Is rectovaginal endometriosis a progressive disease?

OBJECTIVE: The purpose of this study was to observe the natural history of untreated asymptomatic rectovaginal endometriosis. STUDY DESIGN: This was a prospective, observational study. Eighty-eight patients with untreated asymptomatic rectovaginal endometriosis were followed for 1 to 9 years. Pain symptoms and clinical and transrectal ultrasonographic findings were evaluated before and every 6 months after diagnosis. RESULTS: Two patients had specific symptoms that were attributable to rectovaginal endometriosis that was associated with an increase in lesion size and underwent surgery. In 4 other patients, the size of the endometriotic lesions increased, but the patients remained symptom free. The estimated cumulative proportion of patients with progression of disease and/or appearance of pain symptoms that were attributable to rectovaginal endometriosis after 6 years of follow up was 9.7%. For the remaining patients, the follow-up period was uneventful, with no detectable clinical nor echographic changes of the lesions and with no appearance of new symptoms. CONCLUSION: Progression of the disease and appearance of specific symptoms rarely occurred in patients with asymptomatic rectovaginal endometriosis.     

腹腔镜诊断盆腔深部浸润型子宫内膜异位症的临床价值

目的 探讨盆腔深部浸润型子宫内膜异位症（DIE）病灶分布的特点和腹腔镜诊断的准确性。 方法 收集中山大学附属第一医院2008年8月到2012年5月以DIE为手术指征患者79例,行腹腔镜下子宫内膜异位症根治术,腹腔镜诊断后切除各个部位的DIE病灶。以病理诊断为标准,分别计算腹腔镜诊断不同部位DIE病灶的阳性预测值（PPV）、阴性预测值（NPV）、敏感度（SEN）和特异度（SPE）。结果 取得盆腔DIE病灶组织274份,其中后盆腔242份（88.32%）,左侧（27.73%,76/274）多于右侧（24.45%,67/274）。盆腔DIE病灶以骶韧带最常见（39.42%,108/274）,依次为直肠（16.06%,44/274）、阴道直肠隔（12.04%,33/274）、阴道后穹窿（9.12%,25/274）。腹腔镜诊断DIE的PPV为98.83%（254/257）,SEN为92.70%（254/274）、NPV为45.95%（17/37）、SPE为85%（17/20）。肠壁和阴道后穹窿的诊断符合率最高为100%（47/47和25/25）,阴道直肠隔为96.97%（32/33）,左、右骶韧带分别为83.64%（46/55）和90.56%（48/53）,左、右输尿管分别为83.33%（10/12）和66.67%（4/6）。结论 腹腔镜下诊断盆腔DIE病灶的病理诊断阳性率较高。     

A novel technique using magnetic resonance imaging jelly for evaluation of rectovaginal endometriosis

OBJECTIVE: To evaluate the usefulness of the magnetic resonance imaging (MRI) jelly method as a preoperative diagnostic means for patients with rectovaginal endometriosis. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Thirty one patients with suspected rectovaginal endometriosis based on clinical symptoms and the results of preoperative pelvic, rectal, and ultrasonographic examinations, who were scheduled to undergo laparoscopic surgery. INTERVENTION(S): Before surgery, jelly for ultrasonography was injected into the vagina and rectum for MRI. The MRI findings were compared with findings obtained through laparoscopic surgery and histopathologic examination of the removed tissues. MAIN OUTCOME MEASURE(S): The complete cul-de-sac obliteration and deep lesion confirmed at the time of the laparoscopic surgery were evaluated by the MRI jelly method. RESULT(S): For detecting the presence of complete obliteration of the cul-de-sac, the accuracy of the diagnosis of rectovaginal endometriosis attained using the MRI jelly method was sensitivity 90.9% and specificity 77.8%. For the presence of a deep lesion, the sensitivity was 94.1% and specificity 100%. CONCLUSION(S): The condition of the cul-de-sac could be imaged clearly via the MRI jelly method. Not only rectovaginal endometriosis presenting with deep lesions, but also complete cul-de-sac obliteration alone could be diagnosed preoperatively at a high rate.     

Rectal endoscopic ultrasound with a radial probe in the assessment of rectovaginal endometriosis

STUDY OBJECTIVE: To evaluate the accuracy of rectal endoscopic ultrasound and to evaluate endometriosis in the rectovaginal septum, rectum, and sigmoid walls. DESIGN: Validation of diagnostic test (Canadian Task Force classification II-1). SETTING: Tertiary care hospital. PATIENTS: Thirty-two consecutive women clinically suspected of having rectovaginal septum endometriosis without previous surgical treatment. INTERVENTION: Colonoscopy, transrectal ultrasound, and rectal endoscopic ultrasound, followed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: The disease was classified according to 1996 standards of the American Society of Reproductive Medicine. Images obtained by colonoscopy, endoscopic ultrasound, and surgery and histologic findings were compared. In 6 patients endometriosis infiltrated bowel muscularis wall, in 20 it infiltrated rectovaginal septum, and in the remaining 6 there was no evidence of lesions. In all women in whom infiltration of the intestinal wall was suspected, rectal endoscopic ultrasound and colonoscopy confirmed the lesions (sensitivity 100%, specificity 67%). CONCLUSION: Endoscopic ultrasound was useful in preoperative assessment of women with endometriosis.     

Surgical management of rectovaginal septum endometriosis from a continuous series of 50 cases

OBJECTIVES: To assess the value of MRI and ano-rectal endosonography (ARES) for the diagnosis and surgical prognosis of rectovaginal septum endometriosis and to analyse the surgical management in order to evaluate its functional results and complications. PATIENTS AND METHODS: Retrospective study of 50 consecutive patients operated for a clinical presumption of endometriosis nodule of the recto vaginal septum. Thirty-nine patients had a MRI, 31 an ARES and 28 both exams. All the patients had a complete dissection of the rectovaginal septum and all lesions were excised. RESULTS: For the diagnosis of rectovaginal septum endometriosis nodule, MRI results are: sensitivity 73%, specificity 50%, positive predictive value (PPV) 89%, negative predictive value (NPV) 25%; for uterosacral ligaments involvement: sensitivity 84%, specificity 95%, PPV 94%, NPV 86% and for rectal wall infiltration: sensitivity 53%, specificity 82%, PPV 69%, NPV 69%. The ARES results for diagnosis of rectovaginal septum endometriosis nodule are: sensitivity 93%, specificity 100%, PPV 100%, NPV 50% and for rectal wall infiltration: sensitivity 100%, specificity 71%, PPV 81%, NPV 100%. ARES appeared more sensitive than MRI for the detection of rectal wall infiltration (P = 0.002) and for rectovaginal septum endometriosis nodule diagnosis (P = 0.03). Eighty-nine percent of the patients had a coelioscopy in first intention and 15 laparoconversions were performed, 11 in order to perform a digestive resection: 45 nodules were found. In 43cases the nodule was excised, associated to 19 digestive resections, 30 colpectomys, and 22 uterosacral ligaments resections. Three patients required an additional surgical treatment by Hartman's procedure with Mickulicz's drainage for peritonitis. Forty-one nodules were endometriosis nodules: the two other cases were fibrosis nodules. Thirty-three patients were interviewed about the evolution of their pains over a mean history of 20 months: 90% of the patients were satisfied with the management results. DISCUSSION AND CONCLUSIONS: Our data support the efficiency of MRI for rectovaginal septum endometriosis nodule and uterosacral ligaments involvement diagnosis; accord ARES to rectovaginal septum endometriosis nodule diagnosis and its reliability in establishing a diagnosis of rectal wall involvement. The surgical cure of rectovaginal septum nodules without digestive infiltration is performed by coelioscopic or coelio-vaginal procedure, but in case of associated digestive affliction, laparotomy is actually the standard procedure in order to achieve a complete cure of the lesions. Complications, in particular peritonitis, are not frequent. Our data support the efficiency of radical surgical treatment for the improvement of pain symptoms. Results on fertility seem to be satisfactory, but complication risks suggest being careful in this indication. Clinical examination during a catamenial period is essential in order to evoke the diagnosis. MRI yields a complete map of the sub-peritoneal and peritoneal lesions and ARES allows for the diagnosis of an infiltration of the rectal wall. Pre-operative association of those two exams is actually indispensable for the surgical management of those patients, which consists of complete excision of endometriosical lesions and is efficient at treating pain symptoms and fertility. Complications are rare but severe, therefore, justifying a cure in specialised centres.     

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.     

Sonovaginography is a new technique for assessing rectovaginal endometriosis

OBJECTIVE: To evaluate the efficacy of a new technique, the sonovaginography, for the assessment of rectovaginal endometriosis. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Forty-six women were scheduled for laparotomic or laparoscopic surgery because of rectovaginal endometriosis suspected on the basis of patient history and/or clinical examination. INTERVENTION(S): Before surgery, all the women underwent transvaginal ultrasonography and then sonovaginography. The latter is based on transvaginal ultrasonography combined with the introduction of saline solution to the vagina that creates an acoustic window between the transvaginal probe and the surrounding structures of the vagina. Ultrasound findings were compared with the results of surgical exploration and histological examination. MAIN OUTCOME MEASURE(S): We assessed the accuracy of transvaginal ultrasonography and of sonovaginography for the detection and the location and extension assessment of rectovaginal endometriotic lesions, as well as compared patient compliance between the procedures. RESULT(S): Sonovaginography diagnosed rectovaginal endometriosis more accurately than did transvaginal ultrasonography, with a sensitivity and specificity of 90.6% and 85.7%, respectively, whereas the transvaginal ultrasonography has shown a sensitivity and specificity of 43.7% and 50%, respectively. Patient discomfort did not differ significantly between the procedures. CONCLUSION(S): Sonovaginography is a reliable and simple method for the assessment of rectovaginal endometriosis and provides information on location, extension, and infiltration of the lesions, which are important factors in selecting the kind of surgery.     

Transrectal ultrasonography in the assessment of rectovaginal endometriosis

Objective: To evaluate the validity of transrectal ultrasonography in the assessment of rectovaginal endometriosis.Methods: We compared the findings of transrectal ultrasonographic examination performed before surgery with the operative and pathologic findings in 140 women who underwent laparoscopy or laparotomy for suspected endometriosis. The ultrasonographer was asked to investigate whether any deep endometriotic lesions were present in the rectovaginal septum and to define the lateral extension on the basis of involvement of the uterosacral ligaments. In addition, infiltration of the rectal and vaginal walls was evaluated.Results: Thirty-four women had endometriosis infiltrating the rectovaginal septum confirmed by combined operative and pathologic findings. Ultrasonography showed a sensitivity and specificity of 97% and 96%, respectively, in the diagnosis of the presence of rectovaginal endometriosis. The sonographer identified infiltration of the rectal and vaginal walls correctly in all cases in whom it was present, but also reported rectal infiltration in three cases not confirmed by the surgeon and pathologist. The sensitivity and specificity in the diagnosis of uterosacral ligament infiltration were 80% and 97%, respectively.Conclusion: If our preliminary results are confirmed by a larger series, transrectal ultrasonography will be considered a valid diagnostic tool in the evaluation of rectovaginal endometriosis.     

Recurrence of endometriosis in women with bilateral adnexectomy (with or without total hysterectomy) who received hormone replacement therapy

OBJECTIVE: To estimate the risk of recurrence after administration of hormone replacement therapy (HRT) among women who have had endometriosis and who underwent bilateral salpingo-oophorectomy (BSO). DESIGN: Prospective randomized trial (115 women receiving HRT and 57 not receiving HRT). SETTING; Public university hospital. PATIENT(S): Women with a histologic diagnosis of endometriosis in whom BSO was performed; 91.8% had a total hysterectomy. INTERVENTION(S): Periodical clinical examination, vaginal ultrasound, and CA-125 levels; surgical evaluation and histologic study. MAIN OUTCOME MEASURE(S): Recurrence rate, prognostic factors, and a mean follow-up time of 45 months. RESULT(S): There was no recurrence among women who did not receive HRT, versus a 3.5% rate (4 out of 115), or 0.9% per year, in women who received HRT. Two recurrences required abdominal surgery. There was one additional patient who required surgery, but the relationship to the endometriosis recurrence was controversial. Among women receiving HRT, the following risk factors were detected: peritoneal involvement > 3 cm (2.4% recurrence per year vs. 0.3%) and incomplete surgery (22.2% per patient vs. 1.9%). CONCLUSION(S): Patients with a history of endometriosis in whom total hysterectomy and bilateral salpingo-oophorectomy have been performed have a low risk of recurrence when HRT is administered. In those patients, HRT is a reasonable option. However, in cases with peritoneal involvement > 3 cm, the recurrence rate makes HRT a controversial option; if HRT is indicated, it should be monitored closely.     

Long-term follow-up and recurrence rate after mesorectum-sparing bowel resection among women with rectovaginal endometriosis

Objective

To demonstrate the quality of a combined vaginal–abdominal surgical approach to rectovaginal endometriosis by analyzing long-term outcome and recurrence rates.

Methods

In a prospective cohort study in Berlin, Germany, women with endometriosis of the rectovaginal septum were enrolled between September 2004 and December 2012. Bowel infiltration was verified intraoperatively and treated by a nerve-sparing, mesentery-preserving vaginal–abdominal operative approach. Operative results were evaluated by assessing short- and long-term complications and recurrence rates.

Results

During the study period, 110 women underwent surgery. For 71 (64.5%) patients, bowel infiltration was confirmed intraoperatively. Overall, 15% of the patients had peri- or postoperative complications. No long-term complications occurred. After a median follow-up of 64 months, no recurrence in the rectovaginal septum was observed among the study patients. The recurrence of pelvic endometriosis was 15%.

Conclusion

The surgical nerve-sparing approach to rectovaginal endometriosis was confirmed to facilitate precise diagnosis and treatment with minimal morbidity and a long-term complication rate of 0%.     

直肠阴道隔子宫内膜异位症的诊断及治疗

目的 探讨直肠阴道隔子宫内膜异位症(内异症)的临床诊断及治疗。方法 回顾分析我院自1992年至2002年收治的10例直肠阴道隔内异症患者的临床资料。结果 临床表现,年龄36—47岁,平均40岁;肛门坠痛6例,性交痛3例,痛经8例,慢性盆腔痛5例;三合诊时均可触及直肠阴道隔结节,平均直径3cm。血清CAl25水平升高者2例。阴道或腹部超声检查均末检出异位病灶。术前4例接受促性腺激素释放激素激动剂3．75mg/28d,共3次的治疗,可短期缓解疼痛,2例病灶体积减小。10例均行手术治疗,其中开腹手术7例、阴式手术1例、腹腔镜联合阴式手术2例。切除病灶经病理检查证实为直肠阴道隔内异症。随诊最长时间5年,完整切除病灶者预后良好,未能完整切除病灶者症状、病灶持续存在。结论 直肠阴道隔内异症以肛门坠痛、性交痛为主要表现,必须进行三合诊检查。B超的辅助诊断意义不大,修订的美国生育协会标准分期不能反映疾病的严重程度。手术是主要的治疗手段。     

深部浸润型子宫内膜异位症诊治进展

深部浸润型子宫内膜异位症（DIE）是指子宫内膜异位病灶在腹膜下浸润深度超过5mm，主要分布于直肠子宫陷凹、子宫骶骨韧带、直肠阴道隔、膀胱及肠道。病史及临床症状仍然是DIE诊断的主要线索；妇科检查是DIE诊断的主要手段；阴道超声、核磁共振成像及直肠超声尤其是内镜直肠超声是DIE诊断和分型的重要辅助检查方法；手术治疗是DIE的主要治疗方法。     

The occurrence of adenocarcinoma in endometriosis of the rectovaginal septum during progestational therapy.

A patient is presented who developed adenocarcinoma in endometriosis of the rectovaginal septum during a second course of hormonal therapy. Malignant transformation in an area of endometriosis during sex steroid therapy has not been previously reported. The rectovaginal septum is recognized as probably the most common site of malignant transformation in extraovarian foci of endometriosis.     

Use of the CEEA stapler to avoid ultra-low segmental resection of a full-thickness rectal endometriotic nodule

A woman with a history of numerous surgical episodes for treatment of aggressive endometriosis experienced rectal symptoms. She was prepared for the possibility of laparotomy with or without colostomy to relieve her symptoms. After extensive laparoscopic dissection of the rectovaginal septum, a circular stapling device (Premium Plus CEEA; Autosuture, Melbourne, Victoria, Australia) was used to excise completely an anterior rectal lesion that otherwise would have resulted in ultra-low rectal resection and anastomosis. Morbidity associated with the latter procedure was avoided; the patient was discharged within 72 hours and experienced no early or late complications. Postoperative barium enema was obviated by rapid return to normal bowel habits and complete resolution of dyschezia and dyspareunia.     

La endometriosis profunda: un desafío diagnóstico y terapéutico

We report a case that illustrates the challenges of deep infiltrating endometriosis of the rectovaginal septum. The patient underwent a total hysterectomy in our department in May, 2011 due to symptomatic uterine leiomyomas, with no clinical or histopathologic findings of endometriosis. She continued to experience incapacitating pelvic pain, dyschezia and urinary symptoms until February 2012, when she developed ureteral obstruction, bilateral hydronephrosis and intestinal pseudo-obstruction that required radical resection of a fibrous pelvic mass, adhering to the rectum and compressing both ureters. The histological diagnosis was endometriosis. We emphasize the diagnostic difficulties of this entity and the aggressive treatment required.     

Enterocele as a consequence of laparoscopic resection of deeply infiltrating endometriosis

Laparoscopic excision of deeply infiltrating endometriosis in the cul-de-sac or the rectovaginal septum by means of electrosurgery or laser is performed frequently. Little is known about the long-term results or complications of this surgery. We suggest that enterocele could be a complication of the procedure. A patient developed a large enterocele 3 years a laparoscopic excision of a deep endometriotic nodule with resection of the uterosacral ligaments. We question whether routine preventive measures should not be taken after excision of a deep endometriotic nodule from the rectovaginal septum.     

Gastrointestinal stromal tumor arising in the rectovaginal septum

We report herein a rare case of malignant gastrointestinal stromal tumor (GIST) originated from the rectal wall, which presented as a tumor on the rectovaginal septum. A 54-year-old Japanese woman, gravida 4, para 3, was admitted complaining of anuresis and severe constipation. She had a history of hysterectomy and right salpingo-oophorectomy for uterine leiomyoma 11 years previously. Pelvic examination revealed an 8.5 x 7.5 x 7.5 cm hard mass in the rectovaginal space. The inferior border of the tumor was 2 cm from the vaginal introitus and 2 cm from the anus. Computed tomography and magnetic resonance imaging showed a well-circumscribed soft-tissue mass filling the rectovaginal space. Urinary bladder and rectum were markedly compressed and displaced. Colon fiberscopy revealed invasion of the tumor into the rectal mucosa. An abdominoperineal resection of the rectum with posterior vaginal wall resection and pelvic lymphadenectomy was performed. The resected specimen showed a rectal submucosal tumor that was 8 x 8 x 7 cm in size. The tumor was diagnosed as a malignant GIST. Immunohistochemical analysis confirmed this diagnosis. The patient is now healthy without evidence of recurrence at 13 months after surgery. Gynecologists should be aware of rectal GIST arising in the rectovaginal space as a differential diagnosis of vaginal submucosal tumor.     

Histopathology-based combined surgical approach to rectovaginal endometriosis

Objective

To describe a new surgical approach to rectovaginal endometriosis. Rectovaginal endometriosis can be infiltrative or superficial involving the bowel. Only infiltrative disease should be treated by intestinal resection. However, infiltration of endometriosis cannot be confirmed by preoperative imaging techniques.

Methods

A total of 48 women with infiltrative rectovaginal endometriosis were included in this prospective study. Surgery was performed using a newly developed technique. All bowel resections were indicated according to operative findings and not on the basis of preoperative imaging technique results.

Results

The decision for rectosigmoidal resection was based on the results of the intraoperative dissection of the rectovaginal septum. Histologically, infiltration of the ventral bowel wall was confirmed in all cases.

Conclusion

This new surgical technique for the treatment of rectovaginal endometriosis allows precise diagnosis and treatment with low morbidity. A resection of the mesorectum is not necessary because the endometriotic nodules are always located on the antimesenteric surface of the bowel.     

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.     

Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules.

OBJECTIVE: To present data from 18 cases of ureteral endometriosis. DESIGN: Prospective clinical study. SETTING: Department of gynecology at a university hospital. PATIENT(S): Four hundred and five patients with severe dysmenorrhea or deep dyspareunia due to a rectovaginal endometriotic (adenomyotic) nodule. INTERVENTION(S): Patients were prospectively evaluated using intravenous pyelography. All patients underwent laparoscopic surgery to remove rectovaginal adenomyosis and ureterolysis. MAIN OUTCOME MEASURE(S): Presurgical and postsurgical evaluation and histologic analysis. RESULT(S): Preoperative intravenous pyelography revealed ureteral stenosis with ureterohydronephrosis in 18 patients (4.4%). A significantly higher prevalence (11.2%) was observed in nodules > or = 3 cm in diameter. Five women (20%) had complete ureteral stenosis. Kidney scintigraphy revealed damaged kidney parenchymal function, which ranged from 18% to 42%. Laparoscopic ureterolysis was done in 16 women; 2 women underwent ureteral resection and uretero-ureterostomy. A significant postoperative decrease in ureterohydronephrosis was noted in all patients; however, renal function improved only slightly. CONCLUSION(S): Ureteral endometriosis was found in 4.4% of patients with rectovaginal endometriotic (adenomyotic) nodules. Ureterolysis and removal of associated adenomyotic lesions was sufficient therapy in most patients; two required resection of the ureteral stenotic segment. Intravenous pyelography should be performed in all women with rectovaginal nodules > or = 3 cm to prevent nonreversible loss of renal function.