STANDARDIZATION OF ORGAN PRESERVING LAPAROSCOPIC TREATMENT OF WOMEN WITH PAIN SYNDROME ASSOCIATED WITH DEEP ENDOMETRIOSIS
DOI:
https://doi.org/10.11603/24116-4944.2024.2.15083Keywords:
deep endometriosis, surgical treatment, laparoscopic surgery, #Enzian, pain syndromeAbstract
The aim of the study – to improve the indicators of surgical treatment of deep endometriosis in women of reproductive age with pain syndrome by creating an algorithm for surgical intervention.
Materials and Methods. A prospective observational single-center cohort study was conducted at our center, which included 210 women of reproductive age with pain syndrome who were operated on for deep endometriosis according to the new method of standardization of surgical treatment of deep endometriosis for the period from January 2020 to December 2023. Classification of all cases was conducted according to #Enzian. Intraoperative, early and long-term postoperative indicators were studied.
Results and Discussion. We obtained a statistically significant improvement in pain scores 6 months after surgery on the VAS scale from 0 to 10 (chronic pelvic pain before surgery 6.87+/-1.41, while after 6 months – 2.41+/-1.59 (p<0.001), dysmenorrhea – 8.46+/-1.16 before and 2.08+/-1.36 after (p<0.001), dyspareunia – 7.42+/-1.07 before and 2.22+/-1.69 after (p<0.001), dyschezia – 3.2+/-3.6 before and 0.8+/-2.0 after (p<0.001), dysuria – 1.2+/-2.6 before and 0.4+/-1.4 after (p=0.026)). Deep endometriosis is by far the most severe form of endometriosis and it is defined as the growth of endometrial-like tissue over and under the surface of the peritoneum; these are nodes that can penetrate into neighboring structures and are associated with fibrosis and disruption of normal anatomy, which makes the surgical treatment of this disease difficult. Damage to organs and tissue structures leads to changes in anatomy with the elimination of organ contours and significant distortion of the operative field, which is a serious problem in surgical treatment even for experienced surgeons. This, of course, must be taken into account at the pre- and intraoperative stage. Currently, there are no regulated documents in the world regarding the surgical treatment of deep endometriosis, namely, standardized approaches to such surgical intervention and an unequivocal opinion about the degree of radicality of the operations. Regarding surgery for deep endometriosis, we have a single document ESGE, ESHRE and WES 2020, but it is devoted to some technical features of the operation and does not contain the strategy of the operation, which is very necessary for the surgeon. Therefore, each surgeon operates on patients with deep endometriosis based on his/her own judgment, such treatment can be too subjective and not always beneficial to patients, so we believe that the time has come to standardize the surgical treatment of deep endometriosis. Our next study will be a retrospective comparison of surgical indicators in patients who were operated on according to the new standardized technique and according to generally accepted methods.
Conclusions. The algorithm of standardized surgical intervention should improve the indicators of surgical intervention of deep endometriosis, namely intraoperative, early and long-term postoperative results, greatly facilitate the work of surgeons and objectify such treatment.
References
1. Frumkin, N., Schmädecker, R., Isermann, R., Keckstein, J., & Ulrich, U. A. (2023). Surgical treatment of deep endometriosis. Geburtshilfe und Frauenheilkunde, 83(1), 79–87. https://doi.org/10.1055/a-1799-2658
2. Bazot, M., & Daraï, E. (2017). Diagnosis of deep endometriosis: Clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertility and Sterility, 108(6), 886–894. https://doi.org/10.1016/j.fertnstert.2017.10.026
3. Condous, G., Gerges, B., Thomassin-Naggara, I., Becker, C., Tomassetti, C., Krentel, H., van Herendael, B. J., Malzoni, M., Abrao, M. S., Saridogan, E., Keckstein, J., Hudelist, G., Aas-Eng, K., Alcázar, J. L., Bafort, C., Bazot, M., Bielen, D., Bokor, A., Bourne, T., ... Wattiez, A. (2024). Non-invasive imaging techniques for diagnosis of pelvic deep endometriosis and endometriosis classification systems: An international consensus statement. Human Reproduction Open, 2024(3), hoae029. https://doi.org/10.1093/hropen/hoae029
4. Becker, C. M., Bokor, A., Heikinheimo, O., Horne, A. W., Jansen, F., Kiesel, L., King, K., Kvaskoff, M., Nap, A., Petersen, K., Saridogan, E., Tomassetti, C., van Hanegem, N., Vulliemoz, N., Vermeulen, N., Altmäe, S., Ata, B., Ball, E., Barra, F., ... Yazbeck, C. (2022). ESHRE guideline: Endometriosis. Human Reproduction Open, 2022(2), hoac009. https://doi.org/10.1093/hropen/hoac009
5. Missmer, S. A., Tu, F. F., Agarwal, S. K., Chapron, C., Soliman, A. M., Chiuve, S., Eichner, S., Flores-Caldera, I., Horne, A. W., Kimball, A. B., Laufer, M. R., Leyland, N., Singh, S. S., Taylor, H. S., & As-Sanie, S. (2021). Impact of endometriosis on life-course potential: A narrative review. International Journal of General Medicine, 14, 9–25. https://doi.org/10.2147/IJGM.S261139
6. Zondervan, K. T., Becker, C. M., & Missmer, S. A. (2020). Endometriosis. The New England Journal of Medicine, 382(13), 1244–1256. https://doi.org/10.1056/NEJMra1810764
7. Martire, F. G., Giorgi, M., D'Abate, C., Colombi, I., Ginetti, A., Cannoni, A., Fedele, F., Exacoustos, C., Centini, G., Zupi, E., & Lazzeri, L. (2024). Deep infiltrating endometriosis in adolescence: Early diagnosis and possible prevention of disease progression. Journal of Clinical Medicine, 13(2), 550. https://doi.org/10.3390/jcm13020550
8. Giudice, L. C., Horne, A. W., & Missmer, S. A. (2023). Time for global health policy and research leaders to prioritize endometriosis. Nature Communications, 14(1), 8398. https://doi.org/10.1038/s41467-023-43913-9
9. 9. Bandini, V., Giola, F., Ambruoso, D., Cipriani, S., Chiaffarino, F., & Vercellini, P. (2024). The natural evolution of untreated deep endometriosis and the effect of hormonal suppression: A systematic literature review and meta-analysis. Acta Obstetricia et Gynecologica Scandinavica. Advance online publication. https://doi.org/10.1111/aogs.14887
10. Keckstein, J., Becker, C. M., Canis, M., Feki, A., Grimbizis, G. F., Hummelshoj, L., Nisolle, M., Roman, H., Saridogan, E., Tanos, V., Tomassetti, C., Ulrich, U. A., Vermeulen, N., & De Wilde, R. L. (2020). Recommendations for the surgical treatment of endometriosis. Part 2: Deep endometriosis. Human Reproduction Open, 2020(1), hoaa002. https://doi.org/10.1093/hropen/hoaa002
11. Vercellini, P., & Somigliana, E. (2023). "Call me by my true names": The utopian search for endometriosis and adenomyosis terminology devoid of ambiguous pathogenic meaning: Just an illusion? Journal of Endometriosis and Uterine Disorders, 1, 100020. https://doi.org/10.1016/j.jeud.2023.100020
12. Garcia Garcia, J. M., Vannuzzi, V., Donati, C., Bernacchioni, C., Bruni, P., & Petraglia, F. (2022). Endometriosis: Cellular and molecular mechanisms leading to fibrosis. Reproductive Sciences, 30(4), 1105–1117. https://doi.org/10.1007/s43032-022-01083-x
13. Limbachiya, D., Tiwari, R., Kumari, R., & Agrawal, M. (2023). Bowel endometriosis management by colorectal resection: Laparoscopic surgical technique and outcome. JSLS: Journal of the Society of Laparoscopic & Robotic Surgeons, 27(1), e2022.00075. https://doi.org/10.4293/JSLS.2022.00075
14. Habib, N., Centini, G., Lazzeri, L., Amoruso, N., El Khoury, L., Zupi, E., & Afors, K. (2020). Bowel endometriosis: Current perspectives on diagnosis and treatment. International Journal of Women's Mijatovic, V. (2020). Towards a more biologically informative system of endometriosis classification. Human Reproduction, 35(12), 2658–2659. https://doi.org/10.1093/humrep/deaa265Health, 12, 35–47. https://doi.org/10.2147/IJWH.S190326
15. Piriyev, E., Schiermeier, S., & Römer, T. (2023). Laparoscopic approach in bladder endometriosis: Intraoperative and postoperative outcomes. In Vivo, 37(1), 357–365. https://doi.org/10.21873/invivo.13086
16. Mijatovic, V. (2020). Towards a more biologically informative system of endometriosis classification. Human Reproduction, 35(12), 2658–2659. https://doi.org/10.1093/humrep/deaa265
17. D'Alterio, M. N., Saponara, S., D'Ancona, G., Russo, M., Laganà, A. S., Sorrentino, F., Nappi, L., & Angioni, S. (2021). Role of surgical treatment in endometriosis. Minerva Obstetrics and Gynecology, 73(3), 317–332. https://doi.org/10.23736/S2724-606X.21.04737-7
18. Burghaus, S., Schäfer, S. D., Beckmann, M. W., Brandes, I., Brünahl, C., Chvatal, R., Drahoňovský, J., Dudek, W., Ebert, A. D., Fahlbusch, C., Fehm, T., Fehr, P. M., Hack, C. C., Häuser, W., Hancke, K., Heinecke, V., Horn, L.-C., Houbois, C., Klapp, C., ... Ulrich, U. A. (2021). Diagnosis and treatment of endometriosis: Guideline of the DGGG, SGGG and OEGGG (S2k level, AWMF registry number 015/045, August 2020). Geburtshilfe und Frauenheilkunde, 81(4), 422–446. https://doi.org/10.1055/a-1380-3693
19. Cho, A., & Park, C.-M. (2023). Minimally invasive surgery for deep endometriosis. Obstetrics & Gynecology Science, 66(6), 489–500. https://doi.org/10.5468/ogs.23176
20. Barra, F., Ferrero, S., Zorzi, C., Evangelisti, G., Perrone, U., Valente, I., Capezzuoli, T., D'Ancona, G., Bogliolo, S., Roviglione, G., & Ceccaroni, M. (2024). "From the tip to the deep of the iceberg": Parametrial involvement in endometriosis. Best Practice & Research Clinical Obstetrics & Gynaecology, 94, 102493. https://doi.org/10.1016/j.bpobgyn.2024.102493
21. Pavone, M., Baroni, A., Campolo, F., Goglia, M., Raimondo, D., Carcagnì, A., Akladios, C., Marescaux, J., Fanfani, F., Scambia, G., & Ianieri, M. M. (2024). Robotic-assisted versus laparoscopic surgery for deep endometriosis: A meta-analysis of current evidence. Journal of Robotic Surgery, 18(1), 236. https://doi.org/10.1007/s11701-024-01954-2
22. Ianieri, M. M., Raimondo, D., Rosati, A., Cocchi, L., Trozzi, R., Maletta, M., Raffone, A., Campolo, F., Beneduce, G., Mollo, A., Casadio, P., Raimondo, I., Seracchioli, R., & Scambia, G. (2022). Impact of nerve-sparing posterolateral parametrial excision for deep infiltrating endometriosis on postoperative bowel, urinary, and sexual function. International Journal of Gynecology & Obstetrics, 159(1), 211–218. https://doi.org/10.1002/ijgo.14089
23. Ianieri, M. M., Nardone, A. D. C., Pavone, M., Benvenga, G., Pafundi, M. P., Campolo, F., Foschi, N., Greco, P., Brutto, M., & Scambia, G. (2023). Are ureterolysis for deep endometriosis really all the same? An anatomical classification proposal for ureterolysis: A single-center experience. International Journal of Gynecology & Obstetrics, 163(3), 1045–1052. https://doi.org/10.1002/ijgo.14790
24. Crestani, A., Dabi, Y., Bendifallah, S., Kolanska, K., Buffet, N. C., Thomassin-Naggara, I., Darai, E., & Touboul, C. (2023). ENDOGRADE: A four-level classification to rate surgical complexity in endometriosis. Journal of Gynecology Obstetrics and Human Reproduction, 52(8), 102632. https://doi.org/10.1016/j.jogoh.2023.102632
25. Roman, H., Chanavaz-Lacheray, I., Hennetier, C., Tuech, J.-J., Dennis, T., Verspyck, E., & Merlot, B. (2023). Long-term risk of repeated surgeries in women managed for endometriosis: A 1,092-patient series. Fertility and Sterility, 120(3), 658–667. https://doi.org/10.1016/j.fertnstert.2023.05.156
26. Keckstein, J., Hoopmann, M., Merz, E., Grab, D., Weichert, J., Helmy-Bader, S., Wölfler, M., Bajka, M., Mechsner, S., Schäfer, S., Krentel, H., & Hudelist, G. (2022). Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis. Archives of Gynecology and Obstetrics, 307(1), 5–19. https://doi.org/10.1007/s00404-022-06766-z
27. Saridogan, E., Becker, C. M., Feki, A., Grimbizis, G. F., Hummelshoj, L., Keckstein, J., Nisolle, M., Tanos, V., Ulrich, U. A., Vermeulen, N., & De Wilde, R. L. (2017). Recommendations for the surgical treatment of endometriosis. Part 1: Ovarian endometrioma. Human Reproduction Open, 2017(4), hox016. https://doi.org/10.1093/hropen/hox016
28. Guerriero, S., Condous, G., van den Bosch, T., Valentin, L., Leone, F. P. G., Van Schoubroeck, D., Exacoustos, C., Installé, A. J. F., Martins, W. P., Abrao, M. S., Hudelist, G., Bazot, M., Alcázar, J. L., Gonçalves, M. O., Pascual, M. A., Ajossa, S., Savelli, L., Dunham, R., Reid, S., ... Timmerman, D. (2016). Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: A consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound in Obstetrics & Gynecology, 48(3), 318–332. https://doi.org/10.1002/uog.15955
29. Keckstein, J., & Hoopmann, M. (2023). Endometriosis, ultrasound and #Enzian classification: The need for a common language for non-invasive diagnostics. Ultraschall in der Medizin–European Journal of Ultrasound, 44(3), 233–239. https://doi.org/10.1055/a-2055-6712
30. Metzemaekers, J., Bouwman, L., de Vos, M., van Nieuwenhuizen, K., Twijnstra, A. R. H., Smeets, M., Jansen, F. W., & Blikkendaal, M. (2023). Clavien-Dindo, Comprehensive Complication Index and classification of intraoperative adverse events: A uniform and holistic approach in adverse event registration for (deep) endometriosis surgery. Human Reproduction Open, 2023(2), hoad019. https://doi.org/10.1093/hropen/hoad019
31. Gladchuk, I., & Haidarzhi, K. D. (2023). Subtypes of deep endometriosis according to laparoscopic revision. Scientific Digest of the Association of Obstetricians and Gynecologists of Ukraine, 1(51), 5–10. https://doi.org/10.35278/2664-0767.1(51).2023.294837
32. Abuzeid, O., Hebert, J., Ashraf, M., Mitwally, M., Diamond, M. P., & Abuzeid, M. I. (2018). Safety and efficacy of two techniques of temporary ovarian suspension to the anterior abdominal wall after operative laparoscopy. Journal of Minimally Invasive Gynecology, 25(7, Suppl.), S43–S44. https://doi.org/10.1016/j.jmig.2018.09.067
33. Dehbashi, Z., Khazali, S., Tanha, F. D., Mottahedian, F., Ghajarzadeh, M., Samimi Sadeh, S., & Kamali, K. (2019). Effectiveness of ovarian suspension in preventing postoperative ovarian adhesions in patients with severe pelvic endometriosis: A case-control study. Gynecological Surgery, 16(1), 10. https://doi.org/10.1186/s10397-019-1063-y
34. Dhanawat, J., Pape, J., Freytag, D., Maass, N., & Alkatout, I. (2020). Ovariopexy before and after endometriosis surgery. Biomedicines, 8(12), 533. https://doi.org/10.3390/biomedicines8120533
35. Keckstein, J., & Keckstein, S. (2024). The catheter method in sclerotherapy in the management of ovarian endometriomas. CardioVascular and Interventional Radiology. Advance online publication. https://doi.org/10.1007/s00270-024-03775-0
36. Bafort, C., Beebeejaun, Y., Tomassetti, C., Bosteels, J., & Duffy, J. M. N. (2020). Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews, 10, CD011031. https://doi.org/10.1002/14651858.CD011031.pub3
37. Vercellini, P., Sergenti, G., & Somigliana, E. (2020). Surgery for rectal endometriosis: The technique or the indication, that is the question. Fertility and Sterility, 113(6), 1169–1170. https://doi.org/10.1016/j.fertnstert.2020.04.007
38. Donnez, O., & Roman, H. (2017). Choosing the right surgical technique for deep endometriosis: Shaving, disc excision, or bowel resection? Fertility and Sterility, 108(6), 931–942. https://doi.org/10.1016/j.fertnstert.2017.09.006
39. Donnez, O., & Donnez, J. (2020). Deep endometriosis: The place of laparoscopic shaving. Best Practice & Research Clinical Obstetrics & Gynaecology, 65, 98–110. https://doi.org/10.1016/j.bpobgyn.2020.05.006
40. Donnez, O. (2021). Conservative management of rectovaginal deep endometriosis: Shaving should be considered as the primary surgical approach in a high majority of cases. Journal of Clinical Medicine, 10(21), 5183. https://doi.org/10.3390/jcm10215183
41. Cope, A. G., & Khan, Z. (2020). Delving deep into excision of bowel endometriosis. Fertility and Sterility, 114(6), 1187–1188. https://doi.org/10.1016/j.fertnstert.2020.10.034
42. Bendifallah, S., Puchar, A., Vesale, E., Moawad, G., Daraï, E., & Roman, H. (2021). Surgical outcomes after colorectal surgery for endometriosis: Systematic review and meta-analysis. Journal of Minimally Invasive Gynecology, 28(4), 711–726. https://doi.org/10.1016/j.jmig.2020.08.015
43. Leonardi, M., Espada, M., Kho, R. M., Magrina, J. F., Millischer, A.-E., Savelli, L., & Condous, G. (2020). Endometriosis and the urinary tract: From diagnosis to surgical treatment. Diagnostics, 10(10), 771. https://doi.org/10.3390/diagnostics10100771
44. Barra, F., Scala, C., Biscaldi, E., Vellone, V. G., Ceccaroni, M., Terrone, C., & Ferrero, S. (2018). Ureteral endometriosis: A systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility. Human Reproduction Update, 24(6), 710–730. https://doi.org/10.1093/humupd/dmy027
45. Roman, H., Chanavaz-Lacheray, I., Forestier, D., Magne, E., Celhay, O., Pasticier, G., Susperregui, J., & Merlot, B. (2020). Complications postopératoires immédiates dans un centre chirurgical multidisciplinaire exclusivement dédié à l'endométriose: Une série de 491 patientes. Gynécologie Obstétrique Fertilité & Sénologie, 48(6), 484–490. https://doi.org/10.1016/j.gofs.2020.03.009
46. Leborne, P., Huberlant, S., Masia, F., de Tayrac, R., Letouzey, V., & Allegre, L. (2022). Clinical outcomes following surgical management of deep infiltrating endometriosis. Scientific Reports, 12(1), 21918. https://doi.org/10.1038/s41598-022-25751-9
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