Outcomes and treatment options in rectovaginal endometriosis

PURPOSE OF REVIEW: This review aims to explore the recent literature surrounding the role of colorectal surgery in rectovaginal endometriosis. RECENT FINDINGS: Recent findings would suggest that excision of a portion of the rectum along with complete excision of surrounding endometriosis is beneficial in terms of improvement in quality of life and recurrence of disease. However, further randomized controlled trials are needed to clarify this finding. SUMMARY: The optimal management of women with deeply infiltrating rectovaginal endometriosis remains a challenge to physicians involved in this disease process. The choice between medical and surgical treatments is not clearly defined, and neither is the role of adjunctive medical therapy prior to or following surgery. It is only when these questions have been asked in the context of well conducted clinical trials, with good outcome data, can the answers be given.     

Surgical treatment of rectovaginal endometriosis with rectal involvement

Rectovaginal endometriosis (RVE) is one of the most serious and incapacitating forms of presentation of this disease. Traditionally, medical treatment has not been considered effective for the majority of patients, being surgery the only reasonable and therapeutic choice in these cases. This exposes patients to a potentially serious morbidity, thus a careful evaluation should be done by a surgical board considering the impact of the disease as well as the quality of life of the patients. The main surgical techniques used are the shaving of the rectal wall affected by the endometriosic implants, the discoid excision of the front rectal wall, and the segmental intestinal resection, and there is no consensus concerning which is the most effective and suitable between them. The bibliography published in the last 10 years relating to the surgical treatment of RVE is being reviewed with the intention of updating the knowledge base about the topic and looking for common ground between different studies, allowing us to come closer to reaching a consensus about treatment for this pathology.     

Gonadotropin-releasing hormone agonist treatment for endometriosis of the rectovaginal septum

OBJECTIVE: This study was undertaken to evaluate the effectiveness of a 6-month course of gonadotropin-releasing hormone agonist treatment for patients with symptomatic endometriosis of the rectovaginal septum. STUDY DESIGN: Fifteen patients with rectovaginal endometriosis and moderate to severe pain symptoms were the subjects of the study. None of these patients had either clinical or objective evidence of ovarian endometriosis, nor was there evidence of any obstructive lesions of the intestine or ureters. All patients were given leuprolide acetate depot at 3.75 mg, 1 ampule intramuscularly every 28 days, and treatment had a planned duration of 6 months. Follow-up evaluations were set every 2 months during the treatment phase and every 3 months thereafter until the completion of 1 year after discontinuation of medical therapy. At each follow-up visit pain symptoms were recorded, and clinical exploration, transvaginal ultrasonography, and transrectal ultrasonography were performed. RESULTS: Two patients stopped the treatment early after the second and fourth leuprolide doses; in both cases the reason was persistence of pain, and both requested a surgical solution. The other 13 patients showed a marked improvement with respect to pain during the 6-month treatment course but had early pain recurrence after drug suspension; 11 of them required further treatment within the first year of follow-up. The failure rate of gonadotropin-releasing hormone agonist therapy to produce 1-year pain relief after treatment discontinuation was 87% (13/15) on an intent-to-treat basis. The endometriotic lesions showed a slight but significant reduction in size during therapy but had returned to the original volume within 6 months after cessation of the gonadotropin-releasing hormone analog treatment. CONCLUSION: Our results suggest that gonadotropin-releasing hormone analogs should not be considered a real therapeutic alternative to surgical treatment for patients with symptomatic endometriosis of the rectovaginal septum, except possibly in a limited and unpredictable number of cases.     

Limited segmental anterior rectal resection for the treatment of rectovaginal endometriosis: pain and complications

The aim of this cohort study was to assess the long-term response, complications and quality of life in patients undergoing segmental anterior rectal resection for endometriosis. The subjects consisted of patients who have undergone a segmental anterior rectal resection for endometriosis in the setting of a tertiary referral unit for the management of severe endometriosis. The data were obtained by means of a case note review and patient questionnaire. The main outcome measures were surgical complications and overall subjective improvement. Dysmenorrhoea, dyspareunia, dyschezia and chronic daily pain were measured using a visual analogue scale. Twenty-one anterior resections were performed by laparotomy and 24 by laparoscopy. There was no complication in 64% of the cases, and 83% of patients felt that their pain had resolved completely or was greatly improved. The Mean Self-Rated Health Status was significantly lower in the study group than in the general population. Deeply infiltrating endometriosis was confirmed in 92% of rectal specimens. Based on these results, we conclude that segmental anterior rectal resection is a relatively safe procedure for very severe rectovaginal endometriosis and also a very effective treatment.     

Letrozole and norethisterone acetate in rectovaginal endometriosis

This open-label prospective study evaluated the efficacy of letrozole (2.5 mg/day) combined with norethisterone acetate (2.5 mg/day) in the treatment of pain symptoms related to the presence of rectovaginal endometriosis. The treatment significantly and quickly decreased the intensity of symptoms, but pain recurred at 3-month follow-up; five women underwent surgery during the follow-up, and histologic examination of rectovaginal nodules revealed the presence of active endometriotic lesions.     

Parametrial and rectovaginal adenocarcinoma arising from endometriosis

Malignant extragonadal tumors arising from endometriosis are rare. We report on two cases. A 41-year-old gravida 1, para 1 (G1P1), with adenocarcinoma of the right parametrium arising from endometriosis and a 51-year-old G1P1 with endometriosis-associated rectovaginal adenocarcinoma were treated. Treatment included radical surgery plus radiation therapy. While the former patient was doing well 2 years after the primary diagnosis, the latter suffered a local pelvic recurrence 2 years later. Although there are no randomized controlled studies, radical surgery followed by radiation therapy seems generally to be the treatment of choice. The analysis of PTEN in various forms of endometriosis and its malignant transformation may help in understanding the early steps of tumorigenesis.     

输尿管子宫内膜异位症的诊断和治疗

目的 探讨输尿管子宫内膜异位症(内异症)的诊断和治疗策略.方法 1983年至2010年在北京协和医院住院且经手术证实为输尿管内异症的46例患者,分析其临床表现、辅助检查、手术方式、手术发现、病理结果、术后药物治疗、复发的处理及相关因素.结果 46例患者在本院接受了 1～2次的手术治疗,其中48%(22/46)的患者术前没有能够诊断输尿管内异症,46%(21/46)的患者没有症状或仅有痛经表现.输尿管粘连松解术和开腹手术是最主要的手术类型和手术路径,分别为72%(33/46)和63%(29/46).64%(25/39)的患者仅左侧输尿管受累,80%(37/46)为外生型输尿管内异症.87%(40/46)的患者合并盆腔内异症和子宫腺肌病.总计15%(7/46)的患者复发,术后至复发时间的中位数为24个月(13～49个月);复发后均接受再次手术治疗.仅术后是否使用促性腺激素释放激素激动剂与复发有显著相关性,与术后用药的患者相比,术后没有用药的患者复发的OR值为23.2(95%CI为2.4～221.7,P=0.002).结论 输尿管内异症与生殖道内异症关系密切,发病隐匿,早期诊断困难.手术切除后盆腔深部内异症及处理卵巢子宫内膜异位囊肿,对预防内异症进一步累及输尿管有意义.术后积极治疗盆腔内异症是防止复发的关键.

Abstract：

Objective To investigate strategies of diagnosis and treatment of ureter endometriosis. Methods From 1983 to 2010, the cases registered in Peking Union Medical College Hospital and confirmed as ureter endometriosis by surgery were enrolled in this study. Clinical manifestatios, preoperative examinations, surgical categories and routes, surgical and pathological findings, post-operative medical treatment, relapse and relating factors were collected and studied. Results Totally 46 patieuts with ureter endometriosis underwent one or two surgeries. Forty-eight per cent (22/46) of patients were not be diagnosed with ureter endometriosis pre-operatively, and 46% (21/46) only presented dysmenorrhea or even no symptoms. Ureterolysis (72%, 33/46) and laparotomy (63%, 29/46 ) were the most common surgical category and surgical approach. There were 64% (25/39) of patients had left ureter involved and 80% (37/46) had extrinsic ureter endometriosis. Fifteen per cent (7/46) of patients had relapsed disease with median recurrent time of 24 months (13 -49 months), and they all received second surgeries. Logistic regression analysis showed that only gonadotropin releasing hormone analogue agents were related with recurrence when compared with those patients without medical treatment post-operatively significantly ( OR =23.2, 95% CI:2. 4 -221.7, P =0. 002). Conclusions Ureter endometriosis was related with reproductive tract endometriosis. It has insidious process resulting in difficulty for early diagnosis. It's important to treat pelvic deep infiltrating endometriosis and ovarian endometrioma to prevent ureter from further involvement. Post-operative treatment of pelvic endometriosis is the key point of preventing relapse of ureter endometriosis.     

Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis

OBJECTIVE: To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum. DESIGN: Prospective therapeutic non-randomized, self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months. SETTING: Tertiary referral center for treatment of deep endometriosis. PATIENT(S): Eleven symptomatic patients with rectovaginal endometriosis. INTERVENTION(S): A levonorgestrel-releasing IUD was inserted and maintained for 12 months. MAIN OUTCOME MEASURE(S): Severity of dysmenorrhea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography. RESULT(S): Dysmenorrhea, pelvic pain, and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment. CONCLUSION(S): Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.     

肠道子宫内膜异位症诊断及治疗

摘要：肠道子宫内膜异位症是指子宫内膜异位症病灶侵入或生长于部分或全部肠壁的浆肌层,主要表现是痛经、性交痛、排便痛。肠道子宫内膜异位症可以位于整个消化道的许多部位,但以乙状结肠和直肠交界处最常见。直肠气钡双重造影、经阴道超声、直肠内镜超声、磁共振成像(MRI)、多层螺旋CT等有助于明确诊断。药物治疗可以暂时控制症状,但不能使患者长期获益。根治性子宫内膜异位症病灶切除,包括肠道子宫内膜异位症病灶切除,是治疗肠道子宫内膜异位症的有效方法。肠道子宫内膜异位结节切除方法有表面病灶切除术,病灶碟形切除术和肠管节段性切除吻合术。尽管手术切除肠道子宫内膜异位症病灶还存在争议,但是越来越多的研究显示创伤性的手术改善了肠道子宫内膜异位症患者的症状及生存质量,增加了患者受孕机会。     

Laparoscopic resection of rectovaginal endometriosis: a case report

Two patients aged 35 i 40 years after extensive clinical evaluation were operated by means of combined approach--laparoscopy and vaginal resection of endometriotic tumors. First laparoscopy was performed in order to dissect rectovaginal septum and separate rectum from the vagina in order to facilitate complete vaginal resection of endometriotic lesions. The integrity of rectum was checked by means of bubble test and after the control of the haemostasis endoscope was removed. The post operative period was uneventful and the patients were discharged from the hospital on the 5th and 8th day of surgery. The combined laparoscopic and vaginal approach in order to dissect endometriotic rectovaginal tumor is in our opinion the treatment of choice for this peculiar localization of ectopic endometrium.     

Laparascopically assisted vaginal resection of rectovaginal endometriosis

BACKGROUND: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. TECHNIQUE: The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. EXPERIENCE: Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. CONCLUSION: The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.     

Diagnosis and laparoscopic treatment of an unusual case of advanced extragenital endometriosis

Endometriosis is considered to be a benign gynaecological disorder, although several pathophysiological aspects of endometrial lesions resemble the behaviour of malignant tissue: similar to carcinomas, endometriotic cells are able to invade and destroy surrounding anatomical structures. Although the medical treatment of endometriotic lesions, including the use of GnRH analogues or gestagens, show temporary effectiveness and have been reported to cause a regression of disease, they rarely provide long-term relief of symptoms in advanced stages of endometriosis involving extragenital organs, such as the rectum or the urinary system. We here describe the diagnosis and minimally invasive surgical treatment of an unusually advanced case of endometriosis involving the rectosigmoid, the urinary bladder and the ureter, leading to secondary hydronephrosis and loss of renal function.