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), European Society of Human Reproduction and Embryology (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 interests: 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; non-financial support and other from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals, and Merck SA, outside the submitted work. The other authors had nothing to disclose.

Keywords: deep endometriosis; endometriosis; extrapelvic; frozen pelvis; good practice recommendations; hysterectomy; laparoscopy; surgery.

Figure 1

The layers of the recto-sigmoid colon, as graphical representation (upper figure), in eosin-stained healthy recto-sigmoid colon (lower left) and eosin-stained endometriosis-affected recto-sigmoid colon (lower right). 1. Serosa (sigmoid) or Adventitia (rectum); 2. Subserosa; 3. Tunica muscularis (outer longitudinal layer, inner circular layer) with Plexus myentericus in between; 4. Submucosa with Plexus submucosus, blood, and lymphatic vessels; 5. Mucosa.

Figure 2

Anatomical landmarks in DE surgery (vessels, nerves, ureter, bladder, bowel) which may be involved and have to be respected carefully. DE: deep endometriosis. (Image courtesy of Complete Anatomy (reprinted with permissions).

Figure 3

Revised ENZIAN-classification for DE. The system classifies the clinical findings of endometriosis according to their localisation (compartment) and size (<1 cm, 1-3cm, > 3cm). The ENZIAN classification focusses on the three dimensions (compartments) in the pelvis: A= craniocaudal axis or compartment (rectovaginal space, vagina), B= laterodorsal axis (uterosacral and cardinal ligaments), C= dorsal axis (rectosigmoid). Other localisations as uterus, bladder, ureter, other bowel involvement and extragenital localisations are respected as well and described with suffix F). The ENZIAN Classification is under revision (2019) again which is under publication.

Figure 4

MRI picture of the pelvis. DE in the rectum with small, dense adhesions between the posterior wall of the cervix and ante- rior wall of the rectum (right circle) and adenomyosis (left circle).

Figure 5

Deep endometriosis of the rectosigmoid. The extent of the white nodules (multifocal) which infiltrate the muscular layer are not visible by colonoscopy and also difficult to identify completely by laparoscopy.

Figure 6

Transvaginal ultrasound of the rectosigmoid with signs of infiltration of the muscular layer. Length >3 cm Enzian C3. Hypodense ultrasound pattern (halfmoon shaped) represents the hyperplasia of the lamina muscularis with inclusion of epithelium, stroma and fibrosis.

Figure 7

Deep endometriosis in the vagina, rectovaginal septum and the anterior wall of the rectum (Enzian A,C compartment). Two different ways to excise the nodule. A manipulator and a sponge or rectal probe is in situ for a better presentation of the nodule during the excision procedure. (Reprinted with permissions from Keckstein and Hucke, 2000).

Figure 8

Frozen pelvis with invisible deep endometriosis (bi-lateral ovary, left cardinal ligament, ureter left, anterior wall of the rectum).

Figure 9

DE involving the uterosacral ligament, vagina and the rectum. The extent of the disease is not visible during diagnostic laparoscopy. Spaces have to be opened in order to get access to the entire lesion.

Figure 10

Dissection of the posterior compartment. Right uterosacral ligament has already been resected, the vagina is partially open with the manipulator in place.

Figure 11

Symptomatic DE of the sigmoid colon with stenosis. Segmental resection is necessary.

Figure 12

Disc resection of the anterior rectal wall with the circular stapler. Specimen in the open stapling device.

Figure 13

Final view of the rectum with the lining of the stapler in the anterior wall.

Figure 14

Rectoscopy with the view of the stapler lining in the anterior rectal wall.

Figure 15

SDE of the rectosigmoid colon. Segmental resection with linear stapler, resection of the segment outside of the abdominal cavity is followed by the anastomosis with circular stapler (Reprinted with permissions from Keckstein and Hucke, 2000).

Figure 16

Deep endometriosis of the bladder.

Figure 17

DE of the bladder. The cystotomy was closed transversally with 3-0 resorbable running suture. The nodule (3 cm diameter) is presented with the forceps.

Figure 18

Intrinsic endometriosis in the left ureter with stenosis and hydronephrosis.

Figure 19

Segmental resection of the infiltrated part of the ureter.

Figure 20

Incision of the distal stump of the ureter in order to increase the circumference in order to facilitate the end to end anastomosis and to decrease the risk of a post-operative stenosis formation.

Figure 21

Final view of the end-to-end anastomosis (tension-free).