Deep infiltrating endometriosis (DIE) can cause infertility and pelvic pain. There is little evidence of a clear connection between DIE and infertility, and the absolute benefits of surgery for DIE have not been established. This paper aimed to review the current literature on the effect of surgery for DIE on fertility, pregnancy, and IVF outcomes. Clinicians should bear in mind that a comprehensive clinical history is useful to identify patients at risk for endometriosis, although many women remain asymptomatic. Imaging can be useful to plan surgery. The effect of surgery on the fertility of women with DIE remains unanswered due to the heterogeneous nature of the disease and the lack of trials with enough statistical power and adequate follow-up. Surgery is not recommended when the main goal is to treat infertility or to improve IVF results. Decisions should be tailored according to the individual needs of each woman. Patients must be provided information on the potential benefits, harm, and costs of each treatment alternative, while the medical team observes factors such as presence of pelvic pain, patient age, lesion location, and previous treatments. In this scenario, management by a multidisciplinary endometriosis team is a key step to achieving successful outcomes.
Endometriosis is a benign gynecological disease afffecting about 10% of all reproductive-age women which can significantly impair quality of life. As the clinical presentation is variable, with some women experiencing several severe symptoms while others remain asymptomatic, there are no sufficiently sensitive and specific signs and symptoms or diagnostic tests for the clinical diagnosis of endometriosis. The aim of this article is to review the current literature regarding the accuracy of clinical signs and symptoms in the diagnosis of endometriosis. Besides the wide spectrum of symptoms, an overlap with other causes of pelvic pain such as irritable bowel syndrome and pelvic inflammatory disease is also reported. Moreover, most of the signs and symptoms of endometriosis do not correlate with the severity (staging) of the disease. Knowledge of the characteristics of pelvic pain symptoms is important in the preoperative assessment of patients with suspected endometriosis. Pelvic tenderness, a fixed retroverted uterus, tender uterosacral ligaments or enlarged ovaries identified during a standard pelvic exam are suggestive of endometriosis. Clinical examination during menstruation apparently improves diagnostic yield. Although the clinical diagnosis of endometriosis presents low sensitivity and specificity, it should be thoroughly performed as it is the first fundamental step in the diagnostic workup. Clinical assessment helps to identify patients at high risk of endometriosis and selects those who need further testing in order to reduce diagnostic delay. Laparoscopy preferably performed in conjunction with histologic evaluation of excised lesions, however, still remains the gold standard for diagnosis as well as staging of endometriosis.
Background. Endometriosis is a chronic benign gynecologic disease that can cause pelvic pain and infertility affecting almost 10% of reproductive-age women. Deeply infiltrating endometriosis (DIE) is a specific entity responsible for painful symptoms which are related to the anatomic location of the lesions. Definitive diagnosis requires surgery, and histological confirmation is advisable. The aim of this paper is to review the current literature regarding the possibility of diagnosing DIE accurately before surgery. Despite its low sensitivity and specificity, vaginal examination and evaluation of specific symptoms should not be completely omitted as a basic diagnostic tool in detecting endometriosis and planning further therapeutic interventions. Recently, transvaginal ultrasound (TVUS) has been reported as an excellent tool to diagnose DIE lesions in different locations (rectovaginal septum, retrocervical and paracervical areas, rectum and sigmoid, and vesical wall) with good accuracy. Conclusion. There are neither sufficiently sensitive and specific signs and symptoms nor diagnostic tests for the clinical diagnosis of DIE, resulting in a great delay between onset of symptoms and diagnosis. Digital examination, in addition to TVS, may help to gain better understanding of the anatomical extent and dimension of DIE which is of crucial importance in defining the best surgical approach.
We report the case of a 33 year-old woman who complained of severe dysmenorrhea since menarche. From 2003 to 2009, she underwent 4 laparoscopies for the treatment of pain associated with endometriosis. After all four interventions, the pain recurred despite the use of gonadotropin-releasing hormone (GnRH) analogues and the insertion of a levonorgestrel intrauterine system (LNG-IUS). Finally, a colonoscopy performed in 2010 revealed rectosigmoid stenosis probably due to extrinsic compression. The patient was advised to get pregnant before treating the intestinal lesion. Spontaneous pregnancy occurred soon after LNG-IUS removal in 2011. In the 33rd week of pregnancy, the patient started to feel severe abdominal pain. No fever or sings of pelviperitonitis were present, but as the pain worsened, a cesarean section was performed, with the delivery of a premature healthy male, and an intestinal rupture was identified. Severe peritoneal infection and sepsis ensued. A colostomy was performed, and the patient recovered after eight days in intensive care. Three months later, the colostomy was closed, and a new LNG-IUS was inserted. The patient then came to be treated by our multidisciplinary endometriosis team. The diagnostic evaluation revealed the presence of intestinal lesions with extrinsic compression of the rectum. She then underwent a laparoscopic excision of the endometriotic lesions, including an ovarian endometrioma, adhesiolysis and segmental colectomy in 2014. She is now fully recovered and planning a new pregnancy. A transvaginal ultrasound (TVUS) performed six months after surgery showed signs of pelvic adhesions, but no endometriotic lesions.
Objective: Evaluate the type and incidence of postoperative complications after surgery for deep infiltrative endometriosis at Biocor Hospital. Methods: Our observational study involved a multidisciplinary surgical team that performed laparoscopy on 154 patients suffering from pelvic pain. Surgical complications occurring up to the 30 th postoperative day were recorded. Results: Mean age patient age was 34.1 years. Infertility was present in 69 (45%) although 31% had not attempted to get pregnant. Dysmenorrhea was the most frequent symptom (79.3%) followed by chronic pelvic pain (59.7%) and deep dyspareunia (48,7%). Most cases required extensive surgery as the majority (n=117; 76.9%) were classified as severe endometriosis (ASRM grade IV). The most frequent surgical procedures were: 136 adhesiolysis, 100 intestinal surgeries (85 retosigmoidectomies), 92 peritonal lesion excision, 39 vaginal resections, 19 myomectomies, 21 hysterectomies and 5 partial bladder resections. Postoperative complications were recorded in 14 (9.59%) patients: 8 (5.48%) major complications and 6 (4.11%) minor. Major complications included blood transfusion (n=2) retosigmoid anastomosis dehiscence (1), rectovaginal fistula (n=1), urinary fistula (n=1), deep vein thrombosis (n=1), lower limb compartment syndrome with motor deficit (n=1) and one intestinal obstruction (n=1). Minor complications were abdominal wall infection (n=3), peripheral neuropathy (n=3), bladder atony (n=1) and bladder perforation (n=1). No deaths were observed. All major complication cases underwent retosigmoidectomy associated with vaginal resection (n=6), uterosacral ligament excision (n=5) or hysterectomy (n=3). Conclusion: The surgical treatment of DIE is complex and subject to complications. The surgical expertise of a multidisciplinary team plays a vital role in this setting.
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