Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literature

Abstract

Objective: To highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture. Design: Case series and review of the literature. Setting: Endometriosis referral hospitals. Patient(s): Seven young women who underwent laparoscopic resection of DIE, six of whom had uterine rupture before or during labor; the seventh patient had a posterior wall defect that placed her at increased risk of future uterine rupture. Intervention(s): Diagnosis of uterine rupture before or during labor in patients with a history of prior resection of DIE, leading to delivery by emergency delivery section or emergency laparotomy for exploration and repair. Main Outcome Measure(s): Immediate neonate and maternal salvaging caesarean delivery or laparotomy followed by surgical correction of the rupture. Result(s): As of 2019, no publications in the literature had considered uterine rupture among the obstetric complications of endometriosis. The reporting of such findings is crucial because of the increase in surgical management of endometriosis. We report seven cases of uterine rupture in pregnancy in women who had undergone resection of DIE. In six patients, surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient. Conclusion(s): Our case series sheds light on the potential increased risk of uterine rupture during pregnancy among women who have had a prior resection of DIE. In future, if these patients are considered high-risk pregnancy cases, their care should be managed by highrisk obstetric specialists.

Nonvisualized palpable bowel endometriotic satellites

“…The standard of care for symptomatic bowel endometriosis includes laparoscopy ( Abrao et al , 2015 ; Roman et al , 2016 ; Vercellini et al , 2020 ), laparotomy ( Weed and Ray, 1987 ; Moore et al , 1988 ; Martin, 1991 ; Bailey et al , 1994 ; Roman and FRIENDS group (French coloRectal Infiltrating ENDometriosis Study group), 2017 ), segmental resection, disk resection, shaving and intentional incomplete resection. Intentional incomplete resection is used in circumstances such as inadequate preoperative preparations, preservation of the uterus and dissection to avoid endometriosis/adenomyosis in the posterior cervix where cervical incompetence and uterine rupture are concerns ( Martin, 1988 ; Carmona et al , 2009 ; Ziadeh et al , 2020 ). Laparoscopy appears best for visualization while laparotomy is better for palpation ( Weed and Ray, 1987 ; Moore et al , 1988 ; Martin, 1991 ; Bailey et al , 1994 ).…”

Uterine rupture following laparoscopic excision of deeply invasive rectovaginal endometriosis: Is it the song or the singer?

“…It is doubtful that the short procedure-to-pregnancy intervals of 5 and 9 months allowed adequate time for tissue repair (4). Similarly, three of the seven patients described by Ziadeh et al also conceived within 1 year of the laparoscopic resection procedure (3).…”

“…Uterine rupture occurred prior to the onset of labor at 32 and 33 weeks of gestation, respectively (4). For the remaining five cases reported in the literature, uterine rupture occurred intrapartum and involved the lower posterior uterine segment (3). All five patients had undergone laparoscopic resection of extensive rectovaginal endometriosis.…”

“…However, certain principles and techniques may guide surgeons to perform the most effective and least harmful procedure. In most of the reported cases with uterine rupture, extensive use of energy such as monopolar and bipolar electrosurgery or ultrasonic for dissection of recto-vaginal septum is reported (3,4). Extensive use of energy may devascularize tissue and predispose to poor tissue healing.…”

“…We must not subject our patients to any increased risk without first understanding the nature of the complications. The current publications describing uterine rupture following resection of DIE are confined to case reports and small series (3,4). They reflect different disease presentations, surgeons, surgical techniques, as well as selection biases.…”