Posterior Deep Endometriosis. What is the best approach? Dept Gyn Obst CHU Clermont Ferrand France

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Ophelia Bruce
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1 Posterior Deep Endometriosis What is the best approach? Dept Gyn Obst CHU Clermont Ferrand France

2 Posterior Deep Endometriosis Organs involved - Peritoneum - Uterine cervix - Rectum - Vagina

3 Should we perform a routine excision of the vagina?? décembre 16 WES Melbourne

4 Deep disease in the Posterior cul de sac The lesion is visible vaginally. We have two signs - blue cysts - pseudo polyps

6 Postoperative clinical examination < n % n % No nodule preop Normal post op clinical exam Lost to follow up Persistent nodule décembre 16

7 Background The first line management of deep infiltrating endometriosis is surgery; however, which surgical technique to use is an ongoing debate. It is unclear whether the posterior vaginal fornix must routinely be excised.

8 Objective To evaluate histologically whether the routine excision of the posterior vaginal fornix was necessary in the surgical management of patients with large rectovaginal endometriotic nodules.

9 Patients Prospective database: Oct./2001-Mar./2007 Rectovaginal endometriotic nodules > 2 cm in size 61 patients: for the present histological analysis - 29 patients: 3cm > nodule >2cm, - 32 patients: nodule 3 cm. rasrm stage I: 3 patients; stage II: 18 patients stage III: 8 patients; stage IV: 32 patients

10 Methods The minimum distance on histological sections was measured using a computerized analysis system H&E V V E E E V V: Vaginal mucosal epithelium; E: Endometriotic lesions

11 Results The minimum distance between the vaginal mucosal epithelium and the endometriotic glands Distance ( m) 500 < No. of patients 20 (32.8%) 10 (16.4%) 14 (23.0%) 5 (8.2%) 5 (8.2%) 6 (9.8%) 30 patients (49.2 %) <1000 m 44 patients (72.1%) < 2000 m 60 patients (98.4% ) < 5000 m

12 Results The minimum distance: with or without pre-operative medical treatment Treatment group No treatment (n=21) GnRHa (n=18) Continuous oral P (n=14) Continuous OC (n=3) Cyclic OC(n=5) Distance ( m) 1829± ± ± ± ±1127 Data: mean ± SD

13 Conclusion Excision of posterior vaginal fornix is necessary for the complete removal of large rectovaginal endometriotic nodules in more than 70% of the cases.

14 If we avoid vaginal excision to perform a safer bowel resection Do we transform the treatment of a gynecological disease in a colo rectal procedure? décembre 16

15 Surgical technique: Initial steps Effective uterine manipulator Exposure of the pelvis Adhesiolysis of the sigmoid colon up to the superior pelvic brim so as to facilitate the identification of the left ureter Identification of the ureters Dissection of the ureter if the nodule involves the US or is more than 2 cm in diameter Dissection of the para rectal area on both sides Dissection of the lateral and inferior surface of the nodule in the para rectal spaces

18 Limits (1e)

19 Limits (1f)

20 Limits (1h)

21 Initial steps It is essential to identify vulnerable structures in a normal area It is essential to increase the mobility of the nodule so as to facilitate the following steps of the procedure It is essential to preserve the hypogastric and splanchnic nerves whenever possible (both sides are rarely involved, but when the nerves are involved by the nodule they cannot be preserved

24 Then The nodule is fixed to the uterus, to the vagina anteriorly and to the rectum posteriorly

25 The best surgical approach? Dissection of the rectum from the nodule first Excision of the vagina first

26 Dissection of the rectum first Examples

27 Technique (1)

28 Technique (5)

29 Technique (6)

30 Technique (7)

31 Technique (8)

32 Advantages of the rectum first Most difficult part of the operation at the beginning of the procedure The nodule is retracted by the vagina and or the cervix The vision from the ombilicus is good behind the cervix Earlier diagnosis of the bowel involvement

34 Severe complications N = 230 N =176 Rectovaginal fistula Ureteral fistula Ureteral stenosis Ureteral injury Hemorrhage Septicemia Pelvic abscess P< 0.02

35 Severe complications increased Diameter of the nodule increased The conversion rate decreased The surgical approach was more agressive The incidence of vaginal excision, rectal procedure and patients with extensive adhesion increased Main explanations for recto vaginal fistula were Surgical mistakes (if you have a complication, you have to accept that you did something wrong) Very large nodule 4 cm Previous surgery for deep disease

36 Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis. Darai E et al Thirty-six women (90%) underwent laparoscopic segmental colorectal resection and 4 required laparoconversion. Major complications occurred in 4 cases (10%), including 3 rectovaginal fistulae and 1 pelvic abscess.

37 «The reverse technique»

38 The Reverse technique: Rationale The most important part of the procedure is the treatment of the rectum either «skinning» or bowel resection Vaginal excision is easier! Exposure is the key of surgery Mobility of the treated organs is the key to exposure To achieve the most important part of the procedure the exposure should be optimal To improve the exposure mobility should be improved The only way to improve the mobility of the nodule before the treatment of the rectum is to separate it from the uterus and from the normal vagina décembre 16

39 The reverse technique

40 The reverse technique

41 1 2 3 décembre 16 WES Melbourne

42 The reverse technique

43 The reverse technique

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45 décembre 16

46 Vagin ouvert 1 décembre 16

47 1 2 3 décembre 16

48 1 2 3 décembre 16

49 1 2 décembre 16

50 décembre 16 WES Melbourne

51 The reverse technique

52 décembre 16

53 décembre 16 1

54 1 2 3 décembre 16

55 décembre 16 1

56 1 3 2 décembre 16

57 2 1 décembre 16

58 The reverse technique

59 The «reverse technique»

60 Comparative Results patients 35 patients treated with the standard technique 40 patients treated with the reverse technique

61 Data of the groups Mean age Mean BMI Parity Size of the nodule Standard technique N = ± ± 3 0 (0-3) 2 (0.5-5) Reverse Technique N = ± ± 3 0 (0-3) 2 ( )

62 Perioperative outcomes Standard N = 35 Reverse N = 40 p value Operating time ± ± Blood loss 50 (20 700) 50 (20 700) 0.18 Ureterolysis 32 (91.4 %) 33 (82.5%) 0.26 Rectal surgery 0.86 Shaving 32 (91.4%) 37 (92.5%) Resection 3 (8.6%) 3 (7.5%)

63 Post operative outcomes Standard N = 35 Reverse N = 40 p value Major per op Complication 1 (2.9%) Conversion Paralytic ileus (h) 24 (12 72) 24 (12 48) 0.14 Mean hospital stay (d) 3 (1-22) 3 (1 24) 0.59 Size of the nodule (cm Path) 3.4 ± ±

64 Post operative complications Standard N = 35 Reverse N = 40 p value Minor 4 (11.4%) 4 (10%) 0.84 Major 8 (22.9%) 2 (5%) 0.02 Recto vaginal fistula * 1 (2.9%) 1 (2.5%) 0.92 Standard group: 3 Post operative bleeding, 2 pelvic abscess, 2 ureteral fistulae, 1 recto vaginal fistula Reverse group : 1 pelvic abscess, 1 stenosis of the ileostomy

65 Conclusion In the present study, the use of reverse laparoscopic technique in patients with rectovaginal endometriosis who required both rectal surgery and vaginal resection reduced the major postoperative complication rate compared to the standard technique. Further and larger studies are necessary to confirm this initial finding.

66 Conclusion Shorter learning curve??

67 There are bowel resection which should be performed

68 décembre 16

69 There are rectal resection which are not necessary!

70 décembre 16

71 décembre 16

72 décembre 16 WES Melbourne

73 décembre 16

74 décembre 16

75 Bladder endometriosis Tubes

76 Bladder endometriosis

77 Bladder endometriosis

80 Bladder endometriosis

81 Bladder Endometriosis

82 Bladder endometriosis

83 Ureteral endometriosis

84 Ureteral endometriosis

85 Ureteral endometriosis

Posterior Deep Endometriosis. What is the best approach? Posterior Deep Endometriosis. Should we perform a routine excision of the vagina??

Posterior Deep Endometriosis. What is the best approach? Posterior Deep Endometriosis. Should we perform a routine excision of the vagina?? Posterior Deep Endometriosis What is the best approach? Dept Gyn Obst Polyclinique Hotel Dieu CHU Clermont Ferrand France Posterior Deep Endometriosis Organs involved - Peritoneum - Uterine cervix -Rectum