RECTOVAGINAL ENDOMETRIOSIS DEEP ENDOMETRIOSIS OF THE RECTOVAGINAL SEPTUM WITH BOWEL INVOLVEMENT: SURGICAL MANAGEMENT WITH SEGMENTAL RESECTION OF RECTOSIGMOIDS
Guillermo Durruty V.1, Demetrio Larraín de la C.1, Mauricio Cuello F.1, Cristián Pomés C.1, Hugo Vidal A.2, Angie Vergara R.1, Waldo Leiva L1
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile.
2 General Physician, Catholic University of Chile.
We present 3 cases of deep endometriosis of the rectovaginal septum with intestinal involvement, in which segmental resection of the rectosigmoid was performed to achieve complete removal of the disease. The clinical picture, surgical management, complications and subsequent follow-up are analyzed. We reviewed the literature in order to establish some guidelines for the management of this entity.
KEY WORDS: Deep endometriosis, laparoscopy, rectovaginal nodule
We reported 3 cases of deep endometriosis affecting the rectovaginal space with intestinal disease in which a rectosigmoid resection was required to achieve a complete surgical removal of disease. The clinical course, surgical management, complications and follow-up are analyzed. We review the Hterature to define some guidelines in the management of this entity.
KEY WORDS: Deep infiltrating endometriosis, laparoscopy, rectovaginal nodule
Endometriosis is defined as the presence of functional endometrial tissue (glands and stroma) outside the uterine cavity (1). From an anatomical point of view, endometriosis can be located in the pelvis or outside the pelvis. Within pelvic endometriosis, three forms can be distinguished: ovarian endometriosis, superficial peritoneal endometriosis and deep peritoneal endometriosis. The latter corresponds to the rarest of the three forms mentioned and is diagnosed when there is infiltration of the retroperitoneal space ≥ 5 mm (2). Its incidence is estimated at 1 in 170 to 1 in 3,800 women. Rectovaginal septal endometriosis (RVT) is the most severe form of deep endometriosis, specifically involving the connective tissue between the vagina and the anterior wall of the rectum. It is estimated that 1 in 6 women with deep endometriosis will have VRT involvement, representing 1 in 1000 to 1 in 23,000 women with endometriosis (3). VRT endometriosis can infiltrate both the vagina and the rectum and, in the most severe cases, can extend laterally to involve one or both ureters (3,4). Intestinal com promissiveness, although uncommon, is observed in 3-37% of patients with endometriosis and mainly affects the rectosigmoid (5-9). Medical treatment is ineffective and has little role in the management of these patients (10), who often require aggressive surgical treatment, which may include resection of an intestinal segment for successful treatment (11).
The objective of this paper is to review the experience of the Clinical Hospital of the Pontificia Universidad Católica de Chile in the diagnostic and therapeutic confrontation of patients with deep endometriosis with intestinal compromise (rectosigmoids). A review of the available evidence in the literature is also presented in order to provide some guidelines for its correct diagnosis and management.
PATIENTS AND METHOD
The ward records of our center were reviewed and a database was built with the cases of endometriosis operated between January 2005 and December 2007. All patients diagnosed with VRT endometriosis who were treated surgically and biopsied at the Pathological Anatomy Service of the Clinical Hospital of the Catholic University of Chile were recruited. In retrospect, the clinical records of those cases in which surgical management required segmental colorectal resection due to deep or transmu-ral involvement of the bowel wall were reviewed. Those patients who showed the presence of superficial serous implants in the intestine and only required superficial fulguration of the peritoneum, without entry to the intestinal lumen, or those in whom a wedge resection was performed, without segmental bowel resection, were excluded from the analysis. We included clinical variables such as age at diagnosis, reason for consultation, history of medical treatment for endometriosis, surgical treatment for endometriosis, preoperative evaluation tests, surgical approach, type of surgery performed, operating time, complications and follow-up. In all included cases there was histological confirmation in the piece of deep intestinal involvement by endometriosis. Post-operative controls were recorded and a telephone interview was conducted for follow-up, aimed at determining the presence of symptoms, pregnancy, long-term complications and satisfaction with the surgery.
The clinical history for analysis was recorded in an Excel database version office 2007.
A total of 30 cases of deep endometriosis with VRT involvement were recorded in the study period. Of these, only 3 cases (10%) presented colorectal compromise with the need for segmental resection.
The average age of the patients was 32 years (range: 29-33 years). In all patients there was a history of at least one surgery for endometriosis and/or recurrence of symptoms despite the use of medical treatment.
In all three cases, the reasons for consultation included catamenial dyskinesia, painful defecation, deep dyspareunia and severe dysmenorrhea. One of the patients reported episodes of hematochezia and catamenial rectorragia. Based on these symptoms, in the 3 cases, there was preoperative suspicion of intestinal involvement. On vaginal examination, in the 3 cases sensitive nodules were felt in relation to the posterior fornix. However, on rectovaginal examination, no specific nodules or pain points were palpable. It should be noted that in one of the patients it was necessary to perform the examination under anesthesia due to the intensity of her symptoms.
The imaging study included pelvic magnetic resonance imaging (MRI) and rectal endosonography. In 2 of the cases, MRI confirmed the presence of a nodule in the VRT, one of which had obvious transmural involvement of the rectum. For its part, endosonography was suggestive of infiltration of the rectal wall in one case. Given the large size of the nodule (greater than 3 cm), elimination pyelogram was performed in two cases. None of the patients reported irritative or obstructive urinary symptoms prior to diagnosis. In both cases the pyelogram showed bilateral hydroureteronephrosis. In both cases a double J catheter was installed bilaterally, in a retrograde form, by cystoscopy, prior to surgery. Such installation was performed in order to facilitate the identification and release of the ureters during surgery (ureterolysis). It should be noted that one of these patients, despite the installation of a bilateral double J, presented post-natal renal failure secondary to ureteral obstruction, requiring compensation of her renal function prior to surgery.
Due to the clinical suspicion of intestinal involvement, all patients underwent colonoscopy. In one of them (case 3) there was evident involvement of the rectal mucosa. In this case biopsies were taken by endoscopy due to their inflammatory and necrotic aspect, suggestive of neoplastic involvement. These biopsies only showed inflammation and fibrosis.
The treatment was surgical with a conservative approach to fertility (preservation of the uterus and at least one ovary) in all three cases. In 2 of the cases the approach was primarily laparoscopic. In the third case, laparotomy was chosen because of bilateral ureteral involvement and the complexity of the surgery.
Regardless of the route of approach, mechanical preparation of the intestine and antibiotic prophylaxis were performed in all patients according to local regulations (12). The surgery was planned and performed by a multidisciplinary team composed of a gynecologist, coloproctologist and urologist.
Once the pneumoperitoneum was performed and the optics installed (or the abdominal cavity opened), in all 3 patients, the main finding was the presence of sealing or obliteration of the posterior pouch. Once the pelvis was freed, it was possible to demonstrate the presence of deep endometriosis with VRT involvement in all three cases. Coexistence of ovarian endometriosis was observed in only one patient. In two patients the lateral extension of the nodule was evident. When the retrouterine peritoneum was opened and the avascular spaces of the pelvis (para-rectal spaces) developed, uni or bilateral ureteral involvement was demonstrated in two cases.
In all three patients, in order to achieve complete resection of the VRT nodule, segmental resection of the rectosigmoid with primary anastomosis was performed using a bracket. Evaluation of the proper seal of the anastomosis was performed by a pneumatic test by insufflation of transrectal air (Petzer probe). In one of the patients, given the magnitude of the surgery (ultra-low primary anastomosis), a protective ileostomy was performed, which was closed 3 months later.
In one of the patients approached primarily by laparoscopy, conversion was necessary. This conversion was due to the need for ureteral reimplantation. This procedure was performed in both cases with ureteral involvement. In one of them the re-implantation technique required a psoic bladder. This patient presented lateral extension of the nodule with unilateral ureteral involvement. In the other patient, with extensive bilateral ureteral involvement (same patient who experienced renal failure) it was necessary to remove both ureters segmentally in the portion attached to the nodule. Given the length of the resected segment, the reimplantation was done using the Casati-Boari bladder flap technique.
In one of the three surgeries it was possible to perform the complete procedure by laparoscopy, complete removal of the nodule, intestinal resection and primary anastomosis.
The average operating time was 403 minutes, being longer in the cases with ureteral reimplantation.
In all cases there was histological confirmation of deep endometriosis of the RVT with involvement of the colorectal wall (Figure 1 illustrates one of the cases).
In the immediate postoperative period no major complications (including anastomotic leakage) were recorded. One of the cases required transfusion due to symptomatic anaemia. However, there was a late major complication, following the patient’s discharge, which corresponded to a pulmonary thromboembolism 2 weeks after discharge. The patient was re-hospitalized and an inferior vena cava filter was installed plus the initiation of anticoagulation (TACO), which was indicated for a minimum of 3 months.
With an average follow-up of 20 months (range: 16-26 months), 2 of the 3 patients are in good condition. The third required reexamination due to ureteral reimplantation stenosis. Recently the patient with the pulmonary thromboembolism finished her TACO; in her image control the presence of bilateral ovarian endometriosis was noted, which is why re-examination surgery has been planned.
Table I summarizes the clinical characteristics, surgical and follow-up aspects of the three patients included in the series.
Intestinal endometriosis was first described by Sampson in 1922 (13), and is defined as the infiltration of the intestinal wall by ectopic endometrial tissue, compromising the muscular tissue itself (14). The reported incidence ranges from 3 to 37% and depends on the center from which the series originated (5-9). Usually the highest incidence is observed in reference centers such as ours. At present, the estimated incidence for our centre is 10%.
Trying to define a characteristic clinical picture for deep endometriosis with intestinal involvement, which distinguishes it from other forms of endometriosis, is difficult. However, certain elements of the anamnesis should make us think about it. Firstly, it should be noted that VRT endometriosis mainly presents with pelvic pain, which can have different patterns (e.g. dysmenorrhoea, deep dyspareunia, non-cyclic pelvic algae). Along with this “typical” pain pattern, low gastrointestinal symptoms and/or changes in bowel habit, all of which are secondary to colorectal involvement, may coexist, such as rectal bleeding, rectal urgency, catamenial dyskinesia, and painful bowel movements during menstruation (8,15,16). Therefore, the association of pelvic pain to any of these symptoms should motivate a directed search for such involvement. But more importantly, it is important to understand that the clinical picture of endometriosis with intestinal involvement is very varied, making its diagnosis difficult and requiring a high level of suspicion. Therefore, we strongly recommend that every patient with a presumptive or known diagnosis of severe endometriosis be questioned for any of these symptoms since there is a correlation between the history of endometriosis, its location and the probability of intestinal involvement (16,17). As an example, in our series, all the patients had a history of severe endometriosis and presented some of the symptoms already described.
The usefulness of the physical examination in the diagnosis of VRT endometriosis is controversial, but it should not be omitted. The findings are varied and depend on the location of the lesions and the day of the menstrual cycle when the examination is performed (18). Although it is most frequent to palpate a sensitive nodule in the posterior vaginal pouch (evoking exactly the symptoms referred to by the patient), its absence does not rule out the possibility. According to Chapron, in 65% of patients with deep endometriosis and rectal involvement, painful nodules are not palpated on vaginal touch (19). The presence of red lesions during speculation is another highly suggestive finding of VRT endometriosis. However, this finding is absent in 70% of cases of intestinal endometriosis (19). With respect to the rectovaginal examination, in addition to being an uncomfortable procedure, it is clear that its usefulness is limited (11,20), since the lesions are usually located higher out of reach. This is why we do not perform it routinely. Based on our experience, we strongly recommend examining the patient during the menstrual period, particularly if the initial clinical examination has been doubtful and the anamnesis suggests the presence of deep endometriosis.
In order to maximize therapeutic success, it is essential to establish as accurately as possible the actual extent and location of the disease. This knowledge will influence treatment planning (including who will be involved in its management) and the risk of disease recurrence resulting from partial treatments, leading to increased costs and added morbidity.
In this regard, some authors have defined the examinations that should be carried out in case of suspicion of this entity and according to their results have established classifications that allow predicting the complexity of the treatment required and the possibility of failure (14,21). Within these classifications, in our centre, we have used the classification proposed by Donnez et al (22), which considers the findings in pelvic magnetic resonance imaging (MRI) and transrectal ultrasonography (USTR) (Table II). It should be noted that in these patients, the use of different imaging methods is frequent in order to increase diagnostic accuracy (23). Table III summarizes the values of sensitivity, specificity, predictive value and likelihood ratio for the different imaging methods used for the diagnosis of deep endometriosis with bowel involvement.
Among the examinations used, USTR is a useful test for suspected rectovaginal septal endometriosis and bowel involvement. However, its correct interpretation requires trained personnel and routine performance, which is not the case in many centres (24). In our centre, although it is performed, it is still not usually indicated. Other centres have recommended the use of transvaginal ultrasonography (USTV). Under this image, endometriotic lesions appear as linear fat pads or hypoechoic nodules of variable size (25). Bazot et al (26), in a prospective controlled study, in which 142 patients were included, demonstrated that USTV was a useful tool in the diagnosis of intestinal endometriotic compromise. However, as with the USTR, it required the radiologist to be familiar with both the normal appearance of the colorectal wall and when it is compromised by these lesions. In our experience, although the USTR is the first line examination during the study of patients with chronic pelvic algia (cyclic or non-cyclic), it does not show utility in the diagnosis of endometriosis of the rectovaginal or intestinal septum. Its usefulness is restricted to those cases where endometriomas coexist (25,27). Its diagnostic capacity with endometriomas justifies its use since deep endometriosis with intestinal involvement rarely occurs in isolation and generally coexists with these other forms of pelvic endometriosis (9,14,23).
In our series, in one of the cases endometriomas and deep endometriosis with colorectal involvement coexisted (1 of 3 cases). Although our series is small, such frequency of coexistence is consistent with what is reported in the literature. That is, between 39.7 to 53% of cases of deep endometriosis coexist with endometriomas (26,28). It should also be added that the presence of endometriomas is a marker of severe disease and an independent risk factor for the need for intestinal resection during surgical treatment. In an analysis of 1785 patients with ovarian endometriosis, only 1% had endometriomas as a single lesion (29). This means that if a gynaecologist diagnoses and treats ovarian endometriosis alone, there is a 99% chance of leaving other major lesions untreated (29). This is why the gynaecologist, faced with the discovery of endometriomas, must expect to be confronted with an extensive disease and the possibility of ending up with complex surgery with the risk of major complications. Although diagnostic studies do not suggest it, during the surgical exploration other lesions should always be looked for and if they exist, treated.
MRI of the pelvis is an increasingly used diagnostic tool in the preoperative evaluation of deep endometriosis of the posterior pelvis. This technique is superior to ultrasonography as it is not operator dependent and provides more complete and objective information of the pelvic anatomy. MRI is very accurate in diagnosing certain locations of deep endometriosis such as the rectovaginal septum or rectosigmoid. However, MRI shows some limitations with the presence of endom-triomas in the vicinity of the utero-sacral ligaments or with retroverted uterus (30). In our experience, MRI has a strong correlation with intraoperative findings.
A test that has fallen into disuse but has been used for more than 30 years, in the face of suspicion of intestinal involvement, is the double contrast baryte enema (31). In this respect only one study has evaluated its diagnostic efficacy (32). In this examination it is possible to observe the deformation of the anterior wall of the colon or rectosigmoids due to the presence of the disease. In our centre we do not use it routinely.
Endosonography is currently the test of choice when there is suspicion of endometriotic involvement of the intestinal wall (9). This test allows us to delimit with great accuracy both the depth of the lesion affecting the intestinal wall and the distance from it to the anal margin (33-36). Chapron et al (37), showed that endosonography has greater sensitivity and negative predictive value than MRI for the diagnosis of rectal involvement in patients with deep endometriosis of the posterior pelvis. However, this test has disadvantages. These include the requirement for a trained operator, the inconvenience of previous preparation by evacuating enema, and the visualization of only a small portion of the pelvis. In our center we have used it only in those cases where there is a strong clinical suspicion of rectal involvement.
Recently, evidence has emerged with the use of multi-slice computed tomography (CT) with enteroclysis. This test appears to be a very effective method in the diagnosis of intestinal endometriosis (38,39). To date, we do not have experience with this technique in patients with endometriosis.
A frequently performed examination in patients with suspected deep endometriosis with intestinal involvement is colonoscopy. The aim of this test is to identify lesions with transmural intestinal involvement and to biopsy them. However, mucosal involvement is extremely rare, so the test will usually be normal or with signs of extrinsic compression. If the lesions are observed and biopsied, they will only show chronic inflammation, which may confuse or generate erroneous interpretations (6,40), as occurred in one of our cases where the diagnosis was between retroperitoneal fibrosis, suspected neoplastic pathology and deep endometriosis. In our opinion, the major role of colonoscopy would be to make a differential diagnosis of patients with rectal bleeding and to exclude malignant tumors.
Having confirmed the diagnosis of deep endometriosis with intestinal involvement, the only reasonable and effective therapeutic alternative, in symptomatic patients, is to achieve complete surgical resection of the ectopic endometrial tissue. However, such surgery is extremely complex and is associated with possible intestinal, ureteral and vaginal complications (41). Therefore, pre-planning and coordination involving a multidisciplinary team (gynaecologist, urologist and digestive surgeon) is crucial.
Regarding the use of medical therapy, before or after surgery, either to facilitate the procedure or to decrease the risk of recurrence, there is no evidence to support this (42). However, in some cases, it may be a pre-surgical option (differing the timing of the surgery), particularly if the surgical alternative involves too complex and/or risky surgery or if the patient is at high surgical risk (e.g. patients with coagulation disorders) (9,43). It should be noted, that such an option is only transitory and should not constitute the definitive management alternative. In our experience as well as in that of other groups, the efficacy of medical treatment in patients with deep endometriosis is minimal with a high rate of symptomatic recurrences, ultimately requiring surgery in most cases (10,11,44).
One aspect to consider in patients with this disease refers to the involvement by disease of other pelvic structures, particularly the ureter. This involvement varies in extension and depth. It usually corresponds to trapping or stenosis secondary to fibrosis surrounding the rectovaginal nodule and involving it by proximity. Fortunately, such involvement is rare. However, in large nodules (≥ 3 cm) and/or with lateral extension, such involvement may reach 11% of cases (4). Establishing a diagnosis prior to or during surgery is of vital importance since, without treatment and as a result of the obstruction, it can lead to the silent and irreversible loss of renal function (4). Symptoms suggestive of obstructive uropathy or the occurrence of catamenial lumbago are rare and most patients remain asymptomatic (45). Therefore, in large nodules and/or with lateral extension, the urinary tract should always be studied, regardless of whether or not there are associated symptoms. Elimination pyelogram is the test of choice against the presumption of ureteral involvement (22). It should be noted that our two patients with ureteral involvement had no urinary symptoms. Based on the above, we have decided in our center to perform pyelogram studies, as part of the preoperative evaluation, on all patients with type III nodules according to the Donnez classification (Table II), those larger than 3 cm or those with lateral extension. In these patients, the preoperative installation of double J catheters allows identification of the ureter and facilitates ureterolysis. Even so, the surgical treatment is complex and may require partial resection of the ureter and subsequent reimplantation of the proximal portion into the bladder. Different techniques of ureteral reimplantation have been described, with the Psoic bladder and Casati-Boari being the most commonly used (45). In our series, one of the cases required a psoic bladder. In the second case, as a result of extensive and bilateral involvement, the solution was ureteral reimplantation using a double Casati-Boari (in juxtaposed barrel shotgun).
Intestinal endometriosis is often an unexpected intraoperative finding for the gynaecologist, who often has no adequate training in intestinal surgery. This, coupled with the lack of adequate bowel preparation, often results in incomplete surgery for this entity. Because of this, we recommend always performing intestinal preparation in the case of suspicion or finding of endometriomas as well as in all patients with a history of endometriosis. In addition, a digestive surgeon should work in coordination with the patient to assist in the management of the endometriosis.
The technique and surgical approach chosen will depend on both the extent and location of the disease and the experience of the surgeon. There is no clear consensus on the indications for intestinal resection in endometriosis, but in general it is indicated in symptomatic patients, when there is suspicion of malignancy, in the presence of deep implants involving >50% of the intestinal perimeter, with nodules > 3 cm, multiple nodules or with transmural involvement (9,46,47,48). Can-didates to this surgery should be adequately informed about the possibility of conversion, ureteral injury, colostomy and the persistence of urinary and digestive symptoms after surgery.
For years both the deep involvement of the intestinal wall and the need for ureteral reimplantation were absolute indications for laparotomy (23,49). Table IV summarises the results of the main series of deep endometriosis with bowel involvement in which segmental bowel resection by laparotomy was performed. However, the scenario has changed, since the advances in laparoscopic technique and the greater experience of surgeons with it, have made it possible to tackle this pathology by this route.
Since the first laparoscopic bowel resection by endometriosis was carried out in 1991 (53), this option has become a possible and increasingly attractive alternative for the management of deep endometriosis of the posterior pelvis with bowel involvement (54). The minimally invasive approach offers results comparable to open surgery, with the advantage of minimizing surgical trauma and allowing better visualization of the deep pelvis (49,55,56). However, such an approach requires expert and well-trained surgeons. It is not enough to have a laparoscopic gynecologist; the rest of the team must also use these techniques (digestive surgeon and urologist).
Table V summarises the results of the main series of intestinal resection in deep endometriosis carried out by laparoscopy.
It should be emphasised with some of these series that segmental resection constitutes a small proportion of the total number of cases with intestinal surgery for pelvic endometriosis (47,57,58).
It is important to stress that conversion to laparotomy should not be considered as a complication but as a possible scenario in the context of highly complex surgery. Both in our series and others (57, 63), most conversions occurred in patients requiring segmental resection or ureteral reimplantation. The case is different with other forms of endometriosis where the conversion is infrequent as they are less complex surgeries.
When analyzing the results of series with patients operated for deep endometriosis with intestinal compromise, in which it was necessary to perform an intestinal resection, we can point out that they are good, with acceptable morbidity rates and satisfactory results with respect to fertility and improvement in quality of life (56,64). Our casuistry is still small to draw solid conclusions but at least it supports the feasibility and safety of the procedure, after a study and well-planned surgery.
Deep endometriosis with intestinal involvement corresponds to a rare variety within the different forms of endometriosis. Despite this, the gynaecologist cannot be exempt from offering adequate management. This entity opens a new frontier and a source of challenge for the specialist, forcing the most advanced knowledge of anatomy and a new physiopathology. In addition, it is necessary that their training is accompanied by knowledge and practice that have traditionally been considered as belonging to other areas. In addition to a high rate of suspicion, which is key to diagnosis, it is necessary to perform an appropriate study in which pelvic MRI and endosonography play a central role. Finally, adequate treatment planning is necessary, which may require highly complex surgeries. Surgical treatment, either by laparoscopy or laparotomy, is effective in decreasing the symptoms, as long as complete removal of the disease is achieved. Finally, surgical treatment must be individualized and performed in specialized centers where multidisciplinary management is truly possible.
Acknowledgements: The authors would like to thank Mr. Hernán Ahumada Poblete and Mrs. Carmen Gloria Sandoval Tillería, library assistants at the Pontificia Universidad Católica de Chile, for their assistance in collecting the material used in the preparation of this manuscript.
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