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Objective: To describe the robotic full-thickness rectal excision using a transanal circular stapler in rectovaginal endometriosis nodule infiltrating the rectum >3 cm., Design: Surgical video article. The local institutional review board was consulted, and the requirement for institutional review board approval was waived because the video describes a technique and the patient cannot be identified whatsoever. Written informed consent was obtained from the patient for the use of personal data., Setting: A tertiary referral center., Patients: Patients undergoing excision of rectal endometriosis., Intervention(s): Standardized technique of full-thickness disk excision of large rectovaginal endometriosis nodules employing a combined robotic and trans anal approach., Main Outcome Measure(s): Feasibility of the technique., Result(s): The technique is designed for deep rectovaginal nodules infiltrating middle and low-rectum up to 3 to 5 cm in length. The procedure was performed with robotic assistance. The 7-degree freedom mobility of the robotic scissors allows for a deep rectal shaving, with the goal of progressive reduction of the thickness of rectal wall. The scissors follow the rectal wall tangentially and leave behind a thin rectal wall which can be bent and pushed into the trans anal stapler's jaws. We employed end-to-end, 33 mm-diameter, circular trans anal staplers to increase the area of rectal wall to be caught into the stapler. A stitch was placed on the superior and the inferior limits of the shaved area, then the shaved area was bent and pushed into the stapler by tying a suture. The general surgeon closed and fired the stapler, then the stapler was removed together with a rectal patch of 4- to 6-cm diameter. The procedure ended in the bubble test which checked the integrity of the stapled line. Supplementary stitches may be placed to reinforce the suture, if required., Conclusion(s): The preliminary rectal shaving represents the real keystone of this procedure, and our experience suggests that the robotic assistance improves its feasibility in large nodule responsible for intrarectal protrusion., (Copyright © 2023 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate the prevalence of endometrioma and deep infiltrating endometriosis (DIE), assessed by systematic transvaginal ultrasound examination, in women with subfertility accepted for their first assisted reproductive treatment and to describe the prevalence of endometriotic lesions in different anatomical locations of the pelvis., Design: Cross-sectional study., Setting: Reproductive Medicine Center, Department of Obstetrics and Gynecology, University hospital., Patient(s): A total of 1,191 women with subfertility aged 25-39 years accepted for their first assisted reproductive treatment between December 2018 and May 2021., Intervention(s): All women underwent a systematic transvaginal ultrasound examination. The endometriotic lesions visible on ultrasound examination were described according to the International Deep Endometriosis Analysis group consensus opinion for systematic approach to assess endometriotic lesions., Main Outcome Measure(s): Prevalence of endometrioma and DIE in women with subfertility and prevalence of endometriotic lesions in various anatomical locations of the pelvis., Result(s): Endometriosis prevalence was 21.8%, with endometriotic lesions found in 260 of the 1,191 women. Overall, 125 (10.5%) women had endometrioma and 205 (17.2%) women had DIE. Of these 260 women, 197 (75.8% of women with endometriosis) did not have any previous knowledge about having endometriosis. The most common location for endometriotic lesions was the uterosacral ligaments, with lesions found in 151 (12.7%) of all women. The second most common location was the ovaries containing endometrioma, found in 125 (10.5%) women. Most women had 1 (n = 121, 10.2%) or 2 (n = 82, 6.9%) endometriotic lesions., Conclusion(s): The prevalence of endometrioma and DIE in women with subfertility, diagnosed by systematic transvaginal ultrasound examination, was 21.8%. Of these, three-fourth of women had no knowledge about the presence of disease., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the impact of the implementation of a national enhanced recovery after surgery (ERAS) program for posterior deep infiltrating endometriosis (DIE) surgery on the length of hospital stay, the rate of postoperative complications, and readmission within 30 days., Design: Comparative exposed/nonexposed observational study., Setting: Study based on the French national medicoeconomic database of the Program of Medicalization of Information System., Patients: Seven hundred and sixty-four women who underwent DIE surgery were involved and matched (1:3 ratio) into two groups: ERAS group for the year 2019 and non-ERAS group for the year 2015., Interventions: Surgical management for posterior DIE., Main Outcome Measures: The length of hospital stay, the rate of postoperative complications during the initial hospital stay, and readmission within 30 days., Results: The ERAS group included 191 women, and the non-ERAS group included 573 women. The mean length of hospital stay was shorter in the ERAS group than in the non-ERAS group (4.28 ± 3.80 days vs. 5.42 ± 4.04 days, respectively). The rate of postoperative abdominal or pelvic pain syndromes was lower in the ERAS group than in the non-ERAS group (5/191 (2.62%) vs. 48/573 (8.38%), respectively; relative risk, 0.31 [0.125-0.7969]). The rate of postoperative complication and the rate of readmission within 30 days were not different between the two groups., Conclusions: The implementation of ERAS has a significant positive impact on patient outcomes after DIE surgery. The length of hospital stay and abdominal or pelvic pain syndromes were reduced without increasing complications or readmission within 30 days., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether it is possible to predict the risk of ureteral endometriosis (UE) using a mathematical model based on preoperative findings., Design: Prospective observational study conducted between January 2017 and April 2020., Setting: Tertiary-level academic referral center., Patient(s): Three hundred consecutive women of reproductive age with a diagnosis of posterior deep infiltrating endometriosis (DIE) scheduled for laparoscopic surgery., Intervention(s): Before surgery, anamnestic data and the severity of endometriosis-related symptoms were evaluated, and all patients underwent a complete gynecological examination. Transvaginal and transabdominal ultrasound were performed to map the endometriotic lesion. Ureteral involvement was surgically and histologically confirmed., Main Outcome Measure(s): To select important risk factors for UE and determine a suitable functional form for continuous predictors, we used the multivariable fractional polynomial., Results: UE was surgically found in 145 women (48.3%). Based on our multivariable polynomial mathematical model, UE was significantly associated with adenomyosis, parametrial involvement, and previous surgery for endometriosis. A posterior DIE nodule with a transverse diameter >1.8 cm was associated with a higher probability of ureteral involvement., Conclusions: Posterior DIE nodule with a transverse diameter >1.8 cm, adenomyosis, parametrial involvement, and previous surgery for endometriosis appear to be good predictors of UE., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To demonstrate the use of a single-stapler technique during rectosigmoid resection in women with deep infiltrating endometriosis (DIE)., Design: A step-by-step video demonstration of rectosigmoid resection and end-to-end anastomosis using two circularly placed sutures and one circular stapler., Setting: Institute for the Care of Mother and Child, Prague, Czech Republic., Patient(s): A 39-year-old woman presented with primary sterility and deep infiltrating endometriosis, and an EZIAN score of A2,B2,C3. A nodule was located 9 cm from the anus and was 38 × 9 mm in size. This included an intramural fibroma of 6 cm and a left-sided ovarian endometriotic cyst of 6 cm. Her pain on the visual analogue scale were dysmenorea 6, dyspareunia 5-6, dyschezie 7, dysuria 0, and acyclic pain 5., Interventions: The primary objective was to replace the linear-stapler resection with two simple, strictly circularly placed sutures, to cut the intestinal wall between them, and to form the end-to-end anastomosis with a circular stapler. The one-stapler technique consisted of the following steps: intestinal wall cleansing as in the limited segmental resection; placement of one strictly circular suture just below the DIE nodule, without fixation; placement of the first circular suture just below the DIE nodule, ideally with at least three full-thickness "bites" of the intestinal wall; placement of the second circular stitch approximately 2 cm below the first one in a similar manner (three full-thickness "bites"); interruption of the intestinal wall with a harmonic scalpel; end-to-end intestinal anastomosis with a circular stapler; and airtightness test of the anastomosis. This results in only one incision line and therefore a lower risk of leakage. Intestinal resection time was on average 10 minutes longer compared to that for the linear stapler technique. So far, we have successfully performed the procedure in 25 women. Perioperative leakage was observed in two of these 25 patients in the classical procedure group and in none of the 25 patients in the group with the one-stapler technique. There were no differences in C-reactive protein (CRP) on third and fifth postoperative days or in other complications such as bleeding and pyrexia). The cost of procedure is lowered by the decrease in the number of staplers from 3 to 1. The patients' postoperative follow-up was uneventful, and they were discharged from the hospital at the same time as the women in whom the classical stapler technique was performed., Main Outcome Measures(s): The primary outcome was the development of a new surgical approach to resection rectosigmoid endometriotic nodules that would decrease the number of incision lines on the intestine. The secondary outcome measures were peri- and postoperative complications (i.e., bleeding, intestinal leakage, postoperative infection, CRP), length of the surgery and hospitalization, and cost of the procedure., Conclusion: Multiple incision lines following resection of the rectosigmoid colon and end-to-end anastomosis are risk factors for postoperative intestinal leakage. Therefore, a single incision line formed with two circular sutures, and one circular stapler may reduce the risk of postoperative complications and also financial expenses of the procedure. We believe that this method is suitable and easiest for nodules located less than 6 cm from the anal verge because of possible complications with angulation of linear stapler., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the presence of focal adenomyosis of the outer myometrium (FAOM) at preoperative magnetic resonance imaging is associated with the severity of deep infiltrating endometriosis., Design: Observational cross-sectional study involving 255 symptomatic deep infiltrating endometriosis patients. Comparisons were performed according to the presence of FAOM., Setting: University hospital., Patient(s): Women with a preoperative magnetic resonance imaging and complete surgical exeresis of endometriotic lesions with histologically documented deep infiltrating endometriosis., Intervention(s): Surgical management for deep infiltrating endometriosis., Main Outcome Measure(s): The presence of multiple deep infiltrating endometriosis lesions, the mean number and location of deep infiltrating endometriosis lesions, and the mean total revised American Society for Reproductive Medicine scores., Result(s): The prevalence of FAOM at preoperative magnetic resonance imaging in the 255 patients with deep infiltrating endometriosis was 56.5%. The mean number of deep infiltrating endometriosis lesions was significantly higher in the FAOM(+) group than in the FAOM(-) group: 3.5 ± 2.1 vs. 2.2 ± 1.5. The mean total revised American Society for Reproductive Medicine score was higher in case of FOAM coexisting with deep infiltrating endometriosis. After adjusting for confounding factors, the presence of FAOM was significantly associated with multiple deep lesions., Conclusion(s): FAOM was significantly associated with greater deep infiltrating endometriosis severity. This needs to be integrated into the management strategy. Furthermore, a pathogenic link between deep infiltrating endometriosis and FAOM cannot be excluded., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the feasibility of using indocyanine green (ICG) to estimate the vascularization of the resected zone during a laparoscopic rectal shaving., Design: Indocyanine green can highlight blood vascularization when injected intravenously. There is no relevant, objective, intraoperative method to assess the vascularity of the resected zone during a laparoscopic rectal shaving for deep infiltrating endometriosis (DIE) to prevent fistula. We conducted a registered clinical trial examining the feasibility of the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving (Institutional Review Board number 2016-002773-35)., Setting: Tertiary university hospital., Patient(s): Twenty-one patients underwent laparoscopic surgery for DIE with a rectal shaving., Intervention(s): Patients undergoing laparoscopic surgery for DIE received ICG intravenously at the end of the endometriosis resection., Main Outcome Measure(s): The main evaluation criteria was the fluorescence degree in the operated rectal area and in the vaginal suture. We used a visual assessment with a Likert-type scale from 0 to 4 (0 = no fluorescence; 4 = very good fluorescence)., Result(s): No adverse reaction was recorded. Most of the patients (81%) showed very good fluorescence levels at the rectal shaving area. The protocol did not increase the operating time. In one patient we changed the surgical strategy making two stitches to bring the rectal muscularis closer together, which improved the degree of fluorescence. There was no case of digestive fistula., Conclusion: Indocyanine green fluorescent imaging is feasible in endometriosis surgery and may be considered as a potential candidate to further enhance patient safety in endometriosis bowel surgery., Clinical Trial Registration Number: NCT03080558., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To study the prevalence of oligo-anovulation in women suffering from endometriosis compared to that of women without endometriosis., Design: A single-center, cross-sectional study., Setting: University hospital-based research center., Patient (s): We included 354 women with histologically proven endometriosis and 474 women in whom endometriosis was surgically ruled out between 2004 and 2016., Intervention: None., Main Outcome Measure(s): Frequency of oligo-anovulation in women with endometriosis as compared to that prevailing in the disease-free reference group., Results: There was no difference in the rate of oligo-anovulation between women with endometriosis (15.0%) and the reference group (11.2%). Regarding the endometriosis phenotype, oligo-anovulation was reported in 12 (18.2%) superficial peritoneal endometriosis, 12 (10.6%) ovarian endometrioma, and 29 (16.6%) deep infiltrating endometriosis., Conclusion(s): Endometriosis should not be discounted in women presenting with oligo-anovulation., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the association between ultrasound measurements of endometriosis nodules on the uterosacral ligament (USL) and the risk of ureteral involvement, as well as to assess whether associations with other ultrasound variables increase the sensitivity and specificity of the diagnosis of ureteral endometriosis., Design: Cross-sectional, observational study., Setting: University hospital., Patient(s): Four hundred sixty-three women with deep infiltrating endometriosis (DIE)., Intervention(s): Patients diagnosed with DIE underwent transvaginal ultrasound endometriosis mapping before laparoscopic surgery for full excision of endometriotic lesions., Main Outcome Measure(s): Preoperative ultrasound evaluation, intra- and postoperative assessment, and anatomopathologic confirmation., Result(s): Of the 463 patients who participated in the study, 111 (23.97%) presented with endometriosis nodules with USL involvement on ultrasound examination conducted by a single radiologist. Receiver operating characteristic curve analysis showed that the size of the USL nodule had a statistically significant association with ipsilateral ureteral involvement. After multivariate logistic regression, the variables reduction in ovarian mobility, ureteral changes on the right side, size of the USL nodule, and presence of endometrioma on the left side were significantly associated with a ureteral endometriosis nodule. However, the combined result for the variables cited was worse than the diagnostic analysis using only the size of the USL nodule., Conclusion(s): Uterosacral ligament nodules with ultrasound measurements of 1.75 cm and 1.95 cm on the right and left sides, respectively, significantly increase the risk of ureteral involvement. Even with the association of other ultrasound variables, there was no improvement in sensitivity. Therefore, USL nodule size is a key measure for therapeutic planning and consent of the patient., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the prevalence of urinary tract endometriosis (UTE) in patients with deep infiltrating endometriosis (DIE) and to define potential criteria for preoperative workup., Design: Retrospective study., Setting: University hospital., Patient(s): Six hundred ninety-seven patients with endometriosis., Intervention(s): Excision of all endometriotic lesions., Main Outcome Measure(s): Correlation of preoperative features and intraoperative findings in patients with UTE., Result(s): Out of 213 patients presenting DIE, 52.6% suffered from UTE. In patients with ureteral endometriosis, symptoms were not specific. Among the patients with bladder endometriosis, 68.8% complained of urinary symptoms compared to 7.9% in the group of patients without UTE. In patients with rectovaginal endometriosis, the probability of ureterolysis showed a linear correlation with the size of the nodule. We found that 3 cm in diameter provided a specific cutoff value for the likelihood of ureteric involvement., Conclusion(s): The prevalence of UTE has often been underestimated. Preoperative questioning is important in the search for bladder endometriosis. The size of the nodule is one of the few reliable criteria in preoperative assessment that can suggest ureteric involvement. We propose a classification of ureteral endometriosis that will allow the standardization of terminology and help to compare the outcome of different surgical treatment in randomized studies., (Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

To determine the interest of using robotic laparoscopic surgery in the management of female infertility, we reviewed our own activity and searched the Medline database for publications on robotic technology in infertility surgery, with the use of the following search words: robotic laparoscopy, tubal anastomosis, myomectomy, deep infiltrating endometriosis, and adnexal surgery. Robot-assisted laparoscopic surgery has seen rapid progression over the past few years. It has been mostly used for myomectomy, proximal tubal reanastomosis, and deep endometriosis surgery. Despite its increased range of indications, no randomized control studies are available. The place of robotic surgery in the management of infertility remains undetermined., (Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)