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To provide evidence regarding the significance of painful symptoms among women suffering from infertility. An observational retrospective cross-sectional study. University hospital-based research center. Infertile patients aged between 18 and 42 years surgically explored for benign gynecological conditions between 01-2004 and 12-2020. For each patient, a standardized questionnaire was completed during a face-to-face interview conducted by the surgeon in the month preceding the surgery. Preoperative assessment the pain symptoms was recorded. Pain intensity was assessed with a 10cm visual analog scale (VAS). The pain was considered to be severe when the VAS score was ≥ 7. Surgery was performed in 839 infertile women. 451 women had severe pelvic pain. Infertile patients with severe pain significantly more often had endometriosis (67.4% versus 30.7% respectively; p <.001) than infertile women without severe pelvic pain, and especially deep infiltrating lesions (43.2% versus 8.5% respectively; p <.001). Moreover, these women more often had intestinal endometriosis lesions (28.4% vs 1.8%; p <.001). After multivariable regression analysis, the presence of endometriosis, irrespective of the phenotype (superficial lesions (OR1.84 [1.19–2.86] and/or ovarian endometrioma OR 2.79 [1.70–4.59] and/or deep infiltrating endometriosis OR 4.49 [2.69–7.51]), and the presence of at least one intestine endometriosis lesion (OR6.49 [2.69–7.51] were significantly associated with severe pelvic pain. Severe pelvic pain is significantly associated with endometriosis and especially deep infiltrating lesions in a population of infertile women. These results demonstrate the importance of thorough questioning regarding pelvic pain symptoms during the initial management of infertile patients. [ABSTRACT FROM AUTHOR]

To investigate the progression of deep infiltrating endometriosis using transvaginal ultrasound surveillance of patients undergoing conservative management. Retrospective single cohort. Australian tertiary university hospital One hundred twenty two women with endometriosis proven on transvaginal ultrasound who had not undergone surgical management. The progression of endometriosis lesions demonstrated on transvaginal ultrasound in women receiving conservative management over the course of 24 months. A total of 122 patients fulfilled the inclusion criteria. All women had 2 ultrasounds that were performed at least 6 months apart. The median follow-up time was 490.5 days (255.4–725.6). At second scan, 22% (95% CI: 15–30%) of cohort experienced an increase in the number of endometriosis nodules compared to first scan, with 51% (95% CI: 42–60%) remaining static while 27% (95% CI: 19–35%) experienced a decrease. While there was no statistically significant difference in the volumes of uterosacral ligament, retro cervical, and bowel endometriosis, endometrioma volumes were significantly lower at second scan (Median = 3.24 mL, IQR = 0.6–16.87) as compared to the first scan (Median = 7.41 mL, IQR = 2.04–28.95), p <.001. Individuals with deep infiltrating endometriosis are unlikely to see significant disease progression over time. Both surgical and nonsurgical interventions are effective in managing endometriosis in terms of endometriotic nodule size and number, as measured by ultrasound. [ABSTRACT FROM AUTHOR]

To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary. We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures. 224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms. Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal. [ABSTRACT FROM AUTHOR]

To compare demographic characteristics of women with and without a diagnosis of endometriosis. Data were collected from the National Survey of Family Growth—a publicly available survey designed and administered by the Centers for Disease Control, which uses a nationally-representative sample of the United States population. Univariate data were reported as survey-weighted percentages and means and were analyzed using chi-square, t tests, and logistic regression. Analyses accounted for complex survey design. United States. Interviews were conducted with 6141 female respondents, aged 15 to 50, between 2017 and 2019. Data were collected through in-person interviews. Nationally, 5.7% reported a diagnosis of endometriosis (95% CI 4.6–6.9%). Those with endometriosis were older, with a mean age of 39 (95% CI 38.1–39.9), compared to 31.7 (95% CI 31.2–32.2) among those without (p <.0005). Endometriosis diagnosis was significantly associated with race. Compared to non-Hispanic White women, Hispanic women had an adjusted odds ratio (aOR) of 0.37 (95% CI 0.21–0.65) for diagnosis of endometriosis, and non-Hispanic Black women had an aOR of 0.54 (95% CI 0.35–0.84). We also observed a difference in diagnosis by health insurance: compared to those with private insurance or Medi-Gap coverage, those with Medicare or military insurance had an aOR for endometriosis diagnosis of 2.49 (95% CI 1.36–4.55). Finally, compared to those with less than a high school education, those who had completed high school or greater had an aOR for endometriosis diagnosis of 2.84 (95% CI 1.15–6.99). These disparities in endometriosis diagnosis suggest that intersecting barriers may preclude certain groups from accessing timely endometriosis diagnosis and management. Further studies are warranted to explore these hypothesis-generating data and to identify and address specific barriers to equitable endometriosis diagnosis and management. [ABSTRACT FROM AUTHOR]

The main objective is to describe the feasibility and report a single-center experience of a standardized laparoscopic modified radical hysterectomy technique among patients with severe endometriosis and pouch of Douglas obliteration. A single-center case series of laparoscopic modified radical hysterectomy performed at the Poissy Hospital between December 2012 and May 2021. Single-center, gynecology unit (level III) with a focus on endometriosis. Patients with severe endometriosis (stage 4 American Fertility Society) and pouch of Douglas obliteration. Fifty-two patients with severe endometriosis underwent the surgical procedure. Of these patients, 23.1% underwent a rectal shaving (n = 12), 1.9% a discoid resection (n = 1), and 17.3% a rectal resection (n = 9), including a protective ileostomy in 1 case. Ureterolysis was performed on 82.7% of patients (n = 43). The average hospital stay was 3.3 days. Seven patients required intermittent self-catheterization (13.5%). Minor complications (Clavien-Dindo grade 1 and 2) occurred in 25.9% of the patients and severe complications in 3.8% of them (Clavien-Dindo grade 3, no grade 4). Two patients (3.8%) were reoperated: one for a postoperative occipital alopecia (balding) and the other for vaginal dehiscence with evisceration. Approximately 50 patients (96.2%) had a complete resection of endometriosis. The median follow-up was 14 months (interquartile range, 6–23 mo) with 94.3% of them improved (much and very much) and 3.8% minimally improved. In our experience, laparoscopic modified radical hysterectomy is a reliable procedure with a low rate of severe complications. This technique needs to be assessed by other surgeons and others centers across the country and abroad, to determine the likelihood of it succeeding. [ABSTRACT FROM AUTHOR]

To assess the duration needed for regaining normal bladder voiding function in patients with postoperative bladder dysfunction requiring intermittent self-catheterization after deep endometriosis surgery and identify risk factors that might affect the recovery process. Retrospective study based on data recorded in a large prospective database. Endometriosis referral center. From September 2018 to June 2022, 1900 patients underwent excision of deep endometriosis in our center; 61 patients were discharged with recommendation for intermittent self-catheterization and were thus included in the study. Intermittent self-catheterization after endometriosis surgery. A total of 43 patients (70.5%) stopped self-catheterization during the follow-up period. Median follow-up was 25 weeks (range, 7–223 wk). Surgery was performed laparoscopically in 48 patients (78.7%) and robotically in 13 (21.3%); 47 patients (77%) had nodules involving the digestive tract, 11 (18%) had urinary tract involvement, 29 had parametrial nodules (47.5%), and 13 (21.3%) had sacral plexus involvement. The probability of bladder voiding function recovery and arrest of self-catheterization was 24.5%, 54%, 59%, 72%, and 77% at 4, 8, 12, 52, and 78 weeks, respectively. Cox's multivariate model identified preoperative bladder dysfunction as the only statistically significant independent predictor for arrest of self-catheterization (hazard ratio, 0.36; 95% confidence interval, 0.15–0.83). Patients requiring intermittent self-catheterization for bladder dysfunction after deep endometriosis excision may spontaneously recover bladder function in 77% of cases. Symptoms suggesting preoperative bladder voiding dysfunction should be reviewed before planning surgery, and patients should be informed of the higher postoperative risk of long-term bladder voiding dysfunction. [ABSTRACT FROM AUTHOR]

To evaluate the effect of hormonal suppression of endometriosis on the size of endometriotic ovarian cysts. The authors searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov from January 2012 to December 2022. We included studies of premenopausal women undergoing hormonal treatment of endometriosis for ≥3 months. The authors excluded studies involving surgical intervention in the follow-up period and those using hormones to prevent endometrioma recurrence after endometriosis surgery. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The protocol was registered in PROSPERO (CRD42022385612). The primary outcome was the mean change in endometrioma volume, expressed as a percentage, from baseline to at least 6 months. Secondary outcomes were the change in volume at 3 months and analyses by class of hormonal therapy. The authors included 16 studies (15 cohort studies, 1 randomized controlled trial) of 888 patients treated with dienogest (7 studies), other progestins (4), combined hormonal contraceptives (2), and other suppressive therapy (3). Globally, the decrease in endometrioma volume became statistically significant at 6 months with a mean reduction of 55% (95% confidence interval, −40 to −71; 18 treatment groups; 730 patients; p <.001; I2 = 96%). The reduction was the greatest with dienogest and norethindrone acetate plus letrozole, followed by relugolix and leuprolide acetate. The volume reduction was not statistically significant with combined hormonal contraceptives or other progestins. There was high heterogeneity, and studies were at risk of selection bias. Hormonal suppression can substantially reduce endometrioma size, but there is uncertainty in the exact reduction patients may experience. [ABSTRACT FROM AUTHOR]

To develop a noninvasive predictive model based on patients with infertility for identifying minimal or mild endometriosis. A retrospective cohort study. This study was conducted at a tertiary referral center. A total of consecutive 1365 patients with infertility who underwent laparoscopy between January 2013 and August 2020 were divided into a training set (n = 910) for developing the predictive model and a validation set (n = 455) to confirm the model's prediction efficiency. The patients were randomly assigned in a 2:1 ratio. Sensitivities, specificities, area under the curve, the Hosmer-Lemeshow goodness of fit test, Net Reclassification Improvement index, and Integrated Discrimination Improvement index were evaluated in the training set to select the optimum model. In the validation set, the model's discriminations, calibrations, and clinical use were tested for validation. In the training set, there were 587 patients with minimal or mild endometriosis and 323 patients without endometriosis. The combination of clinical parameters in the model was evaluated for both statistical and clinical significance. The best-performing model ultimately included body mass index, dysmenorrhea, dyspareunia, uterosacral tenderness, and serum cancer antigen 125 (CA-125). The nomogram based on this model demonstrated sensitivities of 87.7% and 93.3%, specificities of 68.6% and 66.4%, and area under the curve of 0.84 (95% confidence interval 0.81–0.87) and 0.85 (95% confidence interval 0.80–0.89) for the training and validation sets, respectively. Calibration curves and decision curve analyses also indicated that the model had good calibration and clinical value. Uterosacral tenderness emerged as the most valuable predictor. This study successfully developed a predictive model with high accuracy in identifying infertile women with minimal or mild endometriosis based on clinical characteristics, signs, and cost-effective blood tests. This model would assist clinicians in screening infertile women for minimal or mild endometriosis, thereby facilitating early diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Endometriosis is a benign condition afflicting women of reproductive age that significantly impacts their quality of life (QoL). Given its debilitating symptoms and prevalence, it is essential to define its proper management. In this study, we have assessed patient-reported outcomes among women having undergone segmental colorectal resection for deep infiltrating endometriosis. Any correlation between preoperative nutritional status and overall postoperative complications has also been analyzed. Prospective observational study. Public medical center. One hundred forty consecutive patients that had undergone segmental colorectal resection for DIE between November 2020 and October 2021 at IRCCS Sacro Cuore Don Calabria Hospital of Negrar of Valpolicella (Verona, Italy). Patient-reported outcomes were measured using data collected from the MD Anderson Symptom Inventory for gastrointestinal surgery patients and Euro-QoL Group EQ-5D-5L (EQ-5Q-5L) questionnaires, which were administered preoperatively (T0), at discharge (T1) and at 4 to 6 weeks after surgery (T2). Nutritional status was examined through the Mini Nutritional Assessment Short form and Prognostic Nutritional Index. A significant improvement in the EQ-5Q-5L and MDASI-GI scores was noted between T0 and T2 (p <. 001 and p <. 001, respectively.) No statistically significant differences were found in scores at T2 between patients who had experienced postoperative complications and those who had not. No statistically significant association was observed between the presence of malnutrition and overall postoperative complications and their severity. This study confirms, through patient-reported outcomes, the pivotal role of surgery in improving the QoL at 4 to 6 weeks of women affected by endometriosis who have previously been unresponsive to medical therapy. [ABSTRACT FROM AUTHOR]

To evaluate the safety and clinical efficacy of percutaneous imaging-guided cryoablation for the management of anterior abdominal wall endometriosis. Patients with abdominal wall endometriosis underwent percutaneous imaging-guided cryoablation and had a 6-month follow-up. Data dealing with patients' and anterior abdominal wall endometriosis (AAWE) characteristics, cryoablation, and clinical and radiologic outcomes were retrospectively collected and analyzed. Twenty-nine consecutive patients underwent cryoablation from June 2020 to September 2022. Interventions were performed under US/computed tomography (CT) guidance or magnetic resonance imaging (MRI) guidance. Cryoprobes were directly inserted into the AAWE, and cryoablation was performed with a single 5 to 10 minute freezing cycle, which was stopped when the iceball expanded 3 to 5 mm beyond AAWE borders as assessed on intra-procedural cross-sectional imaging. Fifteen patients (15/29; 51.7%) had prior endometriosis, 28 (28/29; 95.5%) had previous cesarian section, and 22 (22/29; 75.9%) referred association between symptoms and menses. Cryoablation was performed under local (16/29; 55.2%) or general anesthesia (13/29; 44.8%) and mainly in an out-patient basis (18/20; 62%). There was only one (1/29; 3.5%) minor procedure-related complication. Complete symptom relief was recorded in 62.1% (18/29) and 72.4% (21/29) patients at 1 and 6 months, respectively. In the whole population, pain significantly dropped at 6 months compared to the baseline (1.1 ± 2.3; range 0–8 vs 7.1 ± 1.9; range 3–10; p <.05). Eight (8/29; 27.6%) patients presented residual symptoms at 6 months, and 4 (4/29; 13.8%) had an MRI-confirmed residual/recurring disease. Contrast-enhanced MRI obtained for the first 14 (14/29; 48.3%) patients of the series, all without signs of residual/recurring disease, demonstrated a significantly smaller ablation area compared to the baseline volume of the AAWE (1.0 cm3 ± 1.4; range 0–4.7; vs 11.1 ± 9.9 cm3; range 0.6–36.4; p <.05). Percutaneous imaging-guided cryoablation of AAWE is safe and clinically effective in achieving pain relief. [ABSTRACT FROM AUTHOR]

Discover the rate of post-operative constipation in participants undergoing elective laparoscopy for benign gynecological indications Prospective observational study Single site, tertiary level gynecology unit with a focus on pelvic pain and endometriosis. Recruited participants were patients of the institution over the age of 18 who had planned to undergo an elective laparoscopy for benign gynecological indications prior to enrolment in the study. Participants were excluded if they were not English speaking, had a chronic bowel condition (with the exception of irritable bowel syndrome), were planned to have bowel surgery, hysterectomy, or converted to laparotomy. In this prospective study, participants completed 3 consecutive surveys. One prior to surgery, one a week post-surgery, and a third 3 months post-surgery. The surveys collected data regarding the participant's bowel habits, pain relief used, laxatives used, and the distress or bother caused by their bowels. Constipation was defined by a modified ROME IV criteria. Opiate use and laxative use were defined by patient-reported tablet counts. The level of distress was measured as a continuously variable scale from 0 to 100. Variables adjusted for included subject's demographics, pre-operative constipation, indication for surgery, duration of surgery, estimated blood loss, opiate use (preoperative, peri-operative, and post-operative), laxative use, and length of stay. A total of 153 participants were recruited, of which 103 completed both the pre-operative and post-operative survey. Post-operative constipation was present in 70% of participants. The mean length of time to first bowel motion was 3 days, with 32% of participants having their first bowel motion after the third post-operative day. The level of bother caused by their bowel habit was higher in the constipation group compared to those without constipation. Post-operatively opiates were used in 84.9% of participants, and laxatives were used in 47.1%. Visits to the general practitioner for constipation occurred in 5.8% of participants. Post-operative constipation is common and bothersome in participants who undergo elective laparoscopy for benign gynecological indications. Analysis of individual variables failed to identify any factors that influenced the rate of constipation. [ABSTRACT FROM AUTHOR]

To study the rate and risk factors for short-term postoperative complications of patients undergoing minimally invasive surgery (MIS) for endometriosis in the United States. Retrospective cohort study. American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. Patients with endometriosis diagnosis. Laparoscopic surgery for endometriosis. We compared women with and without 30-day postoperative major complications, defined according to the Clavien-Dindo classification. A total of 28 697 women underwent MIS during the study period, of which 2.6% had major postoperative complications. Organ space surgical site infection and reoperation were the most common complications (47.0% and 39.8%, respectively). In multivariable regression analysis, African American race (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.61 [1.29–2.01], p <.001), hypertension (aOR 95% CI 1.23 [1.01–1.50], p =.036), bleeding disorders (aOR 95% CI 1.96 [1.03–3.74], p =.041), bowel procedures (aOR 95% CI 1.93 [1.37–2.72], p <.001) and hysterectomy (aOR 95% CI 2.09 [1.67–2.63], p <.001) were independently associated with increased risk of major complications. In multivariable regression analysis of laparoscopies without bowel procedures, African American race, bleeding disorders, and hysterectomy were independently associated with increased major complication risk. Among cases with bowel procedures, African American race and colectomy were independently associated with increased major complication risk. In multivariable regression analysis of women who underwent hysterectomy, African American race, bleeding disorders, and lysis of adhesions were independently associated with increased major complications risk. Among women who underwent uterine-sparing surgery, African American race, hypertension, preoperative blood transfusion, and bowel procedures were independently associated with increased major complications risk. Among women undergoing MIS for endometriosis, African American race, hypertension, bleeding disorders, and bowel surgery or hysterectomy are risk factors for major complications. African American race is a risk factor for major complications among women undergoing surgeries with and without bowel procedures or hysterectomy. [ABSTRACT FROM AUTHOR]

To investigate the postoperative morbidity of laparoscopic hysterectomy (LH) for endometriosis/adenomyosis in terms of operative outcomes and complications. Retrospective multicentric cohort study. Eight European minimally invasive referral centers. Data from 995 patients with pathologically confirmed endometriosis and/or adenomyosis who underwent LH without concomitant urological and/or gastroenterological procedures from January 2010 to December 2020. Total LH. Demographic patients' characteristics, surgical outcomes, and intraoperative and postoperative complications were evaluated. We considered major postoperative surgical-related complications, any grade 2 or more events (Clavien-Dindo score) that occurred within 30 days from surgery. Univariate analysis and multivariable models fit with logistic regression were used to estimate the adjusted odds ratio (OR) and corresponding 95% confidence interval (CI) for major complications. Median age at surgery was 44 years (28–54), and about half of them (505, 50.7%) were on medical treatment (estro-progestins, progestin, or Gonadotropin hormone-releasing hormone-analogues) at the time of surgery. In association with LH, posterior adhesiolysis was performed in 387 (38.9%) cases and deep nodule resection in 302 (30.0%). Intraoperative complications occurred in 3% of the patients, and major postoperative complications were registered in 93 (9.3%). The multivariable analysis showed an inverse correlation between the occurrence of Clavien-Dindo >2 complications and age (OR 0.94, 95% CI 0.90–0.99), while previous surgery for endometriosis (OR 1.62, 95% CI 1.01–2.60) and intraoperative complications (OR 6.49, 95% CI 2.65–16.87) were found as predictors of major events. Medical treatment at the time of surgery has emerged as a protective factor (OR 0.50, 95% CI 0.31–0.81). LH for endometriosis/adenomyosis is associated with non-negligible morbidity. Knowing the factors associated with higher risks of complications might be used for risk stratification and could help clinicians during preoperative counseling. The administration of estro-progestin or progesterone preoperatively might reduce the risks of postoperative complications following surgery. [ABSTRACT FROM AUTHOR]

There is great consensus that the implementation of the enhanced recovery after surgery (ERAS) approach is beneficial for surgical patients, but there is a paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The survey described herein was aimed at gathering detailed information on perioperative management of DE patients who were undergoing sigmoid/rectal (discoid or segmental) resection within the Italian Society of Gynecologic Endoscopy (SEGI) group. Baseline survey. National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). The study did not involve patients. A 63-item questionnaire covering ERAS items for gynecologic/elective colorectal surgery was sent to SEGI centers. Only questionnaires from centers that reported performing ≥10 sigmoid/rectal resections per year were considered for this analysis. Thirty-three of 38 (86.8%) of the questionnaires were analyzed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6% for preoperative, intraoperative, and postoperative items, respectively. The proportion of overall agreement was 56.6%. Preoperative diet, fasting and bowel preparation, correction of anemia, avoidance of peritoneal drains, postoperative feeding, and early mobilization were the most controversial items. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p =.044 and p =.003, respectively) and gynecologist's/surgeon's experience (p =.042 and p =.022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centers that reported ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p =.081) or gynecologist's/surgeon's experience (p =.294). This is the first study on DE conducted on a national scale. The current survey results revealed suboptimal compliance with the ERAS recommendations and underline the need to improve the quality of perioperative care in DE patients undergoing sigmoid/rectal resection. This study is a first step toward building a consistent, structured reporting platform for the SEGI units and facilitating wide implementation and standardization of the ERAS protocol for DE patients in Italy. [ABSTRACT FROM AUTHOR]

Externally validate the American Association of Gynecologic Laparoscopists (AAGL) staging system against surgical complexity and compare diagnostic accuracy with revised American Society for Reproductive Medicine (rASRM) stage, as was done in original publication. Retrospective, diagnostic accuracy study. Multicenter (Sydney, Australia). A total of 317 patients (January 2016–October 2021) were used in the final analysis. A database of patients with coded surgical data was analyzed. Three independent observers assigned an AAGL surgical stage (1–4) as the index test and surgical complexity level (A–D) as the reference standard. Results from the most accurate of the 3 observers were used in the final analysis. The weighted kappa score for the overall performance of AAGL stage and rASRM to predict AAGL level was 0.48 and 0.48, respectively (no difference). This represents weaker agreement with AAGL level than was observed in the reference paper, which reported a weighted kappa of 0.62. Diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) for stage 1 to predict level A was 98.5%, 64.3%, 66.3%, and 98.3%; stage 2 to predict level B 31.2%, 90.5%, 27.0%, and 92.1 %; stage 3 to predict level C 12.3%, 94.1%, 59.3%, and 60.7%; stage 4 to predict level D 95.65%, 88.10%, 38.60%, and 99.62%. Area under the receiver operating characteristic curve for A vs B/C/D (cut point 9) was 0.87, A/B vs C/D (cut point 16) was 0.78, and A/B/C vs D (cut point 22) was 0.94. There was weak to moderate agreement between AAGL stage and AAGL surgical complexity level. Across all key indicators, the AAGL system did not perform as well in this external validation, nor did it outperform rASRM as it did in the reference paper. Results suggest the system is not generalizable. [ABSTRACT FROM AUTHOR]

Study Objective: To compare the accuracy of pre-operative ultrasound in predicting the laparoscopically defined 2021 AAGL Endometriosis Staging.Setting: Three specialized endometriosis surgical centers in São Paulo (Brazil), Barcelona (Spain), and Avellino (Italy) participated.Design: Retrospective multicenter study of patients treated at 3 specialized endometriosis centers.Patients: 878 patients aged 15-45 years with no history of pelvic malignancy underwent laparoscopic treatment for suspected endometriosis.Interventions: Retrospective review of preoperative transvaginal and transabdominal ultrasound (index test) assessed for endometriosis at all sites used in the 2021 AAGL Endometriosis Classification and classified patients into AAGL-ultrasound (AAGL-US) stages 1-4. Results were compared to reference-standard laparoscopic (AAGL-LPS) staging.Measurements and Main Results: The AAGL-US and AAGL-LPS stage were concordant in 586 (66.7%) cases [weighted kappa (WK) 0.759; intraclass correlation = 0.906), with the highest agreement observed in patients with no endometriosis (n=70, 75.3% concordance), AAGL-LPS Stage 1 (104, 50.7%) and Stage 4 disease (358, 88.2%). Endometriosis was most accurately diagnosed in the rectum/sigmoid colon (WK 0.862), bladder (WK 0.911) and ovaries (WK 0.835/0.795 for right/left, respectively), and least accurately diagnosed at superficial peritoneal (WK 0.442), tubal (WK 0.391/0.363 for right/left, respectively) and retrocervical/uterosacral ligament (WK 0.656) sites.Conclusion: Sonographic estimation of the 2021 AAGL Endometriosis staging is greatest in AAGL-LPS stages 1 and 4 as well as among patients with no endometriosis. Ultrasound best identifies endometriosis of the ovaries, bladder, and bowel but is more limited for the tubes and superficial peritoneum. [ABSTRACT FROM AUTHOR]

To evaluate ultrasonographic findings as a first-line imaging tool to indirectly predict the presence of parametrial endometriosis (PE) in women with suspected deep endometriosis (DE) undergoing surgery. Retrospective analysis of a prospectively collected database (ULTRA-PARAMETRENDO I study; NCT05239871). Referral center for DE. Consecutive patients undergoing laparoscopic surgery for DE. Preoperative transvaginal ultrasonography was done according to the International Deep Endometriosis Analysis consensus statement. A stepwise forward regression analysis was performed considering the simultaneous presence of DE nodules and the following ultrasonographic indirect signs of DE: diffuse adenomyosis, endometriomas, ovary fixed to the lateral pelvic wall or the uterine wall, absence of anterior/posterior sliding sign, and hydronephrosis. The gold standard for the presence of PE was surgery with histologic confirmation. Of 1079 patients, 212 had a surgical diagnosis of PE (left: 18.5%; right: 17.0%; bilateral: 15.9%). The obtained prediction model (χ2 = 222.530; p <.001) for PE included, as independent indirect DE signs presence of hydronephrosis (odds ratio [OR] = 14.5; p =.002), complete absence of posterior sliding sign (OR = 3.3; p <.001), presence of multiple endometriomas per ovary (OR = 3.0; p =.001), and ovary fixation to the uterine wall (OR = 2.4; p <.001); as independent concomitant DE nodules, presence of uterosacral nodules with the largest diameter >10 mm (OR = 3.2; p <.001), presence of rectal endometriosis with the largest diameter >25 mm (OR = 2.3; p =.004), and rectovaginal septum infiltration (OR = 2.3; p =.003). The optimal diagnostic balance was obtained considering at least 2 concomitant DE nodules and at least 1 indirect DE sign (area under the curve 0.75; 95% confidence interval, 0.72–0.79). Specific indirect ultrasonographic findings should raise suspicion of PE in women undergoing preoperative assessment for DE. The suspicion of parametrial invasion may be critical to address patients to expert leading centers, where proper diagnosis and surgical treatment for PE can be performed. [ABSTRACT FROM AUTHOR]

The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements. Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control. Tertiary care, academic center. A total of 100 women with endometriosis or pelvic pain. Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists. A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p =.044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p =.013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p =.051; 7.7 vs 5.2, p =.155; 8.1 vs 5.6, p =.118). Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements. [ABSTRACT FROM AUTHOR]

To assess the association between laparoscopic appearance of superficial endometriosis lesions, histopathology, and systemic hormone use. Retrospective study. Tertiary care academic medical center. We identified 266 women who underwent laparoscopic surgery at an endometriosis center with excision of lesions consistent with possible superficial endometriosis between September 2015 and November 2018. Appearance of the peritoneal lesions was confirmed with review of surgical videos and correlated with each pathology specimen. Lesions were dichotomized on positive or negative pathology assessment. All pathology-positive lesions were further dichotomized by hormone use within 1 month of surgery. A total of 841 lesions were biopsied from included subjects during the study period. Of those, 251 biopsies were negative, and 590 were positive for endometriosis on pathology assessment. Lesions had significantly higher odds of positive histology when they were red (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.17–2.48), white (OR, 1.99; 95% CI, 1.47–2.70), blue/black (OR, 2.98; 95% CI, 2.00–4.44), or puckering (OR, 9.78; 95% CI, 2.46–38.91) in appearance. The following combined characteristics had significantly higher odds of positive histology: white and blue (OR, 5.98; 95% CI, 2.97–12.02), red and white (OR, 2.22; 95% CI, 1.38–3.56), red and blue (OR, 4.11; 95% CI, 1.83–9.24), and clear and white (OR, 8.77; 95% CI, 1.17–66.02). Among positive biopsies, those with hormone exposure were more likely to have clear lesions than those without hormone use (OR, 3.36; 95% CI, 1.54–7.34) and were 2.89 times more likely to have clear and white lesions (95% CI, 1.07–7.85). Although lesions suspicious for endometriosis may have differing rates of positive pathology based on appearance, no lesion characteristic was able to exclude the possibility of endometriosis. In addition, hormone use may influence lesion appearance at the time of surgery, with clear lesions more prevalent. These data have implications for appropriate identification of endometriosis at the time of laparoscopy to ensure accurate diagnosis and complete treatment of disease. [ABSTRACT FROM AUTHOR]

Despite various surgical and nonsurgical strategies for abdominal wall endometriosis, the lack of definitive guidance on optimal treatment choice leads to clinical uncertainty. This review scrutinizes the safety and efficacy of abdominal wall endometriosis treatments to aid in decision-making. We performed a systematic literature review of PubMed, Embase, and Cochrane Library databases from 1947 until December 2023. A comprehensive literature search identified studies that assessed both surgical and nonsurgical interventions, including high-intensity focused ultrasound (HIFU), cryoablation, radiofrequency ablation, and microwave ablation. This review is registered in NIHR-PROSPERO (CRD 42023494969). Local tumor control (LTC), local pain relief (LPR), and adverse events (AE) were recorded. This review included 51 articles among 831 identified. All study designs were considered eligible for inclusion. A total of 2674 patients are included: 2219 patients (83%) undergoing surgery, and 455 (17%) undergoing percutaneous interventions (342 HIFU, 103 cryoablation, 1 radiofrequency ablation, 9 microwave ablation). Follow-up length was 18 months in median, ranging from 1 to 235 months. Overall LTC rates ranged from 86% to 100%. Surgical interventions consistently demonstrated the highest rate of LTC with a median rate of 100%, and LPR with a median rate of 98.2% (95% confidence interval [CI]: 93.9–97.7). HIFU showed median LTC and LPR rates, respectively of 95.65% (95% CI, 87.7–99.9) and 76.1% (95% CI, 61.8–90.4); and cryoablation of 85.7% (95% CI, 66.0–99.9) and 79.2% (95% CI, 67.4–91.03). Minor AE was reported after surgery in 17.5% of patients (225/1284) including 15.9% (199/1284) of mesh implantation; 76.4% (239/313) after HIFU; and 8.7% (9/103) after cryoablation. Severe AE was reported in 25 patients in the surgery group and 1 in the percutaneous group. The safety profile and efficacy of nonsurgical interventions support their clinical utility for management of abdominal wall endometriosis. [ABSTRACT FROM AUTHOR]

Study Objective: To assess whether complications incurred during hysterectomy for the treatment of endometriosis differ among racial-ethnic groups.Design: Retrospective cohort study.Setting: American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019. This database is a robust, comprehensive, multi-institutional database with nearly 700 participating hospitals.Patients: Patients with a diagnosis of endometriosis or with an endometriosis-associated symptom as the primary indication for surgery and surgical intraoperative documentation of endometriosis.Interventions: Compare perioperative complications based on patient race and ethnicity.Measurements and Main Results: A total of 5639 patients underwent hysterectomy for endometriosis; of these, 4368 were White patients (77.5%), 528 Black patients (9.4%), 491 Hispanic patients (8.7%), 252 Asian patients (4.5%). There was no association between location of endometriosis and patient race and ethnicity. However, White patients had highest rate, and Asian patients had the lowest rate of laparoscopic hysterectomy, 85.3% vs 69.8%, respectively (p <.01). In addition, there were differences in concomitant procedures performed at time of hysterectomy based on race and ethnicity, with White patients having the highest rates of adnexal/peritoneal surgery at 12.5% (p <.01) compared with patients of the other racial and ethnic groups. Asian patients had the highest rate of ureteral surgery at 6.8% (p <.01) and highest rate of intestinal surgery at 16.3% (p <.01) compared with patients of other racial and ethnic groups. There was no association of rates of concomitant bladder surgery, appendectomy, or rectal surgery with patient race and ethnicity. Black patients had the highest rate of minor complications at 13.5% (p <.01) and the highest rate of major complications at 6.6% (p <.01) compared with patients of other racial and ethnic groups. After multivariable analysis, Black patients still had increased odds of having a major complication compared with patients of other racial and ethnic groups even after controlling for patient characteristics and perioperative factors such as endometriosis lesion location, surgical approach, and concomitant procedures (odds ratio 1.64; 95% confidence interval, 1.10-2.45).Conclusion: Endometriosis lesion location did not differ with patient race and ethnicity. However, patient race and ethnicity did have an impact on the surgical approach and the concomitant surgical procedures performed at time of hysterectomy. Black patients had the highest odds of major complications. [ABSTRACT FROM AUTHOR]

Study Objective: To retrospectively evaluate the ability of routinely collected preoperative ultrasound data to predict bowel resection during surgery for rectovaginal endometriosis.Design and Setting: Patients at the University College London Hospital who underwent surgery for rectovaginal endometriosis during a 6-year period were identified from the prospectively generated hospital (British Society for Gynaecological Endoscopy) database. Imaging data were collected and analyzed to determine associations with the requirement for bowel resection.Patients: We evaluated 228 consecutive women undergoing bowel surgery (shave, disc resection, or segmental resection) for rectovaginal endometriosis.Interventions: The patients in our study underwent surgical resection of rectovaginal endometriosis and interventions included shave, disc resection, and segmental resection of the bowel. All patients underwent a preoperative transvaginal ultrasound to assess the extent of endometriosis.Measurements and Main Results: There were 206 rectal shaves (90.4%), 2 disc resections (0.9%), and 20 segmental bowel resections (8.8%). A multivariable analysis demonstrated an association between bowel resection and ≥2 nodules located in the rectovaginal space (odds ratio [OR] 6.85; 95% confidence interval [CI], 1.37-34.2), nodules in the vesicouterine pouch (OR 5.87; 95% CI, 1.03-33.3), and increasing nodule size (OR 2.39 per 1 cm increase per 1 cm diameter increase; 95% CI, 1.56-3.64).Conclusion: Ultrasound findings of endometriotic nodule location, number of nodules, and increasing size are independent predictors of segmental bowel resection at the time of surgery for rectovaginal endometriosis. This highlights the importance of accurate diagnostic evaluation to aid counseling and surgical planning in the preoperative setting for women with rectovaginal endometriosis. [ABSTRACT FROM AUTHOR]

Objective: To report our 3-year institutional experience of total laparoscopic (TL) segmental sigmoid colon/rectal resection for treatment of bowel endometriosis (BE)., Design: The TrEnd trial is a single-institutional retrospective/prospective study conducted with the aim of systematically collecting data from consecutive patients undergoing segmental colorectal resection for BE. This paper reports the outcomes of patients undergoing intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE) from this database. Primary endpoints were to evaluate the safety and efficacy of this approach in terms of: complications, conversion to conventional technique/open surgery, endometriosis-free bowel resection margins, recurrence. Secondary endpoints were to assess: intraoperative blood loss, operating time, gastrointestinal function recovery, duration of hospital stay, reproductive outcomes., Setting: Malzoni Research Hospital, Avellino, Italy., Participants: Only patients undergoing TL colorectal resection with transanal NOSE were included in the present analysis. Patients were considered non-eligible if they had received concomitant hysterectomy and/or transvaginal NOSE., Interventions: Results presented here are descriptive., Results: Eighty-one patients were included in the present analysis. Post-operative severe complications occurred in 3.7%. No cases of intraoperative complications or conversion to conventional technique/open surgery occurred. Final pathology showed endometriosis-free resection margins in all colorectal specimens. After a median follow-up of 21 months, all patients were free from BE. Median blood loss was 20 mL. Median length of surgery was 160 minutes. Median hospital length of stay was 3 days. All patients achieved the first passage of flatus on post-operative day 1. Median time to first defecation was 4 days. Twenty-six patients attempted to conceive. Nine of them achieved a pregnancy and 2 gave birth to a healthy child., Conclusion: This study represents the main experience on TL segmental colorectal resection for BE treatment. The observed optimal outcomes seem to recommend further studies to assess safety and efficacy of said surgical technique in women with BE. Clinical trial registry name: ClinicalTrials.gov., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To demonstrate the time to place temporary bilateral stents with indocyanine green (ICG) injection, time to intra-operative identification of bilateral ureters - with and without the use of ICG, and number of times for ICG activation in endometriosis excision surgery., Design: Retrospective cross-sectional study SETTING: Single Tertiary Academic Hospital PARTICIPANTS: 50 serial patients with functioning pelvic ureters, who underwent vaginal natural orifice transluminal endoscopic surgery (vNOTES) for all stages of endometriosis excision between September 2023 and May 2024., Interventions: Placement of temporary bilateral ureteral stents with indocyanine green injection before the start of vNOTES, noting the time needed to identify intra-peritoneal ureters with and without ICG activation, and average number of times ICG was activated for endometriosis excision., Results: The median time to place bilateral ureteral stents with ICG injection was 229 seconds. The median time for intra-operative ureteral identification with ICG was 1s (L) and 1s (R). The median time for intra-operative ureteral identification without ICG was 17s (L) and 17s (R). The median time ICG was activated for ureteral identification to perform endometriosis excision was 12 times (L), 11 times (R). From the observations previously described, we share the potential of improved efficiency and efficacy in using ICG in ureteral identification for endometriosis surgery., Conclusion: Placement of temporary bilateral ureteral stents with ICG has the potential for more efficient ureteral identification even after including time for ureteral stent placement and ICG injection. The upfront time needed to place stents may prove to lead to a safer, more efficient procedure., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection., Data Sources: A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: April 30, 2024)., Methods of Study Selection: We included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials, observational prospective or retrospective studies, and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included., Tabulation, Integration, and Results: Nine studies, including 574 women affected by DIE and submitted to urodynamic assessment, were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% confidence interval [CI] 3, 26; I2 = 93.9%, p <.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2 = 78.1%, p <.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2 = 97.2%, p <.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2 = 86%, p <.001), low preoperative bladder compliance was reported in 35% of patients (95% CI 30, 40; I2 = 0%, p = .66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2 = 0%, p = .58). No difference between preoperative and postoperative UDS detrusor overactivity was reported (odds ratio [OR] 0.45; 95% CI -0.10, 1.0, I2 = 0%; p = .66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2 = 49.6%; p = .12)., Conclusion: Abnormal urodynamic findings before surgery are prevalent in women with DIE. Surgery seems not to affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages., Design: Retrospective case series., Setting: Single academic tertiary care hospital in Houston, Texas, USA., Participants: Twenty-eight adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection., Interventions: Hysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform)., Main Results: Twenty-eight patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m 2 (range 19.5-48.4 kg/m 2 ), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0 mL). One case required a mini-laparotomy as the irregularly shaped 1668 g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection., Conclusion: Our findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

To evaluate the intraoperative visual effect of treatment with GnRH-analogues and Dienogest in endometriosis. Retrospective observational study. Every laparoscopy from all the different disciplines in our hospital is documented on video and stored in a database. The study was approved by the local ethics committee. A total of 193 patients with histological proven endometriosis from 2007 to 2021 were included, who underwent 2-step surgical procedure. Indications were endometrioma before CO2-Laser therapy, missing consent because of emergencies or other surgeries from other disciplines, or high active and extended disease. When endometriosis was suspected in a surgery conducted by other disciplines, a gynecological surgeon was called during the surgery. Data and intraoperative videos were reviewed by 2 independent reviewers at one referral center. Only cases with available video of first and second look laparoscopy were included. We excluded patient who had prior hormonal treatment in the last 6 months. Lesions were classified according to the description of Khan et al. Statistical analysis was performed using SPSS (Version 27.0, IBM). Mann-Whitney U test (nonparametric analysis) and χ2 tests were applied. Percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. Significance level was set to p <.05. Seventy-seven received GnRH-analogues and 116 Dienogest for preoperative hormone down-regulation. The median duration of down-regulation with GnRH-analogues or Dienogest was 3 months. The mean age was 32.3 (SD 6.3) years for GnRH-analogues and 32.6 (SD 6.3) years for Dienogest, p =.619 respectively. The visible intraoperative effect will be demonstrated in the video. The effect of a hormonal treatment can be observed macroscopically in endometriosis. This can help to understand the in vivo response to the administrated treatment. This video is showing our past experience, as performing second-look laparoscopy is not state of the art anymore. [Display omitted] [ABSTRACT FROM AUTHOR]

To demonstrate the feasibility of management of large endometrioma laparoscopically. Stepwise demonstration with narrated video footage of the laparoscopic 2-step procedure starting with alcohol sclerotherapy of the large endometrioma followed by CO 2 laser ablation and 6-month follow-up. The debate surrounding the best approach for the management of large endometriomas has been ongoing. Cystectomy especially when treating large endometriomas has been shown to decrease ovarian reserve proportionally to the endometrioma's size. 2,4 This is why 2-step approaches have been considered to preserve the ovarian reserve. 1,3 We present the case of a 22-year-old nulliparous woman who has primary severe dysmenorrhea resistant to medical treatment. Magnetic resonance imaging shows uterine adenomyosis and a 10 cm large endometrioma of the left ovary and no signs of deep infiltrative endometriosis. She has a desire for pregnancy in the distant future. The first step is the laparoscopic ethanol sclerotherapy. After emptying and rinsing the endometrioma's cavity through a 5 mm suction cannula, it is then filled with ethanol through a 14 French Foley catheter to avoid any overflow. 5,6 After a time exposure of 10 minutes, the ethanol is withdrawn and the cavity rinsed (Figure 2). The second step of the surgery is performed 12 weeks later (Figure 3). Using CO 2 laser, the untreated portion of the inner wall of the remaining endometrioma is vaporized along with remaining superficial endometriosis lesions (Figure 1). Laparoscopy sclerotherapy combined to CO 2 laser ablation is a feasible technique for the management of a large endometrioma. Further research is still required to evaluate the benefit of a 2-step surgery approach over standard cystectomy and to understand the long-term effects of ethanol-induced ovarian fibrosis. [ABSTRACT FROM AUTHOR]

Study Objective: To develop a nomogram for predicting the type of ureteral procedure in pelvic deep endometriosis (DE) surgery (1) and to describe the factors and complications associated with the ureteral procedure (2).Design: Retrospective monocentric study of 920 patients who underwent surgery for pelvic DE between June 2009 and March 2020 in the gynecologic surgery department of the Versailles Hospital Center. The main criterion was evaluation of the ureteral procedure, classified as simple (isolation of the ureter) or complex (dissection of the ureter, segmental ureteral resection, or nephroureterectomy). Postoperative complications, including ureteral stenosis and fistula formation, were tabulated.Setting: Tertiary referral hospital and expert center in endometriosis.Patients: A total of 920 patients with DE.Interventions: Ureteral procedure during surgery for DE.Measurements and Main Results: In total, 724 patients (79%) underwent a ureteral procedure, of which 307 (33%) were complex, including 17 (1.8%) segmental ureteral resections. In multivariate analysis, the predictive variables for a complex ureteral procedure were age (p = .036), a previous surgery for endometriosis (p <.01), and ureteral dilatation on magnetic resonance imaging (p <.001). The area under the curve for the model predicting a complex ureteral procedure was 0.68 (95% confidence interval, 0.60-0.71). A complex ureteral procedure was associated with a 3.5% rate of ureteral fistula (n = 15).Conclusion: Age, a previous surgery for endometriosis, a rectovaginal nodule size ≥30 mm, endometriotic involvement of the rectum or sigmoid, and ureteral dilatation are significantly associated with a complex ureteral procedure. Our results allowed us to build a nomogram that can be used to better inform patients, anticipate the therapeutic strategy, and optimize the modalities of postoperative surveillance. [ABSTRACT FROM AUTHOR]

Study Objective: To assess to what degree can digestive symptoms improve after endometriosis surgery for different localizations.Design: A comparative retrospective study employing data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018.Setting: Two referral centers.Patients: A total of 1497 women undergoing surgery because of pelvic endometriosis were divided into 3 groups: superficial endometriosis (Group 1, n = 396), deep endometriosis sparing the bowel (Group 2, n = 337), and deep endometriosis involving the bowel (Group 3, n = 764).Interventions: Surgery for endometriosis.Measurements and Main Results: Preoperative and postoperative gastrointestinal symptoms were evaluated with standardized questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardized questionnaires GIQLI and KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms.Conclusion: Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints. [ABSTRACT FROM AUTHOR]

Study Objective: To investigate the therapeutic efficacy of catheter-directed ethanol sclerotherapy (CDS) and its effect on ovarian reserve in patients with endometrioma at risk of decreased ovarian reserve.Design: Retrospective study.Setting: Teaching hospital.Patients: We evaluated 18 patients with ovarian endometrioma measuring ≥3 cm and preprocedural serum antimüllerian hormone (AMH) levels of <2 ng/mL.Interventions: An 8.5-F catheter was inserted either transabdominally or transvaginally into the endometrioma. After aspiration, sclerotherapy with 99% ethanol was performed, with a subsequent 20-minute ethanol retention.Measurements and Main Results: Ultrasonography was performed preprocedurally and 6 months after CDS to evaluate any recurrence or changes in cyst size. Furthermore, serum AMH levels, cancer antigen 125 (CA-125) levels, and the visual analog scale scores for dysmenorrhea were obtained to analyze the ovarian reserve and treatment efficacy, preprocedurally and at 6 months after CDS. The mean cyst size on ultrasonography and serum CA-125 levels decreased 6 months after CDS (p <.001 and p = .001, respectively). All patients reported a decreased visual analog scale score for dysmenorrhea (p <.001). However, the difference in serum AMH levels before and after CDS was statistically insignificant (p = .875).Conclusion: CDS was efficacious in reducing pain and serum CA-125 levels in patients with low AMH levels without adversely affecting their ovarian reserve. [ABSTRACT FROM AUTHOR]

Study Objective: To assess nerve fiber density and expression of hormone receptors in bowel endometriosis.Design: Cross-sectional study.Setting: Private hospital.Patients: Women with endometriosis undergoing laparoscopic segmental bowel resection (n = 54).Interventions: Tissue samples were obtained from patients with surgically treated rectosigmoid endometriosis.Measurements and Main Results: The rectosigmoid specimen containing the endometriosis nodule was manually sectioned and divided into 3 areas: core of the nodule, margin of the nodule, and healthy bowel tissue. The intensity of expression of estrogen and progesterone receptors was evaluated by immunohistochemistry and measured according to the Allred score. Nerve fibers were stained by immunohistochemistry using Protein Gene Product 9.5, and the density of nerve fillets was counted and expressed in number/mm². All glandular and stromal cells stained for estrogen; however, glandular cells stained more strongly than stromal cells (61.1% vs 35.2%; p = .01). Most of glandular and stromal cells stained strongly for progesterone receptors (90.7% vs 98.1%; p = .2). The density of nerve fibers was very high in the margin of the nodule (172.22±45.66/mm²), moderate in healthy bowel tissue (111.48±48.57/mm²), and very low in the core of the nodule (7.31±4.9/mm²); p = .01.Conclusion: Both glandular and stromal cells within the rectosigmoid endometriosis nodule express estrogen and progesterone receptors. Higher intensity of expression of estrogen receptors occurs in glandular cells. The density of nerve fibers is extremely high at the nodule margin and very low in the center of the nodule. [ABSTRACT FROM AUTHOR]

Study Objective: To identify preoperative and intraoperative risk factors for adnexal torsion after hysterectomy, and to estimate the incidence of the disease in the modern-day era of laparoscopic surgery.Design: Retrospective nested case-control study.Setting: Large urban medical system.Patients: Eighty-nine female patients ages 17 to 51.Interventions: Patients underwent ovarian-sparing hysterectomy.Measurements and Main Results: The estimated incidence of ovarian torsion after hysterectomy was 0.5% (46/8538 ovarian-sparing hysterectomies). The following variables were found to be associated with adnexal torsion after hysterectomy in an adjusted logistic regression: laparoscopic or laparoscopic-assisted approach to hysterectomy vs any other approach (odds ratio [OR], 3.36; 95% confidence interval [CI], 0.86-13.23); younger age at the time of hysterectomy (17-40 years) vs older age (41-51 years) (OR, 3.45; 95% CI, 1.33-8.97); and a gynecologic history significant for endometriosis (OR, 4.07; 95% CI, 1.04-15.88).Conclusion: There is an association between laparoscopic approach to hysterectomy, younger age at time of hysterectomy, and a history of endometriosis with subsequent risk of adnexal torsion. Providers should have a heightened index of suspicion for adnexal torsion after hysterectomy in patients presenting with acute-onset abdominal pain who underwent laparoscopic hysterectomy at a younger age. [ABSTRACT FROM AUTHOR]

Study Objective: To describe the surgical techniques and short-term outcomes for 33 cases of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (RvNOTES) to treat endometriosis.Design: Retrospective case series study.Setting: Academic tertiary care university hospital in Houston, TX.Patients: Patients who underwent RvNOTES resection of endometriosis between March 2020 and March 2021.Interventions: RvNOTES.Measurements and Main Results: A total of 33 cases of patients, with pathology-confirmed endometriosis, who underwent RvNOTES total hysterectomy with resection of endometriosis were included in the study. Thirty-two cases were completed successfully by RvNOTES, and 1 case was converted to robotic transumbilical single-incision laparoscopic surgery plus 1 additional port owing to an obliterated posterior cul-de-sac and upper abdominal wall endometriosis. The average operative time was 141.93 ± 40.22 (85-264) minutes, and the mean estimated blood loss was 52.25 ± 33.82 (25-150) mL. The mean preoperative pain score using the visual analog scale (VAS) score was 8.08 ± 2.39 (2-10). The mean VAS pain score 1 week after surgery was 6.73 ± 2.62 (0-10), which was significantly lower than the preoperative scores (p = .059). The mean VAS pain score in the second and third week after surgery was 4.81 ± 2.42 (0-9) and 2.63 ± 2.36 (0-7) respectively, which were both significantly lower than those before surgery (p = .001). There were 4 postoperative complications: urinary tract infection, pneumonia, headache requiring admission, and conversion disorder.Conclusion: RvNOTES is a safe and feasible approach for the treatment of endometriosis, with promising short-term improvements in pain. [ABSTRACT FROM AUTHOR]

Study Objective: Use machine learning to characterize the content of endometriosis online community posts and comments., Design: Retrospective Descriptive Study., Setting: Endometriosis online health communities (OHCs) on the platform Reddit., Participants: Users of the endometriosis OHCs r/Endo and r/endometriosis., Interventions: Machine learning was used to analyze thousands of posts made to endometriosis OHCs. Content of posts and comments was interpreted using topic modeling, persona identification, and intent labeling. Measurements included baseline characteristics of users, posts, and comments to the OHCs. Machine-learning techniques; topic modeling, intent labeling, and persona identification were used to identify the most common topics of conversation, the intents behind the posts, and the subjects of people discussed in posts. System performance was assessed via accuracy at F 1 -score., Results: A total of 34 715 posts and 353 162 comments responding to posts were evaluated. The topics most likely to be a subject of a post were menstruation (8%), sharing symptoms (8%), medical appointments (8%), medical story (9%), and empathy (7%). The majority of posts were written with the intent of seeking information about endometriosis (49%) or seeking the experiences of others with endometriosis (29%). Users expressed a strong preference for surgeons performing excision rather than ablation of endometriosis., Conclusion: Endometriosis OHCs are mostly used to learn about symptoms of endometriosis and share one's medical experiences. Posts and comments from users highlight the need for more empathy in the clinical care of endometriosis and easier access for patients to high-quality information about endometriosis., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To describe how the knowledge from standard imaging practices can be translated into 3-dimensional visualization techniques and used in the surgical planning and management of endometriosis., Design: Two case studies of patients with endometriosis are described., Setting: Tertiary care academic center., Interventions: Transvaginal ultrasound [1], magnetic resonance imaging, 3-dimensional printing [2], and 3-dimensional virtual reality modeling [3] were used during patient workup and preparation. Three-dimensional modeling was performed by a virtual reality technician and verified for accuracy by a fellowship-trained radiologist. Surgical management for endometriosis was performed., Conclusion: Although expert transvaginal ultrasound and magnetic resonance imaging suffice for most cases, 3-dimensional printing and virtual reality modeling are a novel adjunct to standard imaging modalities. Rendering 2-dimensional images into a 3-dimensional representation allows users to interact with the anatomy and is particularly useful when distorted by complex pathology. These techniques contributed to improved patient understanding and experience and helped medical learners better grasp regular imaging techniques and its translation to pelvic anatomy. Finally, it augmented surgeon comprehension of the relationship between the pelvic structures, allowing for enhanced surgical planning and intraoperative decision making. Further study is being performed to quantify these effects., (Copyright © 2024 AAGL. All rights reserved.)

To demonstrate nerve-sparing laparoscopic eradication of deep endometriosis with rectal and parametrial resection based on the Negrar method [1] using the "touchless" technique. Stepwise video case demonstration with narration. Tertiary level endometriosis unit. The patient was a 28 year-old nulliparous patient referred for surgery with persistent dysmenorrhea, dyspareunia, and dyschezia despite medical management (progestin-containing hormonal pills). Preoperative ultrasound demonstrated bilateral endometriomas, diffuse adenomyosis, and 35 mm × 17 mm stenosing rectal nodule. Histopathology confirmed 60% stenosis of the rectum secondary to the endometriotic nodule up to submucosal layer with margins free of endometriosis. She was discharged 7 days postoperatively with no postoperative complications. Laparoscopic nerve-sparing eradication of deep endometriosis with segmental rectosigmoid resection and bilateral posterior parametrectomy [2] according to the "Negrar method" with nerve-sparing "touchless" technique, sliding the nerve bundles laterocaudally, and keeping intact the visceral pelvic fascia covering them, thus without direct contact with the nerves. In our experience, based on more than 3000 of these procedures [3] , this nerve-sparing procedure, based on identifying the nerves and their laterocaudad dissection, without a direct impact on their fibers but just on their fascial envelopes has proven successful in lowering the rates of postoperative dysfunctions and neural impairment related to neuro-apraxia and edema that occurs by directly affecting them [1]. Although there are no robust data to demonstrate benefit of "touchless" nerve-sparing dissection techniques, neuro-apraxia from compression of neural fibers that has been observed can be minimized [ 1 , 4 , 5 ]. [ABSTRACT FROM AUTHOR]

To show the surgical steps used to perform a laparoscopic double discoid colorectal resection for the excision of 2 distinct deep endometriotic nodules (DENs). Stepwise demonstration of the technique with narrated video footage. To date there is agreement that discoid resection should be the first choice procedure in patients eligible for surgical treatment with rectal, unifocal DENs measuring ≤ 3 cm [1–3]. For surgical management of lesions of the sigmoid colon, current international guidelines suggest to perform segmental resections [3]. Data on surgical treatment of multiple colorectal DENs separated by a great distance from each other are very limited, mostly owing to the rarity of such a diagnosis. In particular, there is paucity of data concerning the efficacy and safety of a double discoid resection for surgical management of distinct DENs found in the sigmoid colon and rectum [4]. In a context of multiple colorectal DENs, the decision-making process with respect to a double discoid excision must take into consideration both the distance between the 2 nodules and the nodules' distance from anal verge. When technically feasible, such organ-sparing surgery allows preserving the healthy bowel interposed between the endometriotic lesions, seeming to offer advantages in terms of quicker return of bowel function and better rectal functional outcomes than segmental colorectal resection. The patient was a 36-year-old woman experiencing drug treatment failure and presenting with refractory constipation, dyschezia, dysmenorrhea, dyspareunia, cyclical abdominal bloating, and chronic pelvic pain. Preoperative ultrasonography revealed the presence of an endometriotic nodule of 19 × 6 × 16 mm deeply infiltrating the tunica muscularis of the sigmoid colon. A second DEN was found at the level of the rectum, the latter measuring 19 × 5 × 12 mm and having a distance of 9 cm from the anal verge. Both the intestinal lesions resulted to have a circumferential extent of 30%. The distance between the 2 nodules was 15 cm. A 3-dimensional laparoscopy was performed. Sigmoid colon and rectal mobilization were performed according to our standardized technique [5–7]. A 31-mm circular stapler was used to excise first the nodule of the sigmoid colon. The stapler, in its closed position, was gently introduced into the rectum via the anus and then progressively advanced inside the large bowel up to the level of the sigmoid nodule. After correct positioning, the stapler was completely opened and the nodule was imbricate between the anvil and staple housing of the stapler. Then, the stapler was closed and fired. The procedure was repeated using a second 31 mm circular stapler to resect the rectal endometriotic nodule. The overall operative time was 90 minutes. The estimated blood loss was 5 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 3 days after surgery. The sigmoid colon and rectal endometriotic nodules measured, respectively, 20 × 6 × 15 mm and 20 × 5 × 12 mm on fresh unfixed specimens. Both nodules were found to have endometriosis-free surgical margins on definitive pathology. The operative technique displayed in this video may contribute to the standardization of a procedure, which could be included among the options available in the surgical armamentarium, to be used in selected cases of multiple colorectal DENs each having 3 cm or less in diameter. Surgeon experience and an adequate preoperative evaluation are of utmost importance to plan the operative strategy and have the best chance of surgical success. [ABSTRACT FROM AUTHOR]

Objective: In the field of endometriosis, several classification, staging and reporting systems have been developed. Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice?Data Sources: A systematic PUBMED literature search was performed. Data were extracted and summarized.Methods Of Study Selection: na TABULATION, INTEGRATION AND RESULTS: Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.Conclusion: Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated for the purpose for which they were developed. The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working towards a universally accepted endometriosis classification. [ABSTRACT FROM AUTHOR]

Objective: Different classification systems have been developed for endometriosis, using different definitions for the disease, the different subtypes, symptoms and treatments. In addition, an International Glossary on Infertility and Fertility Care has been published in 2017 by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) in collaboration with other organisations. An international working group convened over the development of a classification or descriptive system for endometriosis. As a basis for such system, a terminology for endometriosis was considered a condition sine qua non. The aim of the current study was to develop a set of terms and definitions be prepared on endometriosis that would be the basis for standardization in disease description, classification and research.Data Sources: The working group listed a number of terms relevant to be included in the terminology, documented currently used and published definitions, and discussed and adapted them until consensus was reached within the working group. Following stakeholder review, further terms were added, and definitions further clarified. Although definitions were collected through published literature, the final set of terms and definitions is to be considered consensus-based. After finalization of the first draft, the members of the international societies and other stakeholders were consulted for feedback and comments, which lead to further adaptations.Methods Of Study Selection: na TABULATION, INTEGRATION, AND RESULTS: A list of 49 terms and definitions in the field of endometriosis is presented, including a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. Endometriosis is defined as a disease characterized by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process.Conclusion: The current paper outlines a list of 49 terms and definitions in the field of endometriosis. The application of the defined terms aims to facilitate harmonization in endometriosis research and clinical practice. Future research may require further refinement of the presented definitions. [ABSTRACT FROM AUTHOR]

Study Objective: Chronic endometritis (CE), which often presents asymptomatically, is associated with recurrent pregnancy loss, recurrent implantation failure after in vitro fertilization, and endometriosis. Data connecting CE with fallopian tubal occlusion are limited. The aim was to assess a potential association of CE, defined by the presence of syndecan-1 (CD138)-positive plasma cells in endometrial tissue samples, with fallopian tube patency and other factors for infertility, including endometriosis, adenomyosis, and hydrosalpinges.Design: Prospective, monocentral pilot study.Setting: Tertiary care center.Patients: A cohort of 100 women who were infertile was enrolled from July 2019 to December 2020.Interventions: Hysteroscopy with endometrial biopsy and laparoscopy with chromopertubation.Measurements and Main Results: CE was found in 13 women (13.0%) and was associated with endometriosis (p = .034) and unilateral/bilateral fallopian tube blockage (p = .013). In women with endometriosis, the mean number of CD138-positive cells was positively correlated with the revised American Society for Reproductive Medicine score (r = .302, p = .028). In a binary regression model, the presence of a hydrosalpinx on one or both sides (odds ratio 15.308; 95% confidence interval, 1.637-143.189; p = .017) and the finding of CE in the endometrial tissue sample (odds ratio 5.273; 95% confidence interval, 1.257-22.116; p = .023) were significantly associated with fallopian tubal occlusion.Conclusion: CE was significantly associated with blockage of the fallopian tubes and endometriosis. Endometriosis stage was associated with the number of CD138-positive cells in endometrial biopsies. [ABSTRACT FROM AUTHOR]

Study Objective: To develop a prototype of a complex gene expression biomarker for the diagnosis of endometriosis on the basis of differences between the molecular signatures of the endometrium from women with and without endometriosis.Design: Prospective observational cohort study. Evidence obtained from a well-designed, controlled trial without randomization.Setting: Department of reproductive medicine and surgery, A.I. Evdokimov Moscow State University of Medicine and Dentistry.Patients: A total of 33 women (aged 32-38 years) were included in this study. Patients with and without endometriosis were divided into 2 separate groups. The group composed of patients with endometriosis included 19 living patients with endometriosis who underwent laparoscopic excision of endometriosis. The control group included 6 living patients who underwent laparoscopic excision of incompetent uterine scar after cesarean section, with both surgically and histologically confirmed absence of endometriosis and adenomyosis. An additional control/verification group included various previously RNA-sequencing-profiled tissue samples (endocervix, ovarian surface epithelium) of 8 randomly selected healthy female cadaveric donors aged 32 to 38 years. The exclusion criteria for all patients were hormone therapy and any intrauterine device use for more than 1 year preceding surgery, as well as absence of other diseases of the uterus, fallopian tubes, and ovaries.Interventions: Laparoscopic excision of endometriotic foci and hysteroscopy with endometrial sampling were performed. The cadaveric tissue samples included endocervix and ovarian surface epithelium. Endometrial sampling was obtained from the women in the control group. RNA sequencing was performed using Illumina HiSeq 3000 equipment (Illumina, Inc., San Diego, CA) for single-end sequencing. Unique bioinformatics algorithms were developed and validated using experimental and public gene expression datasets.Measurements and Main Results: We generated a characteristic signature of 5 genes downregulated in the endometrium and endometriotic tissue of the patients with endometriosis, selected after comparison with the endometrium of the women without endometriosis. This gene signature showed a capacity for nearly perfect separation of all 52 analyzed tissue samples of the patients with endometriosis (endometrial as well as endometriotic samples) from the 14 tissue samples of both living and cadaveric donors without endometriosis (area under the curve = 0.982, Matthews correlation coefficient = 0.832).Conclusion: The gene signature of the endometrium identified in this study may potentially serve as a nonsurgical diagnostic method for endometriosis detection. Our data also suggest that the statistical method of 5-fold cross-validation of differential gene expression analysis can be used to generate robust gene signatures using real-world clinical data. [ABSTRACT FROM AUTHOR]

Study Objective: Patients share and obtain healthcare-related information on social media platforms. We aim to evaluate the authorship and content of, as well as engagement with, gynecologic topics posted on Instagram.Design: Qualitative and quantitative retrospective content analysis.Setting: Instagram.Patients: Not applicable.Interventions: Not applicable.Measurements and Main Results: A query of endometriosis, adenomyosis, myomas, and hysterectomy yielded 237 hashtags. The top 10 and most recent 20 posts, as determined by Instagram's internal algorithm, were evaluated for 10 hashtags with the most posts. The most popular topic was endometriosis. Of the 300 posts evaluated, 97.3% were by authored by nonhealthcare individuals. The most common content for nonhealthcare authored posts was personal experience (30.67%). Educational content accounted for 4.6% posts and had the greatest average engagement by number of "likes;" 0 educational posts were authored by a healthcare provider.Conclusion: The majority of minimally invasive gynecologic surgery related Instagram posts are regarding endometriosis, are authored by patients, and discuss personal experience. Official healthcare presence was lacking. [ABSTRACT FROM AUTHOR]

Study Objective: Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity.Design: Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis.Setting: Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye.Patients: This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions.Interventions: For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves.Measurements and Main Results: Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031).Conclusion: Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates. [ABSTRACT FROM AUTHOR]

To examine pain improvement after endometriosis surgery and whether it can be predicted by the observed surgical phenotype. Prospective longitudinal survey study. A University hospital. A total of 125 patients completed a preoperative questionnaire (response rate: n = 227 of 277, 81.9%), had surgically confirmed endometriosis (n = 202 of 227), and returned a second postoperative questionnaire (response rate: n = 125 of 202, 61.9%). All patients underwent complete laparoscopic removal of the endometriotic lesions. Surgical phenotype was classified according to the rASRM and #Enzian classification. The intensity of 5 specific pain symptoms was questioned by postal paper-pencil questionnaires with a numerical rating scale (0–10) both preoperatively (3.01 ± 2.72 months before surgery) and one year after surgery (12.62 ± 1.59 months). A postoperative pain improvement score was computed (postoperative pain—preoperative pain) for each specific pain symptom (0–10) and for the overall/global pain sum score (0–50). The mean intensity of all pain scores was lower postoperatively as compared with preoperatively (p <.0001). A statistically significant weak correlation was observed between the surgical phenotype "rectovaginal endometriosis" and postoperative improvement of dyspareunia (r =.265; p =.003). The other 11 hypothesized correlations between surgical phenotype and postoperative improvement of pain intensity failed to reach statistical significance. Clinicians can inform patients that surgery is effective in reducing endometriosis-related pain symptoms and the overall/global pain scores at 12 months postoperatively. From our data, we can conclude that patients with rectovaginal endometriosis might benefit the most from the reduction of their sexual pain. On the basis of these results, we could suggest that deep dyspareunia (even if present as an isolated symptom) might be a valid indication for surgery. Further research could explore the association between a certain surgical phenotype and more detailed assessments of sexual functioning, as well as explore whether feedback from the surgeon on expected pain improvement affects patient-reported outcomes. [ABSTRACT FROM AUTHOR]

To highlight a case where a nephroureterectomy and partial bladder cystectomy needed to be done due to endometriosis. A video article demonstrating a case study and the surgical management. Ureteral endometriosis is a complex form of endometriosis [1]. If left untreated, the ureter can become significantly compressed leading to hydroureter, hydronephrosis and complete loss of kidney function [2]. This is a case of a 29-year-old patient with pelvic pain and cyclical rectal bleeding. Further investigation showed significant left hydronephrosis and almost complete loss of left kidney function (8% on renogram). MRI revealed endometriosis involving the posterior bladder wall and distal left ureter, a large full-thickness sigmoid nodule and a large left endometrioma. The patient underwent a robotic-assisted left nephroureterectomy, partial cystectomy (bladder), excision of pelvic endometriosis and sigmoid resection. This procedure was performed jointly with the gynecologist, urologist, and colorectal surgeon and the SOSURE technique was employed [3]. The specimen (left kidney, whole length of ureter and bladder wall around ureteric orifice) was removed en-bloc through a small 3cm extension of the umbilical incision. As the distance between the sigmoid nodule and the anal verge was 35cm, which was above the limit of the transanal circular stapler, a limited resection was performed over a discoid excision. The patient made a good recovery postoperatively. Ureteral endometriosis is an indolent and aggressive condition which can lead to silent kidney loss. It is essential that hydronephrosis and hydroureter is ruled out in cases with deep endometriosis. Isolated hydronephrosis should also prompt a suspicion for endometriosis. [Display omitted] [ABSTRACT FROM AUTHOR]

To assess long-term urinary function for women having laparoscopic surgery for endometriosis. Institutional Review Board-approved nested cohort study within a larger randomized controlled trial assessing urinary function following any benign laparoscopy for gynecological presentations. Two tertiary-level university-affiliated hospitals. Women with histologically confirmed endometriosis within the randomized controlled trial between April 2012 and November 2019, where baseline urinary function was determined. Women with histologically confirmed endometriosis were contacted between February and October 2020, and urinary function was re-assessed. Urinary function was assessed using validated questionnaires across the domains of filling, voiding, incontinence, and quality of life determined distant from surgery. Higher scores correlated with a greater severity of symptoms. From 518/711 (72.9%) women with histologically confirmed endometriosis, 289/518 (55.8%) consented to the nested study. At a mean of 50 months (range 12–103 months) post-operatively, 35 participants (12.1%) had sought treatment for bladder symptoms, and 81 participants (28.0%) reported at least one urinary tract infection since their index surgery. There was a significant worsening of symptoms for filling, voiding, incontinence, and quality of life pre-operative to post-operatively (2.27 vs 3.32, 0.93 vs 2.02, 1.06 vs 2.32, 0.83 vs 2.13 respectively, p <.001). There was no statistically significant difference in urinary questionnaire scores in participants with and without uterovesical endometriosis. There was no statistically significant difference in any parameter when comparing any revised American Society of Reproductive Medicine (rASM) stage of endometriosis. Participants who had post-operative urinary retention reported a higher mean voiding score than those who did not (3.24 vs 1.94, p =.017), while participants with post-operative urinary tract infection reported a higher mean frequency score than those who did not (5.17 vs 3.24, p =.016). This study suggests a decline in urinary function over time following laparoscopic surgery for endometriosis that is not dependent on the severity or location of the disease. [ABSTRACT FROM AUTHOR]

Objective: The aim of this systematic review and meta-analysis was to perform an updated analysis of the literature in regard to the surgical management of minimal to mild endometriosis. This study evaluated women of reproductive age with superficial endometriosis to determine if the results of surgical excision compared with those of ablation in improved pain scores postoperatively.Data Sources: The following databases were searched from inception to May 2020 for relevant studies: Cochrane Central Register of Controlled Trials, PubMed (MEDLINE), Ovid (MEDLINE), Scopus, and Web of Science.Methods Of Study Selection: From our literature search, a total of 2633 articles were identified and screened. Ultimately, 4 randomized controlled trials were selected and included in our systematic review. The combined total number of subjects was 346 from these 4 studies, with sample sizes ranging from 24 to 170 participants. Data from 3 of the included studies were able to be compared and analyzed for a meta-analysis. The primary outcome was reduction in the visual analog scale (VAS) score for endometriosis-associated pain (dysmenorrhea, dyschezia, and dyspareunia), with follow-up time ranging from 6 to 60 months postoperatively.Tabulation, Integration, and Results: Data extracted from each study included the mean reduction in the VAS score from baseline. A random-effects model was used owing to significant heterogeneity across the studies. Statistical analyses were performed using Review Manager 5.3 software (Cochrane Collaboration, London, United Kingdom). The meta-analyses showed no significant differences between the excision and ablation groups in the mean reduction in VAS scores from baseline to 12 months postoperatively for dysmenorrhea (mean difference [MD] -0.03; 95% confidence interval [CI], -1.27 to 1.22; p = .97), dyschezia (MD 0.46; 95% CI, -1.09 to 2.02; p = .56), and dyspareunia (MD 0.10; 95% CI, -2.36 to 2.56; p = .94). In addition, there were no significant differences between the excision and ablation groups in mean VAS scores at the 12-month follow-up and beyond for dysmenorrhea (MD -0.11; 95% CI, -2.14 to 1.93; p = .92), dyschezia (MD 0.01; 95% CI, -0.70 to 0.72; p = .99), and dyspareunia (MD 0.34; 95% CI, -1.61 to 2.30; p = .73).Conclusion: On the basis of the data from our systematic review and pooled meta-analysis, no significant difference between laparoscopic excision and ablation was noted in regard to improving pain from minimal to mild endometriosis. However, to make definitive conclusions on this topic, larger randomized controlled trials are needed with longer follow-up. [ABSTRACT FROM AUTHOR]

Objective: To establish an endometrioma treatment paradigm (decision tree) in the treatment of an ovarian endometrioma through the review of current literature.Data Sources: A thorough literature search, including PubMed, Google Scholar, and the Cochrane Library, was performed from April 2020 to July 2020. The review was completed by using the following keywords: METHODS OF STUDY SELECTION: Articles published in English that addressed the endometrioma in regard to the following were included: (1) diagnosis, (2) treatment of pain on the basis of size and/or surgical intervention, (3) treatment of fertility on the basis of size and/or surgical intervention, (4) surgical technique, (5) in vitro fertilization success on the basis of size and/or surgical intervention, (6) risk of rupture at the time of egg retrieval, (7) impact on the antimüllerian hormone and antral follicle count postsurgery, and (8) impact on implantation.Tabulation, Integration, and Results: Fifty-six articles were included in this systematic review. While conducting this literature review, several themes were noted. In general, the literature on the ovarian endometrioma seems to be homogeneous in regard to imaging the endometrioma, excision rather than desiccation for an endometrioma ≥3-cm causing pain and/or infertility, minimal use of bipolar energy at the time of ovarian surgery, and risk of severe infection secondary to inadvertent rupture of cysts during egg retrieval. Conversely, studies on the ovarian endometrioma are much more heterogeneous in terms of surgery and assisted reproductive technology, that is, whether surgery should be performed. Certainly, an endometrioma ≥5-cm should be excised before assisted reproductive technology. Moreover, it seems that the antral follicle count and implantation may be enhanced with surgery.Conclusion: By completing an extensive literature review, an easy-to-use algorithm for the diagnosis, evaluation, and treatment of endometriomas was developed to help clinicians in their treatment of patients with endometriosis in the short and long terms. [ABSTRACT FROM AUTHOR]