treatment of intestinal endometriosis. Data regarding indications, results and complications of conservative and radical techniques for the surgical treatment of rectal endometriosis was carefully reviewed. Searches of PubMed, EMBASE, and CENTRAL up to May 2021 were performed to identify randomized controlled trials (RCTs) and observational studies that compared at least two of the three surgical techniques of interest (i.e., shaving, discoid resection, segmental resection). RESULTS: One RCT and nine case series studies with a total of 3,327 patients met the eligibility criteria. Participants ages ranged from a mean of 30.0 to 37.9 years old. Mean follow-up ranged from 1.2 to 42.76 months. With regards the methodological quality, overall the included studies presented a low risk of bias in the majority of the domains. Surgical treatment of rectal endometriosis is indicated for patients with obstructive symptoms and those with pain scores above 7/10. Patients with disease involving beyond muscularis propria of the rectum, documented in magnetic resonance imaging or transvaginal pelvic ultrasound with intestinal preparation, are candidates for discoid or segmental resection. The presence of multifocal disease, extension greater than 3 cm and infiltration greater than 50% of the loop circumference favor the radical technique. The distance from the lesion to the anal verge, age, symptoms and reproductive desire are other factors that influence the choice of the technique to be employed. The risk of complications and unfavorable functional results seems to be directly related to the complexity of the procedure. CONCLUSION: The choice of surgical technique performed for the treatment of rectal endometriosis is a matter of discussion and depends not only on the preoperative staging, but also on the patient’s expectations, risks and potential complications, recurrence rates and the expertise of the multidisciplinary team.

The Role of Magnetic Resonance Imaging in the Planning of Surgical Treatment of Deep Pelvic Endometriosis

“…Surgical treatment is a common approach for the diagnosis and treatment of endometriosis, particularly for patients non-responding to medical therapy and with severe symptoms ( 8 ). Because the surgical treatment may vary depending on the location, severity, and extent of involvement, accurate diagnosis and localization are crucial for appropriate management ( 9 ). In this regard, there are different types of surgeries based on localization.…”

Surgical Treatment of Deep Endometriosis

“…Contrary to previous assumptions, the methods are equivalent in terms of the probability of recurrence [41]. Reviews, retrospective studies, and case control studies demonstrate that avoiding a radical approach has better results in terms of operation-related morbidity and the complication rate [43,44]; however, in the only randomized study on this topic, there wascontrary to expectationsno significant difference [45]. In that sense, the decision must be made together with the patient and with clinical judgment.…”

“…Entgegen früherer Annahmen sind die Methoden hinsichtlich der Rezidivwahrscheinlichkeit gleichwertig 41 . In Übersichten, retrospektiven und Fallkontrollstudien schneidet der Verzicht auf Radikalität mit Blick auf die operationsbedingte Morbidität und die Komplikationsrate besser ab 43 44 ; in der einzigen randomisierten Studie dazu gab es – entgegen der Erwartung – jedoch keinen signifikanten Unterschied 45 . Insofern muss die Entscheidung gemeinsam mit der Patientin und mit klinischem Augenmaß gefällt werden.…”

“…Entgegen früherer Annahmen sind die Methoden hinsichtlich der Rezidivwahrscheinlichkeit gleichwertig [41]. In Übersichten, retrospektiven und Fallkontrollstudien schneidet der Verzicht auf Radikalität mit Blick auf die operationsbedingte Morbidität und die Komplikationsrate besser ab [43,44]; in der einzigen randomisierten Studie dazu gab esentgegen der Erwartungjedoch keinen signifikanten Unterschied [45] Zwerchfell, Pleura, Lungenparenchym (#Enzian F) Die TIE dieser Lokalisationen wird unter dem Begriff "Thorakales Endometriose-Syndrom" (TES) zusammengefasst, wobei die Zwerchfellendometriose hierbei 89 % ausmacht. Typische Sympto-me sind Kurzatmigkeit, rechtsseitige, zyklusabhängige Thorax-, Schulter-und Armschmerzen, der sogenannte katameniale Spontanpneumothorax, der meist rechtsseitig auftritt, oder Hämoptysen.…”

Therapeutic use of cannabidiol in endometriosis: literature review

“…The endometrium, tissue affected in this pathology, is the innermost layer of the uterus and responsible for the implantation of the embryo and its nutrition in the first weeks of pregnancy. However, in this disorder, the proliferation of this layer occurs in a disorderly way to places beyond the uterine cavity, such as abdominal organs or pelvic structures 2 . The main manifestations are dysmenorrhea, non-menstrual pelvic pain and dyspareunia that affect well-being 3 .…”