Nerve-sparing laparoscopic disc excision of deep endometriosis involving the bowel: a single-center experience on 371 consecutives cases

Abstract

Background: Bowel endometriosis is the most common pattern of Deep Endometriosis (DE). Arising from the posterior portion of the cervix and spreading to the recto-vaginal septum, utero-sacral and parametrial ligaments could lead to a distortion of normal pelvic anatomy, causing pain and infertility. Hormonal therapy is the first-line treatment in non-symptomatic patient. Conversely, laparoscopic surgical treatment has to be considered when symptoms relief are not optimal or with signs of bowel occlusion.

Methods: Retrospective experience of consecutive series of patients who referred to a third-level referral center with suspected bowel DE and failure of multiple medical treatments. After an intraoperative evaluation of nodule size with a rectal shaving of its external portion, patients underwent radical DE eradication with concomitant disc excision in rectal nodules < 3 cm with no signs of substantial full-thickness infiltration.

Results: A total of 371 patients were considered eligible for analysis, with a median age of 37 years. The median operative time of was 180 min, with an estimated blood loss of 100 mL and a median diameter of removed rectal nodule of 25 mm. Early postoperative procedure-related complications were 47 cases of acute rectal bleeding (12.7%), that were managed by rectal endoscopy, 3 bowel anastomotic dehiscence (0.8%), 8 hemoperitoneum (2.2%) and 3 ureteral fistula (0.8%). 22 patients experienced postoperative hyperpyrexia (5.9%), while 17 women underwent transient bladder deficiency (4.6%). Median follow-up was 60 months with a bowel recurrence rate of 2.2%. There was an improvement of all symptoms in the immediate postoperative follow-up (p < 0.0001). Among all patients with childbearing desire, the pregnancy rate found was 42.2% and was obtained by in vitro fertilization (IVF) techniques in 32% of cases.

Conclusions: Laparoscopic disc excision for bowel endometriosis is an effective surgical treatment in selected residual rectal nodules < 3.0 cm. The concomitant radical DE excision contributes to a significant improvement of symptoms with an acceptable complications' rate.

Keywords: Bowel endometriosis; Colorectal endometriosis; Deep endometriosis; Disc excision; Nerve-sparing surgery; Rectal resection.