ENDOMETRIOSIS When and how to implement treatment

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1 ENDOMETRIOSIS When and how to implement treatment

2 Francisco Carmona Hospital Clínic

3 ENDOMETRIOSIS TREATMENT It depends on the severity of symptoms the patient's desire for pregnancy the extent of disease the location of disease the age of the patient.

4 ENDOMETRIOSIS TREATMENT TREATMENT OBJECTIVES: - Symptom control - Increase fertility. - Recurrence prevention. - Endometriosis lesions.

5 Endometriosis Treatment Options Expectant Management Medical therapy Progestins Levonorgestrel-releasing intrauterine device Danazol GnRH analogues Oral Contraceptives Analgesics, NSAIDs Surgical therapy Conservative: retains uterus and ovarian tissue Definitive: removal of uterus and possibly ovaries Combination therapy Preoperative medical therapy Postoperative medical therapy

6 MEDICAL TREATMENT Improve patients - Increase QoL - Useful in patients with mild-moderate cases - Some medical treatments reduce the recurrence rate after surgery

7 MEDICAL TREATMENT - It is not a definitive cure for the disease

8 Endometriosis Treatment New options Hormonal treatments Aromatase inhibitors GnRH antagonists Selective progesterone receptor modulators Selective estrogen receptor modulators Selective ER-β agonists Non hormonal treatments Antiangiogenics Dopaminergic agonists Statins TNF α-blockers Infliximab Immunomodulators Pentoxifylline Anti COX-2 agents Peroxisome proliferator-activated receptor γ-ligands Anti-nerve growth factor inhibitor antibody Inducers of apoptosis

Analgesics, NSAIDs Surgical therapy Conservative: retains uterus and ovarian tissue Definitive:

9 Endometriosis Treatment Options Expectant Management Medical therapy Progestins Levonorgestrel-releasing intrauterine device Danazol GnRH analogues Oral Contraceptives Analgesics, NSAIDs Surgical therapy Conservative: retains uterus and ovarian tissue Definitive: removal of uterus and possibly ovaries Combination therapy Preoperative medical therapy Postoperative medical therapy

10 ENDOMETRIOSIS. Importance of presurgical staging OE 24 patients 16 patients 28 patients Adenomyosis 22 patients 30 patients 20 patients Hospital Clinic Results (january-july 2013) 30 patients DIE

11 ENDOMETRIOSIS SURGICAL TREATMENT PHILOSOPHY Conservative towards function Radical towards disease Tailor the surgery To respect patient desires

12 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS - Not always a progressive/recurrent disease Indication for surgery is mainly clinical Diagnosis alone is not an indication for surgery!

13 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS - The first surgery is the most important If incomplete, subsequent surgery will be more difificult

14 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS It is increasingly recognized that endometriosis is one of the most challenges and difficult types of pelvic surgery a gynecologist may face Not all gynecologists/centers are adequately prepared to deal with all cases of DIE

15 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS A decision has to be made according to: - Severity of disease found (both in the preoperative study and during surgery) - Adequacy of preoperative information and consent - Suitability of medical environment - Surgical skill and expertise - Level of postoperative care

16 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS Intraoperative Decision: 1.- See-and-treat 2.- See-and-discuss 3.- See-and-refer

50% hydronephrosis - ICGON: 60% hydronephrosis patients were asympto.

18 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS IMPORTANCE OF PRESURGICAL STAGING: - Several localizations coexist - Previous surgeries: adhesions - Asymptomatic patients: - > 50% hydronephrosis - ICGON: 60% hydronephrosis patients were asympto. - Difficult localizations - Appendicular (4% endometriosis) - ICGON: 5% (100% multiple localizations).

19 ENDOMETRIOSIS SOME IMPORTANT CONCEPTS ADVANTAGES OF PRESURGICAL STAGING: Non invasive Specialized team available Informed consent No incomplete surgeries: recurrences

20 TVUS: 1 st line modality Readily available Well accepted Cost effective Time effective!s, S; LR+, LR-

21 Specific Indications for MRI Some specific localizations or cases Ureter Sigmoid after diagnosis of rectal nodule Right bowel Parametrial affectation USL Extrapelvic locations Pretreatment in UAE or HIFU Adenomyosis (?) Differentiation of endometrioma from Hemorragic or mucinous cyst Differentiation of decidualized cyst from cancer

22 General Surgical Strategy 1 st Step TO KNOW DISEASE SEVERITY To explore the whole abdominal cavity " Visible disease " Retraction/Adhesion " Anatomic distortion

24 General Surgical Strategy 2 nd Step EXPOSITION " Mobilization small bowel " Mobilization uterus " Adhesions disection " Sigma liberation " Sigma Suspension (if needed) " Ovarian Suspension (if needed)

26 General Surgical Strategy 3 rd Step RECTAL DISECTION Ureter Disection (if needed) Start laterally From healthy areas to the disease

28 General Surgical Strategy 4 th Step NODULE DISECTION " Disection between nodule and rectum - Most times, disease in the genital side " To test integrity (Safety tests) - Bubble test - Methilen Blue / Iodine

29 General Surgical Strategy 5 th Step FISTULA PREVENTION Omentoplasty Sealants Drain

30 Specific Surgical Strategy Bowel To decide among shaving/discoid resection and segmental resection

31 Specific Surgical Strategy Bowel To decide among shaving/discoid resection and segmental resection There are no evidence based criteria to help us on that decision

32 Specific Surgical Strategy Bowel - Segmental resection - Discoid resection/shaving - Multiple lesions - Stenosis - % Circumference >40% - Mucous or submucous infiltration - Sigmoid localization (Leak %: 1%) - Single lesion - No Stenosis - % Circumference <40% - No Mucous or submucous infiltration - Rectumlocalization (Leak %: 5-15%) Systematic ileostomy not indicated

33 Specific Surgical Strategy Bowel Ileo cecal area/appendix: special case 4-5% of DIE cases Risk of obstruction Always look at More than two lesions

34 Specific Surgical Strategy Bladder Complete excision is mandatory as associated with symptomps resolution and low recurrence Shaving, mucosal skinning and partial cystectomy are adequate depending on size an infiltration. Preoperative cistoscopy is mandatory

35 Specific Surgical Strategy Bladder Two layer closure technique is used Catheter in place for days Ureteral catheter in place if ureteric resection or trigone afectation

37 Specific Surgical Strategy Ureter Intrinsinc afectation is not frequent Resection: anastomosis; reimplatantion Extrinsinc afectation is common, maninly in the distal third In rectovaginal DIE ureters are tipically pulled medially and have to be dissected

38 Specific Surgical Strategy Ureter Ureter must be checked preoperatively in cases of rectovaginal endo or extensive disease Ureter must be always seen during surgery Uni or bilateral ureterolysis is almost always needed in rectovaginal surgery

39 Specific Surgical Strategy Ureter We do not systematic preoperative ureteral stenting Indications for ureteral stent are: Ureterohydronephrosis (pre) Previous ureteral lesion (pre) Ureteral dilatation not previously recognized Ureteral injury or resection Too much disection

40 Specific Surgical Strategy Endometrioma Ovarian Cystectomy: Ovarian Tissue adjacent to the cyst wall Endometriomas 58.7% Other benign cysts: 5.4% (p < 0,001)

43 OVARIAN ENDOMETRIOMA SURGERY Pro-SURGERY Pro-ART Symptoms Yes No Age Young Old Ovarian Reserve Normal Low Previous surgery No Yes Cyst size Big Small Risc of malignancy Yes No

49 TAKE HOME MESSAGES - Taylor the treatment!!! - Medical treatment may control symptoms. - Adequate presurgical staging is mandatory - Surgery requires specialization

50 Endometriosis and Infertile Woman Rationale Symptoms Pelvic pain of endometriosis or infertility TVUS with Bowel Prep AMH, FSH FSH Pain < 7 (VAS) No Bowel Obstrucion No Ureteral Obstruction Pain >= 7 (VAS) or Bowel Obstrucion or Ureteral Obstruction Ovulation Inducion (normal tubal patency) IVF Low AMH > 30yo Normal AMH < 30yo Cryopreservation Surgery Surgery Ovarian Induction - IVF ET

53 Deep Infiltrating Endometriosis DIE: Endometriosis infiltrating >5mm under peritoneal surface bladder 5 localizations: Utero-sacral ligaments vagina ureter Posterior DIE is the more frequent form, including USL, uterine torus, the posterior vaginal wall and the anterior rectal wall. bowel Koninckx et al. (1994). Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gynecol. Chapron C et al. (2009). Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril.

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