RBMOnline - Vol 18. No 2. 2009 282-289 Reproductive BioMedicine Online; www.rbmonline.com/Article/3467 on web 4 December 2008
Article Outcome after multidisciplinary CO2 laser laparoscopic excision of deep infiltrating colorectal endometriosis Dr Christel Meuleman MD has been trained in reproductive medicine and reproductive surgery at the University Hospital Leuven, Belgium. As Clinical Head she coordinates the program Endometriosis and Fertility Surgery at the Leuven University Fertility Centre of the department of Obstetrics and Gynecology of the University Hospital Leuven. At present she is completing a PhD on quality control in the surgical diagnosis and treatment of endometriosis.
Dr Christel Meuleman Christel Meuleman1, André D’Hoore2, Ben Van Cleynenbreugel3, Nele Beks4, Thomas D’Hooghe1,5 Leuven University Fertility Centre, Department of Obstetrics and Gynecology; 2Department of Abdominal Surgery; 3 Department of Urology, University Hospital Leuven; 4Biomedical Science, University of Leuven, Belgium 5 Correspondence: e-mail:
[email protected]
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Abstract The aim of this retrospective cohort study was to evaluate clinical outcome after multidisciplinary laparoscopic excision of deep endometriosis. Patients (n = 56) were asked to complete questionnaires regarding quality of life (QOL), pain, fertility and sexuality to compare their status before and after surgery, and their medical files were analysed. Statistical analysis was performed with life table analysis, paired Wilcoxon and McNemar tests. Gynaecological pain, QOL and sexual activity improved significantly (P < 0.001; P < 0.0001 to P = 0.008 and P < 0.0001 to P = 0.0003 respectively) during a median follow-up 29 months after surgery. Postoperative complications occurred in 11% but were directly related to surgery in only 5%. The cumulative recurrence rate of endometriosis was 2 and 7% at 1 and 4 years after surgery respectively. Cumulative pregnancy rate was 31 and 70% at 1 and 4 years after surgery respectively. In conclusion, multidisciplinary CO2 laser laparoscopic excision of deep endometriosis with colorectal extension improves pain, QOL and sexuality with high fertility and low complication and recurrence rates. Keywords: colorectal endometriosis, deep infiltrating endometriosis, dysmenorrhoea, dyspareunia, quality of life
Introduction
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Endometriosis is a gynaecological disorder defined by the presence of endometrial glands and stroma outside the uterus, primarily affecting women during their reproductive years and associated with pelvic pain and infertility. Deep infiltrating endometriosis has been defined as endometriosis infiltrating deeper than 5–6 mm beyond the peritoneum (Koninckx and Martin, 1994; Vercellini et al., 2004) and is strongly associated with pelvic pain (Fauconnier et al., 2002; Koninckx et al., 1991; Porpora et al., 1999; Fauconnier and Chapron, 2005) and probably also with infertility (D’Hooghe et al., 2003; Darai et al., 2005; Vercellini et al., 2006). Deep endometriosis can be found in rectovaginal septum, uterosacral ligaments, bowel, ureters and bladder (Vercellini et al., 2004), and may result in complete obliteration of the cul-de-sac, representing a surgical challenge (Redwine and Wright, 2001).
Many clinicians are convinced that deep infiltrating endometriosis is best treated by surgical excision (Garry, 2004) because of the relative ineffectiveness of medical therapy (Olive, 2003; Donnez et al., 2004). There is a positive correlation between the extent of endometriosis resection and the degree of postoperative improvement (Chapron et al., 2004). During reproductive age, radical excision of endometriosis combined with pelvic reconstruction appears to be the best option. This approach requires expertise, available in specialist centres (Redwine et al., 2001; Emmanuel and Davis, 2005; Perry, 2005) with multidisciplinary surgical collaboration in cases of complete obliteration of the cul-desac or the vesicouterine fold (Perry, 2005).
© 2009 Published by Reproductive Healthcare Ltd, Duck End Farm, Dry Drayton, Cambridge CB23 8DB, UK
Article - Laparoscopic excision of deep endometriosis - C Meuleman et al. At the Leuven University Fertility Centre (LUFC) of the University Hospital Leuven, Belgium, a tertiary referral centre for endometriosis, deep infiltrating endometriosis is treated by means of radical but fertility-sparing laparoscopic excision with CO2 laser in a multidisciplinary setting. The gynaecologist (CM), trained in endoscopic surgery for the restoration of fertility is backed up by a colorectal surgeon (AD) and a urologist (BVC), both also adept at laparoscopy. The aim of the present study was to evaluate the complication rate, cumulative recurrence and cumulative fertility rate, pain, quality of life and sexual satisfaction after multidisciplinary fertility-sparing radical CO2 laser laparoscopic excision of deep infiltrating endometriosis.
15 W Super Pulse mode, included resection of endometriotic adhesions and endometriotic cysts, wide excision of diseased peritoneum and radical nodulectomy. To perform a radical nodulectomy, an incision was made in healthy peritoneum surrounding the diseased peritoneum, ‘peeling’ off the affected peritoneum with restoration of normal anatomy. During this procedure, the musculosa of bladder and/or bowel is possibly ‘peeled off’ the mucosa. This procedure was monitored visually and by touching the indurations with the rinsing/aspiration probe. Perforation of the vagina due to segmental resection of the posterior wall was laparoscopically sutured by the gynaecologist.
Materials and methods
Subsequently, the urologist (BVC) evaluated ureters and bladder. An injury of the ureter or a bladder perforation due to segmental resection for bladder endometriosis was laparoscopically sutured by the urologist. The double J stents remained in place for 6 weeks to 3 months in the following cases: extensive coagulation around the ureter, lesion of the ureter with or without suture, or transection of the ureter with suture.
The protocol of this retrospective cohort study (NCT00249834, ClinicalTrials.gov) was approved by the Ethical Committee of the University Hospital Leuven, Belgium.
Patients All women (n = 56) who had undergone CO2 laser laparoscopic radical excision of deep infiltrating endometriosis with active involvement of a colorectal surgeon and/or urologist were selected retrospectively from the list of all patients (n > 2000) operated on at the Leuven University Fertility Centre between September 1996 and July 2004.
Preoperative exploration Before surgery, based on the medical history of the patient, 37 women underwent a bimanual vaginal examination and a speculum examination and 31 women underwent a vaginal ultrasound performed by a gynaecologist with special skills in pelvic ultrasound. An intravenous pyelogram (n = 38) and a bowel barium enema with double contrast (n = 33) were performed in order to map the involvement of the ureters, the bladder and the bowel in the endometriosis process.
Preoperative bowel preparation All patients were asked to follow a low-residue diet during 5 days before surgery. A Fleet Phospho-Soda (Wolfs, Belgium) (2 × 45 ml) was administered the day before operation, followed by 2 l of water without effervescence.
Operative procedure in three steps Endometriosis was scored and staged according to the revised American Society for Reproductive Medicine (formerly American Fertility Society) classification of endometriosis system (rAFS; American Society for Reproductive Medicine, 1997). When peri-ureteral endometriosis was present, double J stents were placed into the ureters by the urologist (BVC) enabling ureterolysis by CO2 ‘micro’-dissection without accidental or unnoticed transection of the ureter. Radical excision of endometriosis by the gynaecologist, using a CO2 laser (Lumenis Inc., USA: Compact 40C CO2 laser) in the RBMOnline®
Finally, the colorectal surgeon (AD) evaluated the integrity of the rectosigmoid colon and took the final decision to either suture the bowel wall (minor seromuscular injury: reinforcing suture) or to resect the bowel segment (with primary anastomosis) that had been involved in the endometriotic nodule and previously cleaned from all visible and palpable endometriosis by the gynaecologist. The treatment of bowel endometriosis depended on the type of the lesion and its extension, and was performed laparoscopically, following the basic rules of bowel surgery. Bowel perforation was the only indication for intravenous administration of broad spectrum antibiotics during 5 days. To perform a resection of the sigmoid, an anterior resection or a colon pouch, the rectosigmoid colon was mobilized. The mesentery was incised and the superior rectal artery was isolated, ligated and divided. The part of the rectum or sigmoid colon to be removed was identified. The proximal sigmoid was then mobilized to ensure a tension free anastomosis after resection of the diseased part. The distal rectum was transected using endoscopic stapling devices (Autosuture; Tyco Healthcare, USA) and the proximal bowel was retrieved through a small (36–38 years), IVF was proposed.
Questionnaires
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All 56 multidisciplinary operated patients were asked to complete the Oxford Endometriosis Quality of Life questionnaire (Jones et al., 2001), a sexual activity questionnaire (Thirlaway et al., 1996) and visual analogue scales (VAS) for dysmenorrhoea, chronic pelvic pain and deep dyspareunia, to compare their status before surgery and at the time of the evaluation (January 2005).
Statistical analysis The cumulative recurrence rate and the cumulative pregnancy rate were calculated using life table analysis (D’Hooghe et al., 2006) up until the closure of the study (January 2005). The answers to the questionnaires were statistically analysed using paired Wilcoxon tests and paired McNemar tests. Statistical significance was reached at a P-value
