Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection?
2017; Elsevier BV; Volume: 108; Issue: 6 Linguagem: Inglês
10.1016/j.fertnstert.2017.09.006
ISSN1556-5653
Autores Tópico(s)Endometrial and Cervical Cancer Treatments
ResumoDeep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon. Deep endometriosis (DE) remains the most difficult endometriotic entity to treat. Medical treatment for DE can reduce symptoms but does not cure the disease, and surgical removal of the lesion is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, and rectal shaving have been described, there is no consensus regarding the choice of technique or the timing of surgery. Our review of publications reporting results and complications of surgery for rectovaginal DE reveals a relatively higher complication rate after bowel resection compared with shaving and disc excision, especially for rectovaginal fistulas, anastomotic leakage, delayed hemorrhage, and long-term bladder catheterization. Data show that shaving is feasible even in advanced disease. The risk of immediate complications after shaving and disc excision is probably lower than after colorectal resection, allowing for better functional outcomes. The presumed higher risk of recurrence related to shaving has not been demonstrated. For these reasons, surgeons should consider rectal shaving as a first-line surgical treatment of rectovaginal DE, regardless of nodule size or association with other digestive localizations. When the result of rectal shaving is unsatisfactory (rare cases), disc excision may be performed either exclusively by laparoscopy or by using transanal staplers. Segmental resection may ultimately be reserved for advanced lesions responsible for major stenosis or for several cases of multiple nodules infiltrating the rectosigmoid junction or sigmoid colon. Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/19987-24762 Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/19987-24762 Endometriosis is one of the most frequently encountered benign gynecological diseases, known to occur in 7%–10% of women of reproductive age (1Giudice L.C. Kao L.C. Endometriosis Lancet. 2004; 364: 1789-1799Abstract Full Text Full Text PDF PubMed Scopus (2550) Google Scholar). It is well established that three different forms of endometriosis can coexist in the pelvis: peritoneal endometriosis, ovarian endometriosis, and deep endometriosis (DE) of the rectovaginal septum (2Nisolle M. Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities.Fertil Steril. 1997; 68: 585-596Abstract Full Text PDF PubMed Scopus (951) Google Scholar). Most rectovaginal DE lesions originate from the posterior part of the cervix and secondarily infiltrate the anterior wall of the rectum (3Donnez J. Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.Hum Reprod. 2010; 25: 1949-1958Crossref PubMed Scopus (209) Google Scholar, 4Donnez J. Jadoul P. Colette S. Luyckx M. Squifflet J. Donnez O. Deep rectovaginal endometriotic nodules: perioperative complications from a series of 3,298 patients operated on by the shaving technique.Gynecol Surg. 2013; 10: 31-40Crossref Scopus (28) Google Scholar). Medical treatment of rectovaginal DE can reduce the symptoms but does not cure the disease and is often associated with side effects such as erratic bleeding, weight gain, decreased libido, and headache (5Vercellini P. Buggio L. Berlanda N. Barbara G. Somigliana E. Bosari S. Estrogen-progestins and progestins for the management of endometriosis.Fertil Steril. 2016; 106: 1552-1571Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar). Pregnancy does not seem to prevent disease progression (6Setúbal A. Sidiropoulou Z. Torgal M. Casal E. Lourenço C. Koninckx P. Bowel complications of deep endometriosis during pregnancy or in vitro fertilization.Fertil Steril. 2014; 101: 442-446Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar), and resection of rectovaginal DE seems to improve fertility outcomes (3Donnez J. Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.Hum Reprod. 2010; 25: 1949-1958Crossref PubMed Scopus (209) Google Scholar, 7Daraï E. Cohen J. Ballester M. Colorectal endometriosis and fertility.Eur J Obstet Gynecol Reprod Biol. 2017; 209: 86-94Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar). Moreover, among pregnant women with endometriosis, rectovaginal DE is associated with prematurity, hospitalization, and low birthweight (8Jacques M. Freour T. Barriere P. Ploteau S. Adverse pregnancy and neo-natal outcomes after assisted reproductive treatment in patients with pelvic endometriosis: a case-control study.Reprod Biomed Online. 2016; 32: 626-634Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 9Borghese B. Sibiude J. Santulli P. Lafay Pillet M.C. Marcellin L. Brosens I. et al.Low birth weight is strongly associated with the risk of deep infiltrating endometriosis: results of a 743 case-control study.PLoS One. 2015; 10: e0117387Crossref Scopus (41) Google Scholar). Surgical removal of rectovaginal DE lesions is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions. Although several surgical techniques such as laparoscopic bowel resection, disc excision, or rectal shaving have been described, there is no consensus regarding the choice of technique or when surgery should be proposed. Although infiltration up to the rectal mucosa and invasion of >50% of the circumference have been suggested as an indication for bowel resection (10Abrão M.S. Podgaec S. Dias Jr., J.A. Averbach M. Silva L.F. Marino de Carvalho F. Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease.J Minim Invasive Gynecol. 2008; 15: 280-285Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 11Goncalves M.O. Podgaec S. Dias Jr., J.A. Gonzalez M. Abrao M.S. Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy.Hum Reprod. 2010; 25: 665-671Crossref PubMed Scopus (130) Google Scholar), this remains a subject of debate (3Donnez J. Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.Hum Reprod. 2010; 25: 1949-1958Crossref PubMed Scopus (209) Google Scholar, 4Donnez J. Jadoul P. Colette S. Luyckx M. Squifflet J. Donnez O. Deep rectovaginal endometriotic nodules: perioperative complications from a series of 3,298 patients operated on by the shaving technique.Gynecol Surg. 2013; 10: 31-40Crossref Scopus (28) Google Scholar, 12Koninckx P.R. De Cicco C. Schonman R. Corona R. Betsas G. Ussia A. The recent article “Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer have more than 40% of the circumference of the rectum affected by the disease”.J Minim Invasive Gynecol. 2008; 15: 774-775Abstract Full Text Full Text PDF PubMed Google Scholar). In their review of the literature, Meuleman et al. reported that out of 3,894 patients, 71% underwent bowel resection, 10% had disc excision, and only 17% were treated with so-called superficial surgery (13Meuleman C. Tomassetti C. D’Hoore A. Van Cleynenbreugel B. Penninckx F. Vergote I. et al.Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.Hum Reprod Update. 2011; 17: 311-326Crossref PubMed Scopus (259) Google Scholar). Conversely, in a more recent survey enrolling 1,135 patients managed for colorectal endometriosis in France in 2015, almost half (48.1%) were treated by rectal shaving, with wide disparities between the approaches of different surgical teams involved in the survey (14Roman H. FRIENDS group (French Colorectal Infiltrating Endometriosis Study group). A national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015: a multicenter series of 1135 cases.J Gynecol Obstet Hum Reprod. 2017; 46: 159-165Crossref PubMed Scopus (82) Google Scholar). Similarly, Malzoni et al. (15Malzoni M. Di Giovanni A. Exacoustos C. Lannino G. Capece R. Perone C. et al.Feasibility and safety of laparoscopic-assisted bowel segmental resection for deep infiltrating endometriosis: a retrospective cohort study with description of technique.J Minim Invasive Gynecol. 2016; 23: 512-525Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar) reported a series of 670 cases with endometriosis invading the bowel, 62.9% of which were operated on by shaving and 37.1% by bowel resection. These discordant data result from the lack of consensus concerning the optimal surgical management of DE infiltrating the bowel. The aim of this paper was to review the available literature comparing the conservative approach (shaving technique and discoid resection) and the more radical approach (bowel resection) in terms of surgical outcomes, complications, and recurrence rates. The shaving technique for the surgical treatment of rectovaginal DE of the Douglas pouch was first described in 1991 (16Reich H. McGlynn F. Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis.J Reprod Med. 1991; 36: 516-522PubMed Google Scholar). The first large series was published in 1995 (17Donnez J. Nisolle M. Casanas-Roux F. Bassil S. Anaf V. Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients.Hum Reprod. 1995; 10: 630-635Crossref PubMed Scopus (164) Google Scholar) and followed by larger series from the same team between 1997 and 2013, with the largest series so far described of about 3,298 cases (3Donnez J. Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.Hum Reprod. 2010; 25: 1949-1958Crossref PubMed Scopus (209) Google Scholar, 4Donnez J. Jadoul P. Colette S. Luyckx M. Squifflet J. Donnez O. Deep rectovaginal endometriotic nodules: perioperative complications from a series of 3,298 patients operated on by the shaving technique.Gynecol Surg. 2013; 10: 31-40Crossref Scopus (28) Google Scholar, 17Donnez J. Nisolle M. Casanas-Roux F. Bassil S. Anaf V. Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients.Hum Reprod. 1995; 10: 630-635Crossref PubMed Scopus (164) Google Scholar, 18Donnez J. Nisolle M. Gillerot S. Smets M. Bassil S. Casanas-Roux F. Rectovaginal septum adenomyotic nodules: a series of 500 cases.Br J Obstet Gynaecol. 1997; 104: 1014-1018Crossref PubMed Scopus (144) Google Scholar, 19Donnez J. Squifflet J. Laparoscopic excision of deep endometriosis.Obstet Gynecol Clin North Am. 2004; 31: 567-580Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar). To individualize the uterus, vagina, and the rectum, a uterine manipulator is necessary, as well as a sponge placed into the vagina and a probe inside the rectum. These three manipulators should be individually mobilized. The principal steps of the shaving technique involve the lateral identification of the ureter far from the lesion itself. For nodules measuring >3 cm, there is ureter involvement in 10% of cases (20Donnez J. Nisolle M. Squifflet J. Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules.Fertil Steril. 2002; 77: 32-37Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar), requiring ureterolysis with or without previous ureteral stenting. When lateral spaces are freed, the uterosacral ligaments are cut to leave the bowel attached to the nodule (Supplemental Video 1). Then shaving consists in the separation of the nodule from the anterior part of the rectum to reach the cleavage plan of the rectovaginal septum (Supplemental Video 2). Shaving is a more than superficial surgical treatment of rectovaginal DE (13Meuleman C. Tomassetti C. D’Hoore A. Van Cleynenbreugel B. Penninckx F. Vergote I. et al.Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.Hum Reprod Update. 2011; 17: 311-326Crossref PubMed Scopus (259) Google Scholar) and consists in excision of the DE nodule, even if during this procedure the bowel lumen could be inadvertently opened. In this case, a bowel suture must be performed in one or two layers (Supplemental Video 3). Three steps have been described: [1] separation of the anterior rectum from the posterior vagina, [2] excision or ablation of the DE nodule from the posterior part of the cervix, and [3] resection of the posterior vaginal fornix and vaginal closure (Supplemental Video 4). Outcomes are presented in Table 1. Shaving of the rectum can be performed using the CO2 laser (3Donnez J. Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.Hum Reprod. 2010; 25: 1949-1958Crossref PubMed Scopus (209) Google Scholar, 18Donnez J. Nisolle M. Gillerot S. Smets M. Bassil S. Casanas-Roux F. Rectovaginal septum adenomyotic nodules: a series of 500 cases.Br J Obstet Gynaecol. 1997; 104: 1014-1018Crossref PubMed Scopus (144) Google Scholar, 21Koninckx P.R. Timmermans B. Meuleman C. Penninckx F. Complications of CO2-laser endoscopic excision of deep endometriosis.Hum Reprod. 1996; 11: 2263-2268Crossref PubMed Scopus (115) Google Scholar, 27Mohr C. Nezhat F.R. Nezhat C.H. Seidman D.S. Nezhat C.R. Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.JSLS. 2005; 9: 16-24PubMed Google Scholar, 29Slack A. Child T. Lindsey I. Kennedy S. Cunningham C. Mortensen N. et al.Urological and colorectal complications following surgery for rectovaginal endometriosis.Br J Obstet Gynecol. 2007; 114: 1278-1282Crossref Scopus (87) Google Scholar), cold scissors (33Afors K. Centini G. Fernandes R. Murtada R. Zupi E. Akladios C. et al.Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis.J Minim Invasive Gynecol. 2016; 23: 1123-1129Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 34Roman H. Moatassim-Drissa S. Marty N. Milles M. Vallée A. Desnyder E. et al.Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series.Fertil Steril. 2016; 106: 1438-1445Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar), ultrasound scalpel or plasma energy (34Roman H. Moatassim-Drissa S. Marty N. Milles M. Vallée A. Desnyder E. et al.Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series.Fertil Steril. 2016; 106: 1438-1445Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar), and monopolar hook (33Afors K. Centini G. Fernandes R. Murtada R. Zupi E. Akladios C. et al.Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis.J Minim Invasive Gynecol. 2016; 23: 1123-1129Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar).Table 1Intraoperative events and postoperative outcomes in series enrolling patients managed for rectovaginal DE, previously published in the literature.AuthorsnMean size of the nodule (cm)Operating time, minutesLength of stay, daysComplications, %Follow-up, moRecurrence pain rate, %Reoperation rate, %Pregnancy rate, %Bowel perforation during shavingLate bowel perforation requiring colostomyLate bowel perforation not requiring colostomyRectovaginal fistulasAnastomotic leakageIntraoperative hemorrhageDelayed hemorrhageUrinary retention <20 dLong-term bladder catheterizationUreteral damageUreteral fistulaShaving Total shaving1.7 (83/4,793)0.12 (6/4,839)0.08 (4/4,637)0.25 (14/5,430)—00.08 (4/4,568)0.61 (28/4,568)0.23 (9/4,731)0.13 (6/4,701)0.3 (14/4,701)7.9 (80/1,010)2.4 (106/4,416)Reich et al. 1991 16Reich H. 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