Segmental resection has been generally associated with increased peri-operative risk of major complications. While major complications are widely acknowledged, minor complications, such as slight, to moderate infections, peripheral sensory disturbances, bladder voiding dysfunction, postoperative urinary obstruction, and sexual disorders are less reported. The aim of this study is to investigate the surgery-related complications and functional disorders, as well as to evaluate their persistence after long-term follow-up in women undergone segmental resection for deep infiltrating endometriosis. Special attention is given to evaluating impairments of bowel, bladder, and sexual function.
All clinical data obtained from medical records of women who underwent segmental resection for intestinal endometriosis between October 2005, and November 2017, in Catholic University Institutions. Perioperative morbidity was classified by Extended Clavien–Dindo classification. Postoperative intestinal, voiding, and sexual morbidity was estimated by the compilation of specific questionnaires.
Fifty women were included in the study. Forty-three high colorectal resections (86%), 6 low resections (12%), and 1 ultra-low resection (2%) were performed, while in 3 cases (6%) multiple resections were needed. The overall complication rate was 44%. Nineteen women (38%) experienced early complications and 3 women (6%) late complications. Long-term functional postoperative complications were composed of intestinal in 30%, urinary in 50%, and sexual in 64% of the study population. Median follow-up was 55.5 months.
Segmental resection, when indicated, offers a radical and feasible approach for bowel deep infiltrating endometriosis, resulting in an improved general quality of life. The bowel and bladder complications appear to be acceptable and often reversible. Postoperative sexual dysfunctions, such as anorgasmia and insufficient vaginal lubrication, appear to persist over time. Surgeons and women have to be aware of the incidence of this kind of complications.
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Koninckx PR, Meuleman C, Demeyere S et al (1991) Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759–765
Ek M, Roth B, Ekström P, Valentin L, Bengtsson M, Ohlsson B (2015) Gastrointestinal symptoms among endometriosis patients—a case-cohort study. BMC Women’s Health 15:59. https://doi.org/10.1186/s12905-015-0213-2
Donnez J, Nisolle M, Casanas-Roux F et al (1995) Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients. Hum Reprod 10:630–635. https://doi.org/10.1093/oxfordjournals.humrep.a136001
Koninckx PR, Martin D (1994) Treatment of deeply infiltrating endometriosis. Curr Opin Obstet Gyneco. 6:231–241
Vitale SG, La Rosa VL, Rapisarda AMC, Lagana’ AS (2017) Impact of endometriosis on quality of life and psychological well-being. J Psychosom Obstet Gynaecol 38(4):317–319. https://doi.org/10.1080/0167482X.2016.1244185
Cosentino F, Turco LC, Ferrandina G et al (2017) Endometrial stromal sarcoma arising from endometriosis incidence, management and treatment of primary extrauterine localization. J Endometr Pelvic Pain Disord. https://doi.org/10.5301/jeppd.5000287
Duffy JM, Arambage K, Correa FJ et al (2014) Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev 4:CD011031
Cosentino F, Vizzielli G, Turco LC et al (2018) Near-infrared imaging with indocyanine green for detection of endometriosis lesions (Gre-Endo Trial): a pilot study. J Minim Invasive Gynecol 25(7):1249–1254. https://doi.org/10.1016/j.jmig.2018.02.023
Abrao MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21:329–339
Bassi MA, Podgaec S, Dias JA, D’Amico FN, Petta CA, Abrao MS (2011) Quality of life after segmental resection of the rectosigmoid by laparoscopy in patients with deep infiltrating endometriosis with bowel involvement. J Minim Invasive Gynecol 18(6):730–733. https://doi.org/10.1016/j.jmig.2011.07.014
Meuleman C, Tomassetti C, Wolthuis A et al (2014) Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis a prospective cohort study. Ann Surg 259(3):522–531. https://doi.org/10.1097/SLA.0b013e31828dfc5c
Roman H, Vassilieff M, Gourcerol G et al (2011) Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach. Hum Reprod 26(2):274–281
Roman H, Vassilieff M, Tuech JJ et al (2013) Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril 99(6):1695–1704. https://doi.org/10.1016/j.fertnstert.2013.01.131
Roman H, Loisel C, Resch B (2010) Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice. Hum Reprod 25(4):890–899. https://doi.org/10.1093/humrep/dep407
Meuleman C, Tomassetti C, D’Hoore A et al (2011) Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 17:311–326
Daraï E, Bazot M, Rouzier R, Houry S, Dubernard G (2007) Outcome of laparoscopic colorectal resection for endometriosis. Curr Opin Obstet Gynecol 19(4):308–313
Roman H, Bubenheim M, Huet E et al (2018) Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod 33(1):47–57
Kent A, Shakir F, Rockall T et al (2016) Laparoscopic surgery for severe rectovaginal endometriosis compromising the bowel: a prospective cohort study. J Minim Invasive Gynecol 23(4):526–534. https://doi.org/10.1016/j.jmig.2015.12.006
Lermann J, Topal N, Adler W (2018) Major and minor complications after resection without bowel resection for deeply infiltrating endometriosis. Arch Gynecol Obstet 298(5):991–999. https://doi.org/10.1007/s00404-018-4875-5Epub 2018 Sep 6
Uccella S, Gisone B, Serati M et al (2018) Functional outcomes of nerve-sparing laparoscopic eradication of deep infiltrating endometriosis: a prospective analysis using validated questionnaires. Arch Gynecol Obstet 298(3):639–647. https://doi.org/10.1007/s00404-018-4852-z
Renner SP, Kessler H, Topal N et al (2017) Major and minor complications after anterior rectal resection for deeply infiltrating endometriosis. Arch Gynecol Obstet 295(5):1277–1285. https://doi.org/10.1007/s00404-017-4360-6
Dávalos M, De Cicco C, D’Hoore A, De Decker B, Koninckx P (2007) Outcome after rectum or sigmoid resection: a review for gynecologists. J Minim Invasive Gynecol 14:33–38
Guerriero S, Ajossa S, Pascual MA (2020) Ultrasonographic soft markers for detection of rectosigmoid deep endometriosis. Ultrasound Obstet Gynecol 55(2):269–273. https://doi.org/10.1002/uog.20289
Mabrouk M, Spagnolo E, Raimondo D et al (2012) Segmental bowel resection for colorectal endometriosis: is there a correlation between histological pattern and clinical outcomes? Hum Reprod 27(5):1314–1319
Ceccaroni M, Clarizia R, Bruni F et al (2012) Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 26(7):2029–2045
The American Fertility Society (1985) Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril 43(3):351–352. https://doi.org/10.1016/s0015-0282(16)48430-x
Vlahos N, Vlachos A, Triantafyllidou O, Vitoratos N, Creatsas G (2013) Continuous versus cyclic use of oral contraceptives after surgery for symptomatic endometriosis: a prospective cohort study. Fertil Steril 100(5):1337–1342. https://doi.org/10.1016/j.fertnstert.2013.07.008
Katayama H, Kurokawa Y, Nakamura K et al (2016) Extended Clavien Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications Criteria. Surg Today 46(6):668–685. https://doi.org/10.1007/s00595-015-1236-x
Nolen-Hoeksema S (2014) Abnormal psychology sixth edition. McGraw-Hill Education, New York, p 368 (ISBN 978-0-07-803538-8)
Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M (2015) Systematic review of endometriosis pain assessment: how to choose a scale? Hum Reprod Update 21(1):136–152. https://doi.org/10.1093/humupd/dmu046
Revicki DA, Wood M, Wiklund I, Crawley J (1998) Reliability and validity of the Gastrointestinal Symptom Rating Scale in patients with gastroesophageal reflux disease. Qual Life Res 7(1):75–83
Kulich KR, Calabrese C, Pacini F, Vigneri S, Carlsson J, Wiklund IK (2004) Psychometric validation of the Italian translation of the Gastrointestinal Symptom-Rating Scale and Quality of Life in Reflux and Dyspepsia Questionnaire in patients with gastro-oesophageal reflux disease. Clin Drug Investig 24(4):205–215
Kulich KR, Madisch A, Pacini F et al (2008) Reliability and validity of the Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD) Questionnaire in dyspepsia: a six-country study. Health Qual Life Outcomes 6:12
Tack J, Talley NJ (2013) Functional dyspepsia-symptoms, definitions and validity of the Rome III criteria. Nat Rev Gastroenterol Hepatol 10(3):134–141. https://doi.org/10.1038/nrgastro.2013.14Epub 2013 Feb 12
Turco LC, Scaldaferri F, Chiantera V et al (2020) Long-term evaluation of quality of life and gastrointestinal well-being after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT QoL). Arch Gynecol Obstet 301(1):217–228. https://doi.org/10.1007/s00404-019-05382-8
Tarjanne S, Heikinheimo O, Mentula M, Härkki P (2015) Complications and long-term follow-up on colorectal resections in the treatment of deep infiltrating endometriosis extending to bowel wall. Acta Obstet Gynecol Scand 94:72–79. https://doi.org/10.1111/aogs.12515
Zilberman S, Ballester M, Touboul C et al (2013) Partial colpectomy is a risk factor for urologic complications of colorectal resection for endometriosis. J Minim Invasive Gynecol 20:49–55. https://doi.org/10.1016/j.jmig.2012.08.775
Keckstein J, Wiesinger H (2005) Deep endometriosis, including intestinal involvement—the interdisciplinary approach. Minim Invasive Ther Allied Technol 14:160–166. https://doi.org/10.1080/14017430510035916
Ruffo G, Scopelliti F, Scioscia M, Ceccaroni M, Mainardi P, Minelli L (2010) Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases. Surg Endosc 24:63–67. https://doi.org/10.1007/s00464-009-0517-0
Roman H, Bubenheim M, Huet E et al (2019) Baseline severe constipation negatively impacts functional outcomes of surgery for deep endometriosis infiltrating the rectum: results of the ENDORE randomized trial. J Gynecol Obstet Hum Reprod. https://doi.org/10.1016/j.jogoh.2019.03.013
Bassi MA, Andres MP, Morales BC et al (2019) Postoperative bowel symptoms improve over time after rectosigmoidectomy for endometriosis. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2019.10.009
Balla A, Quaresima S, Subiela JD, Shalaby M, Petrella G, Sileri P (2018) Outcomes after rectosigmoid resection for endometriosis: a systematic literature review. Int J Colorectal Dis 33(7):835–847. https://doi.org/10.1007/s00384-018-3082-y(Epub 2018 May 10)
Jayot A, Timoh KN, Bendifallah S, Ballester M, Daraï E (2018) Comparison of laparoscopic discoid resection and segmental resection for colorectal endometriosis using a propensity score matching analysis. J Minim Invasive Gynecol. 25(3):440–446. https://doi.org/10.1016/j.jmig.2017.09.019(Epub 2017 Oct 5)
Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady KM, Falcone T (2002) Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement. J Am Coll Surg 195:754–758
De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx PR (2011) Bowel resection for deep endometriosis: a systematic review. BJOG 118:285–291
Slack A, Child T, Lindsey I et al (2007) Urological and colorectal complications following surgery for rectovaginal endometriosis. BJOG 114(10):1278–1282
Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Daraï E (2006) Quality of life after laparoscopic colorectal resection for endometriosis. Hum Reprod 21:1243–1247
Daraï E, Zilberman S, Touboul C, Chereau E, Rouzier R, Ballester M (2012) Urological morbidity of colorectal resection for endometriosis. Minerva Med 103(1):63–72
Dubernard G, Rouzier R, David-Montefiore E, Bazot M, Daraï E (2008) Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gynecol 15(2):235–240. https://doi.org/10.1016/j.jmig.2007.10.009
Lermann J, Topal N, Renner SP, Beckmann MW, Burghaus S, Adler W, Heindl F (2019) Comparison of preoperative and postoperative sexual function in patients with deeply infiltrating endometriosis with and without bowel resection. Eur J Obstet Gynecol Reprod Biol 239:21–29
Ceccaroni M, Clarizia R, Roviglione G, Ruffo G (2013) Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc 27(11):4386–4394. https://doi.org/10.1007/s00464-013-3043-z(Epub 2013 Jun 20 PMID: 23783554)
Ceccaroni M, Clarizia R, Alboni C, Ruffo G, Bruni F, Roviglione G, Scioscia M, Peters I, De Placido G, Minelli L (2010) Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique. Surg Radiol Anat 32(6):601–604. https://doi.org/10.1007/s00276-010-0624-6(Epub 2010 Jan 20 PMID:20087591)
Landi S, Ceccaroni M, Perutelli A, Allodi C, Barbieri F, Fiaccavento A, Ruffo G, McVeigh E, Zanolla L, Minelli L (2006) Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible? Hum Reprod 21(3):774–781. https://doi.org/10.1093/humrep/dei324(Epub 2006 Jan 31. PMID: 16449312)
Uccella S, Marconi N, Casarin J et al (2016) Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy. Arch Gynecol Obstet 294(4):771–778. https://doi.org/10.1007/s00404-016-4115-9
Serati M, Cattoni E, Braga A, Uccella S, Cromi A, Ghezzi F (2013) Deep endometriosis and bladder and detrusor functions in women without urinary symptoms: a pilot study through an unexplored world. Fertil Steril 100(5):1332–1336. https://doi.org/10.1016/j.fertnstert.2013.06.044
Sarrel PM, Sullivan SD, Nelson LM (2016) Hormone replacement therapy in young women with surgical primary ovarian insufficiency. Fertil Steril 106(7):1580–1587. https://doi.org/10.1016/j.fertnstert.2016.09.018(published online 2016 Oct 25)
The authors thank Dr. Richard Renston M.D. for his important contribution in revising the form and the English language of this article.
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R. R. have no conflict of interest to declare. Author declare that they have no conflict of interest.
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Turco, L.C., Tortorella, L., Tuscano, A. et al. Surgery-related complications and long-term functional morbidity after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT morb). Arch Gynecol Obstet 302, 983–993 (2020). https://doi.org/10.1007/s00404-020-05694-0
- Deep infiltrating endometriosis
- Segmental resection
- Intestinal disorders
- Voiding disorders
- Sexual dysfunction
- Personalized medicine