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

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Alexandra Russell
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Posterior Deep Endometriosis Organs involved - Peritoneum - Uterine

1 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 - Vagina Should we perform a routine excision of the vagina?? WES Melbourne 2008

2 Deep disease in the Posterior cul de sac The lesion is visible vaginally. We have two signs - blue cysts - pseudo polyps Postoperative clinical examination < n % n % No nodule preop Normal post op clinical exam Lost to follow up Persistent nodule

3 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. 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. 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

Methods The minimum distance on histological sections was measured using a computerized analysis system H&E V E V E E V V:

endometriotic glands Distance (µm) ) 500 < 500-1000 1000-2000 2000-3000 3000-4000 4000-5000 No. of patients 20 (32.8%) 10 (16.

4% ) < 5000 µm Results The minimum distance: with or without pre-operative medical treatment Treatment group No treatment (n=21)

4 Methods The minimum distance on histological sections was measured using a computerized analysis system H&E V E V E E V V: Vaginal mucosal epithelium; E: Endometriotic lesions Results The minimum distance between the vaginal mucosal epithelium and the endometriotic glands Distance (µm) ) 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 µm 44 patients (72.1%) < 2000 µm 60 patients (98.4% ) < 5000 µm 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 (µm) 1829± ± ± ± ±1127 Data: mean ± SD

5 Conclusion Excision of posterior vaginal fornix is necessary for the complete removal of large rectovaginal endometriotic nodules in more than 70% of the cases. If we avoid vaginal excision to perform a safer bowel resection Do we transform the treatment t t of a gynecological disease in a colo rectal procedure? Preoperative management Clinical symptoms Imaging g Bowel prep Multidisciplinary team - Colo rectal surgeon - Urologist - Pain specialist - Plastic surgeon

Clinical Symptoms Pain No pain No digestive

surgery Surgical technique: Initial steps

pelvis Adhesiolysis of the sigmoid colon up to

the ureter if the nodule involves the US or is

para rectal area on both sides Dissection of

6 Clinical Symptoms Pain No pain No digestive sign Significant digestive complaints No surgery 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

7 Limits (1e) Limits (1f)

Limits (1g) Limits (1h) Initial steps It is

normal area It is essential to increase the

following steps of the procedure It is essential

whenever possible (both sides are rarely involved,

8 Limits (1g) Limits (1h) 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

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

10 The best surgical approach? Dissection of the rectum from the nodule first Excision of the vagina first Dissection of the rectum first Examples Exemple (1)

11 Technique (2) Technique (3) Technique (10)

12 Technique (1) Technique (4) Technique (5)

13 Technique (6) Technique (7) Technique (8)

14 2 nd look after recto vaginal nodule 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

15 Uneventful postoperative course And uneventful pregnancy the following year Indications for surgery N % Dysmenorrhea Dyspareunia Bowel symptoms Infertility

16 Objectives of the treatment Complete excision of the nodule Including bowel and vagina when necessary Conservative surgery to preserve fertility was mandatory in most of these patients Results Between January 1998 and December patients were treated for deep infiltrating endometriosis involving the bladder or the posterior cul de sac Mean age was 31.5 ± 7.5 years old Mean diameter of the nodule (pathology) 2.2 cm (0.5-6cm) Procedures performed (201 cases) % Conversion to laparotomy Adhesiolysis (severe) Ureterolysis Bladder excision Vaginectomy Hysterectomy * Adnexectomy Colon resection Partial or full thickness bowel excision * Decided with the patient before the procedure patients 40 years old

17 Postoperative clinical examination < n % n % n No nodule preop n Normal post op clinical exam n Lost to follow up n Persistent nodule Recurrences 10 % of these patients were reoperated for recurrent pelvic pain or for an ovarian endometrioma Persistent deep disease was found in only 20% of these patients (less than 5% of all the patients) The follow up is shorter Severe complications N = 230 N =176 Rectovaginal fistula Ureteral fistula Ureteral stenosis Ureteral injury Hemorrhage Septicemia Pelvic abscess P< 0.02

18 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 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. Prevention of the complications Omental flap Increased indication for bowel resection? Avoid incision of both the vagina and the bowel? Routine ileostomy when both are opened Careful indication for re operation in such patient Earlier diagnosis and treatment of deep endometriosis Patients and women education Physician education Listen to the patient s pain Careful palpation of the posterior cul de sac

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

19 «The reverse technique» 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 The reverse technique

20 The reverse technique WES Melbourne 2008 The reverse technique

21 The reverse technique

22 Vagin ouvert

23 1 2 WES Melbourne 2008 The reverse technique

26 The reverse technique The «reverse technique» Comparative Results patients 35 patients treated with the standard technique 40 patients treated with the reverse technique

27 Data of the groups Standard technique N = 35 Reverse Technique N = 40 Mean age 30.7 ± ± 6 Mean BMI Parity Size of the nodule 21.9 ± 3 0 (0-3) 2 (0.5-5) 22.6 ± 3 0 (0-3) 2 ( ) 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%) 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 ± ±

28 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 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 p complication rate compared to the standard technique. Further and larger studies are necessary to confirm this initial finding. Conclusion Shorter learning curve??

29 There are bowel resection which should be performed There are rectal resection which are not necessary!

30 WES Melbourne 2008

31 Conclusion today! Do we need a routine bowel resection? Prospective randomised studies are necessary Omental flap almost routinely in difficult cases Routine colostomy or ileostomy when the vaginal and the rectum are both openned at the same time?

32 Bladder endometriosis Tubes Bladder endometriosis Bladder endometriosis

33 Bladder endometriosis

34 Bladder Endometriosis Bladder endometriosis Ureteral endometriosis

35 Ureteral endometriosis Ureteral endometriosis

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

Posterior Deep Endometriosis. What is the best approach? Dept Gyn Obst CHU Clermont Ferrand France Posterior Deep Endometriosis What is the best approach? Dept Gyn Obst CHU Clermont Ferrand France Posterior Deep Endometriosis Organs involved - Peritoneum - Uterine cervix - Rectum - Vagina Should we