Camran Nezhat MD, FACOG, FACS,Megan Kennedy Burns, MD, MA,Lucia DiFrancesco, MD, Stacy Young, MD,Farr Nezhat, MD, FACOG
Corresponding Author: Camran Nezhat, MD, FACOG, FACS (firstname.lastname@example.org)
Endometriosis is one of the most common gynecologic disorders, affecting approximately 10% of all reproductive-aged women and 35-50% of women with pelvic pain and infertility1,2. A chronic, progressive, and estrogen-dependent disease, endometriosis can cause pain, infertility, and organ dysfunction. Patients require a thorough evaluation with attention to their individual treatment goals, and many patients can be managed medically. However, when medical management fails or is not indicated, then surgical treatment may be recommended.
Surgical treatments depend on the location of disease, symptoms, age, and childbearing status, et cetera. In very young patients who have not yet started childbearing, we recommend conservative management. Adolescent patients are more likely to present with atypical symptoms and, as a result, experience a delay in diagnosis. In these patients, we begin with medical management followed by videolaparoscopic surgery and postoperative long-term suppressive hormonal therapy3. Diagnostic and operative videolaparoscopy with or without robotic assistance for treatment of endometriosis and lysis of adhesions is performed with the goal of removing all endometriotic implants and restoration of normal anatomy4.
Patients in their reproductive years with pain and/or infertility and normal male factor may benefit from surgical management. In experienced hands, restoration of anatomy without compromising ovarian function results in excellent pain relief and better postoperative pregnancy rates than IVF, even benefits in patients with previously failed IVF treatments5,6. Studies have shown by decreasing inflammation in the pelvis and the associated toxicity to embryos, uterine receptivity can be improved by thorough treatment of endometriosis7.
In the case of endometriomas, we recommend embryo or gamete freezing prior to surgical intervention since surgical treatment of endometriomas can reduce ovarian reserve4,5,8-10. We caution against drainage and/or irrigation of endometriomas since blood can continue to leak into the peritoneal cavity, causing extensive pelvic inflammation and adhesion formation and resulting in decreased future fecundibility (please see figures 1 through 4 below). It is extremely difficult to thoroughly irrigate endometriomas, even with a double lumen needle, and thus we recommend avoiding endometriomas entirely during egg retrieval. These patients may receive 2-3 months of GnRH suppressive therapy, followed by removal of the entire cyst wall with attention to sparing all healthy ovarian tissue9. In some cases, the degree of induration and adhesion formation may be so extensive as to necessitate the involvement of specialists such as colorectal surgeons and/or urologists to assist in the dissection; these patients are also at an extremely high risk of ovarian remnant syndrome. Endometriomas are classified into two types: Type I endometriomas arise from the invagination of endometrial implants on the surface of the ovary and then hemorrhage into the cyst, while Type II endometriomas arise from the invasion of implants into corpus luteum cysts. The surgical management of the types differs. Type I endometriomas are difficult to remove due to densely adherent fibrous capsules while the difficulty in removing Type II endometriomas correlates with the degree of invasion, with Type IIA being the easiest to remove and Type IIC being as challenging as Type I10.
Figure 1. A large endometrioma that has been slowly leaking after egg retrieval, forming extensive adhesions between the bowel, ureters, uterus, bilateral fallopian tubes, and bilateral ovaries.
Figure 2. Removal of the entire cyst wall of an endometrioma is necessary to prevent recurrence.
Figure 3. In this image, you can see the right ovary densely adhered to the bowel. The left ovarian endometrioma has been partially resected, with visible adhesions to both bowel and bladder.
Figure 4. In this image, the left ovarian endometrioma has been resected and is being elevated off the bowel, with the right endometrioma still visible.
Likewise, in an attempt to minimize inflammation in the pelvis, we recommend conservative management of bowel endometriosis and deferring bowel resection, if possible, until after childbearing is complete11-16. Furthermore, patients who achieve pregnancy postoperatively can experience disease regression and potentially no longer require bowel resection postpartum. In patients who require surgical treatment of bowel endometriosis, we preferentially perform rectal shaving as opposed to disc or segmental resection in order to minimize the risk of complications associated with segmental bowel resection17-21. Patients with bowel stricture may require resection, but we avoid resection near the rectum if possible due to the high risk of injury to the pelvic nerves immediately adjacent to the rectum. Lesions involving the small bowel may be easily resected without significant complications, but resection of lesions at the level of the low rectum requires extensive retro-rectal dissection. Aggressive dissection at this level risks injury to extensive vascularity, pelvic splanchnic nerves, and the superior and inferior hypogastric plexi, as well as other nerves like the iliofemoral, ilioinguinal, and iliohypogastric nerves depending on location and extent of disease16,22. Complications of these injuries include bowel stenosis, incontinence, ischemia resulting in fistula formation, severe constipation, and urinary retention23,24. Nerve-sparing techniques for deeply infiltrating endometriosis are therefore recommended in order to avoid injury to the nervous plexus and to preserve bowel, bladder, and sexual function16,25-27.
In cases of genitourinary endometriosis, surgeons should be prepared to perform ureterolysis in cases of ureteral stricture with or without hydronephrosis, as this can treat up to 90% of cases28,29. Preoperative planning is necessary in these patients to identify renal compromise secondary to ureteral stricture, as ureteral endometriosis is a known cause of silent renal loss30. Ureteral endometriosis is classified as either an intrinsic disease, which involves the ureteral wall and/or mucosa, or an extrinsic disease , which compresses the ureter externally, causing stricture and hydronephrosis. In cases with extensive genitourinary involvement, consultation with an experienced urologist is recommended as these patients may require ureteral reanastamosis or reimplantation. In patients with refractory bladder lesions, videolaparoscopic segmental bladder resection with or without robotic assistance may be needed and has favorable results in terms of symptom relief, progression of disease, and recurrence risk29.
Figure 5. Bowel endometriosis along the ileocecal junction16.
Figure 7. Left ureteral endometriosis prior to excision, demonstrating filmy and fibrous implants and adhesions29.
Older patients who have completed childbearing may be managed more aggressively depending on symptoms and disease severity if all else fails. These patients may need to undergo hysterectomy and/or bilateral salpingo-oophorectomy with thorough elimination of endometriosis. Thoracic endometriosis patients, however, are often best treated as conservatively as possible, starting with medical management, then with laparoscopic treatment of all visible lesions, followed by hormonal suppression and later by thoracoscopic treatment of pulmonary lesions or diaphragmatic resection31,32. Hysterectomy with bilateral salpingo-oophorectomy should be considered as a last resort. Although we have never encountered phrenic nerve injury during treatment of thoracic endometriosis syndrome in any of our patients, the possibility of this rare complication exists, and in the case of phrenic nerve injury the problem created can be worse than the original disease33. In treatment of endometriosis, it should be remembered that injury to the surrounding viscera or neurovascular structures can result in complications worse than the original disease.
Figure 8. Diaphragmatic endometriosis lesions as seen via VATS.
Figure 9. Pleural endometriosis implants as seen via VATS.
The nervous plexus, illustrating the complex innervation of the pelvis.
Endometriosis is primarily a disease of inflammation, with all of its complications, including induration, hyperemia, fibrosis, and necrosis. Resection of endometriotic lesions causes improvements in pelvic pain and infertility, but also decreases the risk of malignant transformation into ovarian cancer34. The most effective treatment, with the best cancer prevention, is complete elimination of all endometriotic lesions, even in patients who are asymptomatic. Patients who have completed childbearing at the time of their surgery may also be offered risk-reducing bilateral salpingectomy to further reduce the risk of developing high grade serous ovarian carcinoma35.
In all patients requiring surgical management of endometriosis, the treatment should be tailored to the patient’s age, extent of disease, and childbearing status. Attention should be paid to removing all endometriotic lesions without removing or injuring normal tissue: removal of normal peritoneum in an effort to remove microscopic implants can be associated with significant complications. We do not recommend removal of all normal tissue and peritoneum as the benefits have not been proven and are questionable. It should be remembered, however, that the success of treatment is more dependent on the skill and expertise of the surgeon in thoroughly treating all disease than on the methods or instrumentation used36. We recommend multidisciplinary management of complicated extragenital endometriosis, starting with medical management and proceeding to conservative surgical measures prior to aggressive surgical peritoneal stripping that may carry a high risk of complications and adhesion formation.
- Nezhat, C., Nezhat, F.R. & Nezhat, C. Nezhat’s Operative Gynecologic Laparoscopy and Hysteroscopy, (Cambridge University Press, Cambridge ; New York, 2008).
- Giudice, L.C. Clinical Practice. Endometriosis. N Engl J Med362, 2389-2398 (2010).
- Dun, E.C., et al. Endometriosis in Adolescents. JSLS19(2015).
- Nezhat C, B.E., Paka C, Nezhat C, Nezhat F. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy, (Cambridge University Press, United States of America, 2013).
- Littman, E., et al. Role of Laparoscopic Treatment of Endometriosis in Patients with Failed in Vitro Fertilization Cycles. Fertil Steril84, 1574-1578 (2005).
- Soriano, D., et al. Fertility Outcome of Laparoscopic Treatment in Patients with Severe Endometriosis and Repeated in Vitro Fertilization Failures. Fertil Steril106, 1264-1269 (2016).
- Giudice, L.C. & Kao, L.C. Endometriosis. Lancet364, 1789-1799 (2004).
- Sampson, J. Perforating Hemorrhagic (Chocolate) Cysts of the Ovary. Their Importance and Especially Their Relationship to Pelvic Adenoma of Endometrial Type (“Adenomyoma” of the Uterus, Rectovaginal Septum, Sigmoid, Etc). Arch Surg3, 245-323 (1921).
- Lewis, M., Baker, V. & Nezhat, C. The Impact on Ovarian Reserve after Laparoscopic Ovarian Cystectomy Versus Three-Stage Management in Patients with Endometriomas: A Prospective Randomized Study. Fertil Steril94, e81-82; author reply e83 (2010).
- Falik, R., et al. Endometriomas: Classification and Surgical Management. OBG Management29(2017).
- Fedele, L., Bianchi, S., Zanconato, G., Portuese, A. & Raffaelli, R. Use of a Levonorgestrel-Releasing Intrauterine Device in the Treatment of Rectovaginal Endometriosis. Fertil Steril75, 485-488 (2001).
- Vercellini, P., et al. Treatment of Symptomatic Rectovaginal Endometriosis with an Estrogen-Progestogen Combination Versus Low-Dose Norethindrone Acetate. Fertil Steril84, 1375-1387 (2005).
- Koninckx, P.R., Ussia, A., Adamyan, L., Wattiez, A. & Donnez, J. Deep Endometriosis: Definition, Diagnosis, and Treatment. Fertil Steril98, 564-571 (2012).
- Donnez, J., et al. Deep Rectovaginal Endometriotic Nodules: Perioperative Complications from a Series of 3,298 Patients Operated on by the Shaving Technique. Gynecological Surgery10, 31-40 (2013).
- Abrão, M.S., et al. Deep Endometriosis Infiltrating the Recto-Sigmoid: Critical Factors to Consider before Management. Human Reproduction Update21, 329-339 (2015).
- Nezhat, C., et al. Bowel Endometriosis: Diagnosis and Management. AJOGIn Press.(2017).
- Mohr, C., Nezhat, F.R., Nezhat, C.H., Seidman, D.S. & Nezhat, C.R. Fertility Considerations in Laparoscopic Treatment of Infiltrative Bowel Endometriosis. JSLS9, 16-24 (2005).
- Darai, E., Ackerman, G., Bazot, M., Rouzier, R. & Dubernard, G. Laparoscopic Segmental Colorectal Resection for Endometriosis: Limits and Complications. Surg Endosc21, 1572-1577 (2007).
- Landi, S., et al. Laparoscopic Disk Resection for Bowel Endometriosis Using a Circular Stapler and a New Endoscopic Method to Control Postoperative Bleeding from the Stapler Line. J Am Coll Surg207, 205-209 (2008).
- Fanfani, F., et al. Discoid or Segmental Rectosigmoid Resection for Deep Infiltrating Endometriosis: A Case-Control Study. Fertil Steril94, 444-449 (2010).
- Roman, H., et al. Rectal Shaving for Deep Endometriosis Infiltrating the Rectum: A 5-Year Continuous Retrospective Series. Fertil Steril106, 1438-1445 e1432 (2016).
- Lemos, N., et al. Laparoscopic Anatomy of the Autonomic Nerves of the Pelvis and the Concept of Nerve-Sparing Surgery by Direct Visualization of Autonomic Nerve Bundles. Fertil Steril104, e11-12 (2015).
- Roman, H., et al. Long-Term Functional Outcomes Following Colorectal Resection Versus Shaving for Rectal Endometriosis. Am J Obstet Gynecol215, 762 e761-762 e769 (2016).
- Soto, E., Catenacci, M., Bedient, C., Jelovsek, J.E. & Falcone, T. Assessment of Long-Term Bowel Symptoms after Segmental Resection of Deeply Infiltrating Endometriosis: A Matched Cohort Study. J Minim Invasive Gynecol23, 753-759 (2016).
- Possover, M., Quakernack, J. & Chiantera, V. The Lann Technique to Reduce Postoperative Functional Morbidity in Laparoscopic Radical Pelvic Surgery. J Am Coll Surg201, 913-917 (2005).
- Ceccaroni, M., et al. Nerve-Sparing Laparoscopic Eradication of Deep Endometriosis with Segmental Rectal and Parametrial Resection: The Negrar Method. A Single-Center, Prospective, Clinical Trial. Surgical Endoscopy and Other Interventional Techniques26, 2029-2045 (2012).
- Darwish, B. & Roman, H. Surgical Treatment of Deep Infiltrating Rectal Endometriosis: In Favor of Less Aggressive Surgery. Am J Obstet Gynecol215, 195-200 (2016).
- Bosev, D., et al. Laparoscopic Management of Ureteral Endometriosis: The Stanford University Hospital Experience with 96 Consecutive Cases. J Urol182, 2748-2752 (2009).
- Nezhat, C., Falik, R., McKinney, S. & King, L. Pathophysiology and Management of Urinary Tract Endometriosis. Nature Reviews Urology14, 359-372 (2017).
- Nezhat, C., Paka, C., Gomaa, M. & Schipper, E. Silent Loss of Kidney Seconary to Ureteral Endometriosis. JSLS16, 451-455 (2012).
- Nezhat, C., Seidman, D.S., Nezhat, F. & Nezhat, C. Laparoscopic Surgical Management of Diaphragmatic Endometriosis. Fertil Steril69, 1048-1055 (1998).
- Nezhat, C., et al. Endometriosis of the Diaphragm: Four Cases Treated with a Combination of Laparoscopy and Thoracoscopy. J Minim Invasive Gynecol16, 573-580 (2009).
- Veeraswamy, A., et al. Extragenital Endometriosis. Clin Obstet Gynecol53, 449-466 (2010).
- Nezhat, F.R., Apostol, R., Nezhat, C. & Pejovic, T. New Insights in the Pathophysiology of Ovarian Cancer and Implications for Screening and Prevention. Am J Obstet Gynecol213, 262-267 (2015).
- Nezhat, F.R., Pejovic, T., Reis, F.M. & Guo, S.W. The Link between Endometriosis and Ovarian Cancer: Clinical Implications. Int J Gynecol Cancer24, 623-628 (2014).
- Nezhat, C.R., Stevens, A., Balassiano, E. & Soliemannjad, R. Robotic-Assisted Laparoscopy Vs Conventional Laparoscopy for the Treatment of Advanced Stage Endometriosis. J Minim Invasive Gynecol22, 40-44 (2015).