Hum. Reprod. Advance Access originally published online on February 22, 2006
Human Reproduction 2006 21(6):1629-1634; doi:10.1093/humrep/del006
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Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up
1 Division of Gynecology, Obstetrics and Pathophysiology of Human Reproduction, Department of Surgery, Maternal–Fetal Medicine, and Imaging, University of Cagliari, Cagliari, Italy and 2 Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
3 To whom correspondence should be addressed at: Division of Gynecology, Obstetrics and Pathophysiology of Human Reproduction, Department of Surgery, Maternal–Fetal Medicine, and Imaging, University of Cagliari, via Ospedale, 09124 Cagliari, Italy. E-mail: sangioni{at}yahoo.it
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Abstract |
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BACKGROUND: The objective of the study is to evaluate the short- and long-term efficacy of complete laparoscopic excision of deep endometriosis, without rectum involvement, with the opening and partial excision of the posterior vaginal fornix. METHODS: Thirty-one patients were included in the study with symptomatic extensive disease including involvement of the cul-de-sac, rectovaginal space and posterior vaginal fornix without rectum involvement. Endoscopic surgery was performed with complete separation of rectovaginal space and in-block resection of the diseased tissue, opening and partial excision of the posterior vaginal fornix and vaginal closure either by laparoscopic or by vaginal route. Patients filled in questionnaires on pain before and 12, 24, 36, 48 and 60 months after surgical treatment. RESULTS: No intraoperative complications were observed; 65% were free of analgesic on post-operative day 2, 38% had total remission of chronic pain and 22% were improved; 38% had total remission of dysmenorrhoea and 22% were improved; 45% had total remission of dyspareunia and 25% were improved. Follow-up improvement of symptoms was statistically significant and was maintained for 5 years without recurrence of the disease or repeated surgery (P < 0.001). CONCLUSION: Complete surgical resection of deep infiltrative endometriosis with excision of the adjacent tissue of the posterior vaginal fornix improves quality of life with persistence of results for long time in patients not responsive to medical treatment.
Key words: chronic pelvic pain/deep endometriosis/dysmenorrhoea/dyspareunia/rectovaginal endometriosis
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Introduction |
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The clinical presentation of endometriosis is variable as is the appearance; there is a poor correlation between the extent of the disease and the severity of symptoms (Davis and McMillan, 2003
). In fact, although deep endometriosis is strongly associated with severe chronic pelvic pain, dyspareunia and dysmenorrhoea, the pain poorly correlates with the revised American Fertility Society (AFS) classification (The American Fertility Society, 1985; Porpora et al., 1999). Endometriotic implants that penetrate the retroperitoneal space for a distance of 5 mm or more are defined as deeply invasive endometriosis and typically involve the Douglas pouch (retrocervical endometriosis), the rectovaginal septum and the uterosacral ligaments (Koninckx et al., 1991). Although disease in this area rarely involves the full thickness of the rectosigmoid colon, it may invade the muscularis of the bowel wall (Nezhat et al., 1994). Generally, in the retrocervical endometriosis the rectum is disease free, whereas in rectovaginal deep endometriosis the rectal wall is often infiltrated (Martin and Batt, 2001; Kavallaris et al., 2003). The clinical features associated with this type of endometriosis include intestinal symptoms such as rectorrhagia, constipation and diarrhoea, in addition to dysmenorrhoea, low abdominal pain and dyspareunia (Nezhat et al., 1992). A recent study has demonstrated that some patients (9.1%) with intestinal endometriosis require segmental intestinal resection (Redwine and Wright, 2001).
Laparoscopic or laparoscopically assisted vaginal resection of intestinal endometriosis has been described (Redwine et al., 1996; Reich et al., 1998; Remorgida et al., 2005). Patients presenting with severe endometriosis report having had symptoms that started shortly after the menarche, symptoms that were ignored or treated medically for many years. Another issue with this condition is the failure to evaluate the extent of the disease. Effective management of the advanced stages of the endometriosis poses greater problems than its diagnosis. Although hormonal treatment is efficient with respect to pain, the side effects of various drugs and especially the risk of recurrence after cessation of the treatment suggest that surgery is the reference treatment in this condition (Ling, 1999). Recent studies support that complete excision of the endometriotic tissue provides the best long-term results (Nezhat et al., 1992; Redwine et al., 1996; Garry, 1997; Possover et al., 2000; Olive and Pritts, 2001; Chapron et al., 2001; Redwine and Wright, 2001). Frequently, there is no need to perform a hysterectomy or oophorectomy; moreover, laparoscopic excision of deep pelvic endometriosis appears to be highly effective at reducing pelvic pain and restoring fertility in women desiring a pregnancy (Vercellini et al., 2000). Despite the growing interest in the condition, there is a continuing debate on the surgical techniques that may be more effective in the long term and that may be performed by most surgical units (Koninckx and Martin, 1994; Jones and Sutton, 2003). There is also a debate on the value of the routine removal of vaginal tissue of the posterior fornix confining to the nodule in such cases, even if there is no macroscopic evidence of invasion of vaginal wall. The purpose of this article was to evaluate the short- and long-term (5 years) outcomes after planned complete laparoscopic excision of deep pelvic endometriosis without intestinal involvement, in which the posterior vaginal fornix was entered and partially excised in the absence of macroscopic infiltration of vaginal mucosa by the endometriotic lesion.
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Subjects and methods |
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Patients
Among 173 women undergoing laparoscopy for endometriosis in our department from May 1998 to April 2000, 31 premenopausal patients (mean age 27.7 years, range 19–38) with deep pelvic endometriosis of the cul-de-sac, retrocervical region and rectovaginal septum without intestine involvement were included in this study. The indication for surgery was pelvic pain in all 31 patients, of whom five patients had associated infertility. All 31 had previous treatment for persistent pelvic pain with medications [estroprogestins and/or GnRH agonist and non-steroidal anti-inflammatory drugs (NSAIDs)] for at least 2 years and incomplete laparoscopic surgery in 15 patients without success. The surgery in these 15 included resection and/or electrocoagulation or laser vaporization of endometriotic lesions, adhesiolysis and/or excision of ovarian endometriomas. These patients had either no resolution of their pain or experienced recurrence within 1 year. Each patient was asked to complete a questionnaire on the presence and severity of dysmenorrhoea, deep dyspareunia and non-menstrual pelvic pain, graded according to a 0–3 point multidimensional categorizing rating scale modified from that devised by Biberoglu (Biberoglu and Beherman, 1981
). The original scale defines dysmenorrhoea according to loss of work efficiency and need for bed rest (absence of pain, 0; some loss of work efficiency, mild, 1; in bed part of 1 day, occasional loss of work, moderate, 2; in bed for 1 or more days, incapacitation, severe, 3), non-menstrual pain according to various degrees of discomfort and use of analgesics (absence of pain, 0; occasional pelvic discomfort, mild, 1; noticeable discomfort for most of the cycle, moderate, 2; pain persisting during the cycle or requiring strong analgesics, severe, 3) and deep dyspareunia according to limitation of sexual activity (no discomfort, 0; tolerated discomfort, mild, 1; intercourse painful to the point of interruption, moderate, 2; intercourse avoided because of pain, severe, 3). The patients filled in the questionnaire both before surgery and 12, 24, 36, 48 and 60 months after surgery during medical consultation at our department. Pelvic examination performed at the follow-up did not show evidence of any recurrence. All women gave their written consent, and the study was approved by the institutional review board of the Department of Gynecology and Obstetrics of the University of Cagliari. Before surgical treatment, each patient underwent clinical examination, transvaginal and transrectal ultrasound, magnetic resonance imaging (MRI) and proctoscopy. Data were analysed using the Statistical Package for Social Sciences 10.1 (SPSS, Chicago, IL, USA).
Statistical analysis
Data analysis included age, history of endometriosis, previous pregnancies, operative procedures, operating room time, intraoperative and post-operative complications, length of stay and 30-day post-operative recovery. They were summarized as the mean and SD for continuous data and as the frequency for categorical data. Within-group variations between baseline and follow-up values were evaluated using Wilcoxon matched pairs test. Significance level was accepted at P < 0.05.
Surgical technique for the resection of the rectovaginal endometriotic lesions
Preoperative mechanical bowel preparation [low-residue diet for 5 days before hospitalization; Selg 1000 (Promefarm, Milan, Italy) the day before surgery] and preoperative i.v. antibiotics were routine. Presurgical evaluation excluded rectal involvement by proctoscopy performed during menstrual cycle, MRI (with and without intestinal contrast) and transvaginal and transrectal ultrasonographic workup. However, the patients were counselled about the risks of entering the rectum, with the associated risk of laparotomy with or without colostomy, and gave their written informed consent to the surgical treatment and the follow-up evaluation. A laparoscopic approach was undertaken in all patients and included resection and electrocoagulation or laser vaporization of all endometriotic lesions, dissection of rectovaginal septum, excision of endometriotic nodules and opening into and excision of the posterior vaginal fornix adjacent to the nodule. Ovarian and peritoneal lesions were evaluated at the time of laparoscopy and staged according to the AFS classification (The American Fertility Society, 1985). Rectovaginal endometriosis was graded according to the suggestion of Adamyan (1993). The goal of the operation was the radical exeresis of all endometriotic lesions and, in particular, of all fibrotic nodules of deep endometriosis, with routine excision of the wall of posterior vaginal fornix. After clinical examination under general anaesthesia, a uterine manipulator was positioned to displace the uterus anteriorly. A 10-mm trocar was introduced through the umbilicus to position the laparoscope (Karl Storz, Tuttlingen, Germany), and two 5-mm trocars were placed in the lower abdomen and one of 10 mm was placed on the suprapubic area. A sponge-holding forceps was inserted into the vagina to push up the posterior fornix, and another one was placed into the rectum. By using these probes as guides, the anterior rectum was separated from the posterior vaginal wall using 5-mm monopolar electrosurgical scissors, making preferentially sharp dissection starting with the dissection of the pararectal spaces. A cleavage plane was identified between the anterior wall of the rectum and the nodule. Haemostasis was achieved with bipolar electrodesiccation. All the recognizable lesions were removed and submitted subsequently to histological examination. The anterior rectum was not reperitonized. The sponge-holding forceps pushed in the vagina enabled the presentation of the posterior vaginal fornix that was opened. A 1.5 cm x 2 cm segment of the posterior vaginal fornix was then excised by laparoscopy and subsequently closed either by laparoscopic or by vaginal access in the horizontal plane using separate stitches (Figure 1). Antibiotic vaginal suppositories were placed into the vagina very close to the suture for 7 days after operation to protect against ascending infections.
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The removal of vaginal tissues was performed both for therapeutic purposes (suspected microscopic involvement) and for the prevention of recurrence or progression of the disease (Chapron et al., 2004). In selected cases, to exclude ureteric and rectal trauma, at the end of the procedure, the ureters were identified by direct visualization or ureteric stents, and 100 ml of air was inflated into the rectum.
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Results |
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At laparoscopy, all patients demonstrated evidence of nodular deep endometriosis in the rectouterine pouch and rectovaginal septum. According to Adamyan proposal, 16 patients were classified at stage I and 15 at stage III (Adamyan, 1993
). Preoperative and post-operative staging of endometriosis at the beginning and at the end of the single surgical intervention is summarized in Table I.
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Radical laparoscopic excision of all detectable endometriotic implants was carried out. Definitive diagnosis of deep endometriosis was histologically proven by the finding of stroma and endometrial glands in the excised tissue, in all 31 cases. The vaginal excised mucosa was apparently normal in all the patients, but in 10% of them microscopic evidence of endometriosis was demonstrated. In many patients, other surgical procedures were performed. These together with other operative and post-operative data are summarized in Tables II and III. There were no intraoperative complications. All the procedures were completed laparoscopically, and no conversion to laparotomy was required. There were no immediate post-operative complications. Two of the patients had post-operative fever >38°C, which decreased after 2 days of antibiotic treatment. Twenty-one (68%) of 31 patients were analgesic free on day 2. All patients were fully recuperated by post-operative day 30.
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Preoperative questionnaires of symptoms reported the presence of severe dysmenorrhoea in 28 women (90%), severe dyspareunia in 24 (77%) and severe pelvic pain in 20 (64%). The patients were followed for 5 years. Post-operative questionnaires on pain at 12, 24, 36, 48 and 60 months showed a significant improvement of well-being. Thirty-eight percentage had total remission of chronic pain and 22% were improved; 38% had total remission of dysmenorrhoea and 22% were improved; 45% had total remission of dyspareunia and 25% were improved. In particular, before surgery, 28 of 31 patients (90%) avoided intercourse because of severe dyspareunia and 20 of them (71%) began a satisfying sexual life after surgery. We did not observe any recurrence during the 5 years of follow-up (Figures 2–4).
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Discussion |
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Cul-de-sac endometriosis may invade the rectovaginal septum and may lead to obliteration of the cul-de-sac by adenomyotic nodules (Donnez et al., 1997
); it frequently presents with pain and dyspareunia. Preoperative vaginal and rectovaginal examination is essential to identify the presence of extensive pelvic disease. Focal tenderness or nodularity of the cul-de-sac and uterosacral ligaments is the best means of identifying the disease (Koninckx et al., 1996). Most medical treatments are based on ovulation suppression or inducing amenorrhoea. The treatment regimens are usually of short duration and have a high discontinuation rate because of intolerable side effects. The recurrence rate of symptoms is high, particularly of chronic pain and dyspareunia, leading to significant changes in quality-of-life scores (Redwine, 1986).
The condition may be missed if laparoscopy is carried out by a gynaecologist not sufficiently familiar with the condition. Such women may be wrongly labelled as having unexplained pain. During thorough inspection of the peritoneal surfaces, the invasiveness of the disease may not be initially apparent (Wright, 2000). Because proper surgical management of the condition requires complete excision of all the lesions, careful palpation of any suspect lesion with a blunt probe to check for possible infiltration and nodularity is essential. Retraction of the rectosigmoid over the adenomyotic nodules in the cul-de-sac frequently obscures disease and can result in incomplete excision. During surgery, identification of disease in the cul-de-sac requires placement of a probe (or a sponge held by a forceps) into the posterior fornix. This improves the exposure and facilitates the excision of the lesions (Redwine, 1990). A limited number of patients may have rectal involvement, and presurgical evaluation (careful history and physical examination, rectal echoendoscopy and/or MRI) is important in identifying the major part of them (Chapron et al., 2004). In our patients, proctoscopy during menstrual cycle, MRI and rectal ultrasonography ruled out involvement of the rectum. However, most patients with deep endometriosis present endometriotic lesions in the retrocervical position and in the higher portion of the rectovaginal septum, as shown by MRI images, and this seems the initial site of deep endometriotic invasion before progression to rectovaginal septum and rectum (Chapron et al., 2002). All patients included in our study presented signs of cul-de-sac or uterosacral ligament endometriosis and were staged according to Adamyan classification of deep endometriosis. This study confirms the low morbidity and benefits in terms of pain reduction associated with complete rectovaginal dissection and excision of the extensive infiltrating pelvic endometriosis along with a segment of the posterior fornix. Our patients presented severe symptoms and were previously treated with medical therapy (estroprogestin and/or GnRH agonist and NSAIDs) for at least 2 years, and 50% had laparoscopic treatment without excision of the deep endometriosis (coagulation of superficial endometriosis, excision of endometriomas and adhesiolysis) but had no success. The proposed radical approach appears difficult—the duration of the operation is prolonged—but it allows the removal of undetectable endometriotic implants of the rectovaginal septum and of the posterior fornix of the vagina. Leaving these implants may result in a high recurrence rate of pelvic symptoms. This type of surgery has been attempted in rectovaginal endometriosis with clear macroscopic infiltration of vaginal tissue with good results (Chapron et al., 2001). Nevertheless, routine excision of posterior vaginal fornix adjacent to the nodule, even in cases without a macroscopic infiltration of the mucosa, may be questionable. Prevention of recurrences and of disease progression to more deep and infiltrating lesions to rectum and vagina seems reasonable, as previously shown (Chapron et al., 2003). In our series, microscopic evidence of endometriosis was present in 10% of the cases apparently free from vaginal involvement. The low percentage of involvement of the posterior fornix demands further evaluation of the benefits of routine excision of this area. Nevertheless, all patients treated with our approach did not show any recurrence or did not require repeated surgery in a very long-term follow-up (5 years). By contrast, in similar cases treated without the routine removal of vaginal tissue adjacent to the nodule, recent studies showed a 25% disease recurrence within 3 years (Fedele et al., 2004).
All patients presented with severe pain with clinical exacerbation at the level of the posterior fornix and uterosacral ligaments before surgery. After surgery, an important reduction in pain scores and in particular dyspareunia was achieved. Before surgery, 90% of our patients avoided intercourse because of severe dyspareunia, and more than 70% of them began a satisfying sexual life after surgery.
The exact mechanism by which the lesion causes pain is still unknown, but several theories have been proposed to explain pain mediation by endometriotic tissue, including production and release of prostaglandins, inflammatory mediators, fibrosis and cyclic haemorrhage. In the particular case of rectovaginal septum endometriotic nodule, an exacerbation of pain is present when pressure is exerted on the nodule during physical examination, suggesting a close relationship between lesion and nerve structures that has been recently demonstrated (Anaf et al., 2000). In many cases without histological demonstration of vaginal tissue involvement with endometriosis, the improvement of symptoms such as dyspareunia may be due to the removal of nociceptive nerve structures and/or by the relief of compression phenomena induced by the nodule that may trigger pain.
The use of rectal and vaginal probes helps the surgeon minimize the risk of opening the rectum. This rare complication may be treated laparoscopically with good results when an accurate intestinal preparation has been done (Nezhat et al., 1991; Redwine, 1992). Surgeon expertise is necessary to reduce complications and to avoid incomplete treatment that results in a high rate of recurrence. In our approach, posterior fornix resection was made at the end of complete rectal dissection and included only the vaginal tissue and the medial part of the uterosacral ligaments with potentially very low risk of complications at this point. The probe pushed in the posterior fornix of the vagina facilitated identification and cutting of the vaginal tissue. With this technique, any potential damage to the rectum, bowel or ureteres was virtually excluded. No additional risks to conventional laparoscopic excision were present.
Our data support the contention that benefits can be obtained without the removal of the uterus and ovaries, thereby maintaining the potential for a successful pregnancy; furthermore, pain relief is maintained for a very long period. Moreover, the excision of the posterior vaginal fornix and rectovaginal tissue involved in the endometriotic process is important to avoid disease progression towards the rectal wall, as suggested by clinical evidence (Chapron et al., 2003).
In conclusion, the laparoscopic radical excision of deep endometriosis with excision of posterior vaginal fornix, even if the vagina is apparently free of disease, is the best approach to this debilitating disease. The procedure is associated with low complication rates, rapid recovery to normal life and long-term well-being in many patients without recurrence of the disease or repeated surgery during 5 years of follow-up. However, this treatment should be carried out by appropriately trained surgeons and subject to scrupulous audit. Large randomized studies are required to validate this approach.
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This study was partially supported by Benessere Donna ONLUS Foundation, Cagliari.
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Submitted on June 8, 2005; resubmitted on December 20, 2005; accepted on December 29, 2005.
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