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Introduction: Endometriosis is a chronic disease that affects up to 190 million women and those assigned female at birth and remains unresolved mainly in terms of etiology and optimal therapy. It is defined by the presence of endometrium-like tissue outside the uterine cavity and is commonly associated with chronic pelvic pain, infertility, and decreased quality of life. Despite the availability of various screening methods (e.g., biomarkers, genomic analysis, imaging techniques) intended to replace the need for invasive surgery, the time to diagnosis remains in the range of 4 to 11 years., Aims: This study aims to create a large prospective data bank using the Lucy mobile health application (Lucy app) and analyze patient profiles and structured clinical data. In addition, we will investigate the association of removed or restricted dietary components with quality of life, pain, and central pain sensitization., Methods: A baseline and a longitudinal questionnaire in the Lucy app collects real-world, self-reported information on symptoms of endometriosis, socio-demographics, mental and physical health, economic factors, nutritional, and other lifestyle factors. 5,000 women with confirmed endometriosis and 5,000 women without diagnosed endometriosis in a control group will be enrolled and followed up for one year. With this information, any connections between recorded symptoms and endometriosis will be analyzed using machine learning., Conclusions: We aim to develop a phenotypic description of women with endometriosis by linking the collected data with existing registry-based information on endometriosis diagnosis, healthcare utilization, and big data approach. This may help to achieve earlier detection of endometriosis with pelvic pain and significantly reduce the current diagnostic delay. Additionally, we may identify dietary components that worsen the quality of life and pain in women with endometriosis, upon which we can create real-world data-based nutritional recommendations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Balogh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Endometriosis is often described as a progressive disease beginning with menarche and menstrual bleeding. However, this is controversial, as the origin of the disease remains unknown. The objective of this study was to investigate the association between the severity of endometriosis and age at initial diagnosis., Material and Methods: This prospective multicenter cohort study included 964 patients, newly and histologically diagnosed with endometriosis during laparoscopic treatment. The main outcome measures were diagnostic lesions with staging according to rAFS (revised American Fertility Society) scores, intensity of pain based on VAS (Visual Analog Scale) scores and quality of life from SF-36 questionnaire results. Age was treated as a categorical variable. Univariate and multivariable analyses (linear and multinomial ordinal) were conducted taking into account two by two multiple comparisons. The results were expressed with effect sizes and 95 % confidence intervals., Main Findings: No significant association between age and rAFS stage was found (p = 0.053). The percentage of patients with a deep nodule ≥ 2 cm was respectively 20 %, 25 %, 21 %, 18 % and 9 % for patients aged ≤ 25, 26-30, 31-35, 36-40 and >40 years respectively (p = 0.005). For dysmenorrhea, 64 %, 61 %, 54 %, 51 % and 32 % of patients aged ≤25, 26-30, 31-35, 36-40 and >40 years respectively reported a VAS score of ≥7 (p ≤ 0.001)., Conclusion: Prospective data obtained in patients newly diagnosed with endometriosis, revealed that the rAFS score is not related to patient age, and that the percentage of patients with a nodule ≥ 2 cm and severe dysmenorrhea did not increase with age. These percentages were significantly lower in patients aged > 40., (Copyright © 2024. Published by Elsevier Masson SAS.)

Importance: Preoperative mapping of deep pelvic endometriosis (DPE) is crucial as surgery can be complex and the quality of preoperative information is key., Objective: To evaluate the Deep Pelvic Endometriosis Index (dPEI) magnetic resonance imaging (MRI) score in a multicenter cohort., Design, Setting, and Participants: In this cohort study, the surgical databases of 7 French referral centers were retrospectively queried for women who underwent surgery and preoperative MRI for DPE between January 1, 2019, and December 31, 2020. Data were analyzed in October 2022., Intervention: Magnetic resonance imaging scans were reviewed using a dedicated lexicon and classified according to the dPEI score., Main Outcomes and Measures: Operating time, hospital stay, Clavien-Dindo-graded postoperative complications, and presence of de novo voiding dysfunction., Results: The final cohort consisted of 605 women (mean age, 33.3; 95% CI, 32.7-33.8 years). A mild dPEI score was reported in 61.2% (370) of the women, moderate in 25.8% (156), and severe in 13.1% (79). Central endometriosis was described in 93.2% (564) of the women and lateral endometriosis in 31.2% (189). Lateral endometriosis was more frequent in severe (98.7%) vs moderate (48.7%) disease and in moderate vs mild (6.7%) disease according to the dPEI (P < .001). Median operating time (211 minutes) and hospital stay (6 days) were longer in severe DPE than in moderate DPE (operating time, 150 minutes; hospital stay 4 days; P < .001), and in moderate than in mild DPE (operating time; 110 minutes; hospital stay, 3 days; P < .001). Patients with severe disease were 3.6 times more likely to experience severe complications than patients with mild or moderate disease (odds ratio [OR], 3.6; 95% CI, 1.4-8.9; P = .004). They were also more likely to experience postoperative voiding dysfunction (OR, 3.5; 95% CI, 1.6-7.6; P = .001). Interobserver agreement between senior and junior readers was good (κ = 0.76; 95% CI, 0.65-0.86)., Conclusions and Relevance: The findings of this study suggest the ability of the dPEI to predict operating time, hospital stay, postoperative complications, and de novo postoperative voiding dysfunction in a multicenter cohort. The dPEI may help clinicians to better anticipate the extent of DPE and improve clinical management and patient counseling.

Endometriosis is a chronic disease in which lesions resembling endometrial tissue are found outside the uterus, mainly in the pelvis or abdomen. It may affect 10% of women of childbearing age. It is the cause of a significant alteration in quality of life and a major cost to the health system. Few research teams are working on this subject, and its pathophysiology is still poorly understood. This article proposes avenues of reflection for research on endometriosis in France, notably based on the mobilization of related scientific communities (involved in cancer, development, epigenetics, and neurosciences research studies)., (© 2022 médecine/sciences – Inserm.)

Objective: To demonstrate the advantages of the fluorescence-guided surgery using indocyanine green (ICG) in the management of deep endometriotic nodules toward more complete and safe excision of the disease in cases when rectal shaving is performed., Design: Surgical video demonstrating the result of the application of a fluorescent dye (ICG) during deep endometriosis surgery. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and the patient cannot be identified., Setting: Tertiary-care university hospital., Patient(s): The patient underwent rectal shaving due to a deep endometriotic nodule located at the level of the rectovaginal septum., Intervention(s): The procedure started with exploration of the lesion and the anatomical structures. The nodule is approached using the "reverse technique." As the nodule is infiltrating the vagina, complete resection of the posterior vaginal wall is performed. At the start of the rectal shaving, ICG is injected and its fluorescence effect is used to provide navigation for the surgeon during the excision. At the end of the procedure the vascularization of the bowel wall and the vagina are evaluated with the help of the ICG., Main Outcome Measure(s): Visual assessment and distinction between the borders of the endometriotic nodule and the rectal wall as a result of the fluorescence effect of the ICG., Result(s): After injection of the ICG, the borders of the healthy rectum are delineated and a clear distinction between the endometriotic nodule and the bowel wall is demonstrated. In addition, the effect of the ICG was used to assess the vascularization of the infiltrated organs (vagina and rectal wall)., Conclusion(s): Deep endometriosis at the level of the rectum usually represents a solid fibrotic nodule. The fibrosis plays a major role in the development of the disease. Indocyanine green is a fluorescent contrast agent, routinely used in a wide range of specialties to assess the blood supply and vascularization of different organs and tissues. Based on the fibrotic nature of the disease, the fluorescence could facilitate the distinction between healthy vascularized tissues and the endometriotic nodule. In the presented case, using ICG, a clear difference between the nodule and the rectum is demonstrated, as well as the vascularization of the bowel wall and the vagina. The implementation of ICG during endometriosis surgery could provide navigation for the surgeon toward a more complete and safer treatment of the disease, reducing the risk of complications and reinterventions. Additional studies are needed to further evaluate ICG fluorescence-guided surgery in the management of deep endometriosis., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: Laparoscopic termino-terminal ureteral anastomosis has all the advantages of a minimally invasive approach in addition to the treatment of the pathologic condition [1]. Ureteral deep endometriosis can lead to severe consequences, such as hydroureteronephrosis and renal failure [2,3]. The main objective of this video is to present our surgical strategy and technique for cases of ureteral deep infiltrating endometriosis, which could help surgeons to understand and perform this surgery in a safe way in patients., Design: Video demonstration of the technique., Setting: French university tertiary-care hospital., Interventions: This video presents a termino-terminal laparoscopic ureteral anastomosis and shows our team's strategy for surgical treatment in a 42-year-old woman with deep infiltrating ureteral left endometriosis, with consequent stenosis and left hydroureteronephrosis. A full resection of the endometriotic ureteral nodule was performed, followed by a termino-terminal anastomosis of the ureter. The use of intravenous indocyanine green to assess the postanastomotic ureteral perfusion and its risk of leakage or fistula are described in the video [2-5]., Conclusion: Ureteral endometriosis can lead to severe consequences, and the surgical treatment can be difficult and, most times, incomplete. This video gives a detailed example of the strategy our team used to perform a termino-terminal ureteral laparoscopic anastomosis in a structured way., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

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

Study Objective: To demonstrate the application of the so-called reverse technique to approach deep infiltrating endometriosis nodules affecting the retrocervical area, the posterior vaginal fornix, and the anterior rectal wall. In Video 1, the authors describe the complete procedure in 10 steps in order to standardize it and facilitate the comprehension and the reproduction of such a procedure in a simple and safe way., Design: A case report., Setting: A private hospital in Curitiba, Paraná, Brazil., Patient: A 32-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 2.4-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the muscularis 10 cm far from the anal verge., Interventions: Not applicable., Measurements and Main Results: Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10-mm trocar at the umbilicus for the 0 degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using a harmonic scalpel (step 5). The anterior rectal wall was closed using X-shaped stitches of 3-0 polydioxanone suture in 2 layers (step 6). The specimen was extracted through the vagina (step 7). The posterior vaginal fornix was reattached to the retrocervical area using X-shaped sutures of 0 poliglecaprone 25 (step 8). A pneumatic test was performed to check the integrity of the suture (step 9). At the end of the procedure, hemostasis was controlled, and the abdominal cavity was irrigated using Lactate ringer solution (step10)., Conclusion: The laparoscopic reverse technique is an alternative approach to face retrocervical or rectovaginal nodules infiltrating the anterior rectal wall. In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed within the traditional technique. This enables the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall because of the increased mobility of the bowel. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection)., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To investigate predictive factors for change in quality of life (QOL) between pre- and postoperative periods in patients with endometriosis., Design: A prospective and multicenter cohort study., Setting: Five districts including a tertiary referral center and private and general public hospitals., Patients: Nine hundred eighty-one patients aged 15 to 50 years underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012., Interventions: Laparoscopic treatment for endometriosis. All revised American Fertility Society stages were included., Measurements and Main Results: QOL was evaluated using the 36-Item Short Form Survey questionnaire. Factors influencing changes for each 36-Item Shorty Form Survey domain score between t0 (before surgery) and 1 year after surgery were predicted on the basis of univariate and multivariable analyses. The effect size (ES) method was used to measure changes in QOL. Univariate analysis revealed that 47% of stage IV endometriosis patients presented an improvement in the postoperative Physical Component Summary (PCS) score (ES ≥ 0.8) versus 26%, 31.3%, and 27.5% of patients with stage I, II, and III, respectively (p <.001). Forty-four percent and 38% of patients with chronic pelvic pain (CPP) presented an improvement in postoperative PCS and Mental Component Summary scores (ES>0.8) versus 23% and 24% of patients without CPP, respectively (p <.001). Multivariable analysis (ES > 0.8 vs ES < 0) revealed that women with CPP were more likely to experience greater improvement in postoperative PCS and Mental Component Summary scores than women without CPP (relative risk [RR] = 2.7; 95% confidence interval [CI], 1.7-4.4; p <.001 and RR = 1.8; 95% CI, 1.2-2.8; p <.01, respectively). Accordingly, fertile patients were more likely to show higher rates of improvement in the postoperative PCS score than infertile patients (RR = 1.8; 95% CI, 1.1-3.1; p <.05)., Conclusion: Patients presenting with severe endometriosis and who experience higher levels of pain are more likely to show improvement in QOL after surgery. CPP is the most significant independent predictive factor for changes in QOL scores., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Laparoscopic cystectomy for endometrioma has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video. We described the surgery in 10 steps, which could help to make this procedure easier and safer., Design: Step-by-step video demonstration of the technique., Setting: A French university tertiary care hospital., Intervention: Two standardized laparoscopic cystectomy were recorded to realize the video. The local institutional review board ruled that approval was not required because the video describes a technique and does not report a clinical case. This video presents a systematic approach to cystectomy for endometrioma clearly divided into 10 steps: (1) preoperative evaluation [1]; (2) diagnosis and exploration [2]; (3) adhesiolysis, mobilization of the ovary; (4) cyst rupture, exposition of the entry site; (5) identification of the cleavage plan; (6) endometrioma easy dissection; (7) endometrioma difficult dissection; (8) hemostasis, reconstruction of the ovary [3]; (9) exploration of the ovarian fossa; and (10) washing, extraction of the cyst [3,4]., Conclusion: Standardization of laparoscopic cystectomy for endometrioma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure easier to realize. Moreover, the standardization of the surgical techniques may reduce the learning curve., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Laparoscopic resection of diaphragmatic endometriosis has the advantages of a minimally invasive approach [1]. The standardization and description of the technique are the main objectives of this video. We described the procedure in 10 steps to make it easier and safer., Design: A step-by-step video demonstration of the technique (Video 1)., Setting: A French university tertiary care hospital., Patients: Patients with diaphragmatic endometriosis confirmed by magnetic resonance imaging [2]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case., Intervention: There are no guidelines on the surgical treatment of diaphragmatic endometriosis [3]. We propose a laparoscopic approach using a right lateral access with the patient in the left lateral decubitus position [4]., Measurements and Main Results: This video presents the procedure divided into the following 10 steps: step 1, set up; step 2, patient position; step 3, installation of the trocars; step 4, releasing the liver; step 5, exposure of the diaphragmatic endometriosis; step 6, making a diaphragmatic defect; step 7, exploring the thoracic cavity; step 8, resection of diaphragmatic endometriosis; step 9, inserting the suction catheter; and step 10, closing the diaphragmatic defect., Conclusion: Standardization of laparoscopic resection of diaphragmatic endometriosis could make this procedure easier and safer to perform. The left lateral decubitus position helps to have complete exposure of the right diaphragmatic muscle and endometriosis. We presented 10 steps to help perform each part of the surgery in logical sequence, making the procedure ergonomic and easier to adopt and learn [5]. Standardization of laparoscopic techniques could help to reduce the learning curve., (Copyright © 2019. Published by Elsevier Inc.)

Study Objective: To assess the impact of surgical treatment of endometriosis on quality of life and pain over a 3-year period of postoperative follow-up., Design: Prospective and multicenter cohort study (Canadian Task Force classification II-2)., Setting: Five districts including a tertiary referral center and private and general public hospitals., Patient: Patients (n = 981), aged 15 to 50years, underwent laparoscopic treatment (preferred approach) for endometriosis between January 2004 and December 2012., Intervention: Laparoscopic treatment for endometriosis. All revised American Fertility Society stages were included., Measurements and Main Results: The mean visual analog scale score for dysmenorrhea fell from 5.3 ± 3.7 (time 0) to 2.6 ± 3.3 at 6 months, and 2.3 ± 3.3 at 36 months of follow-up (p <.001). Mean visual analog scale scores for chronic pelvic pain and dyspareunia fell from 2.6 ± 3.5 and 2.7 ± 3.2, respectively, before surgery to 1.4 ± 2.5 and 1.1 ± 2.2 at 6 months and then 1.3 ± 2.5 and 1.2 ± 2.3 at 36 months of follow-up. The Short Form 36-Item survey analysis revealed the greatest increases linked to physical domains (i.e., bodily pain and role limitations) from 54.6 ± .9 and 63.3 ± 1.3, respectively, at time 0 to 74.4 ± .9 and 81.9 ± 1.1 at 6 months of follow-up (p <.001), with scores subsequently remaining stable. Among mental domains the most favorable results involved social functioning and role limitations due to emotional problems, which increased from 66 ± .8 and 65.7 ± 1.3 at time 0 to 75.6 ± .9 and 77.4 ± 1.3 at 6 months of follow-up, respectively (p <.001), with scores remaining stable over time., Conclusions: Surgical treatment of endometriosis improves pelvic and sexual pain postoperatively in many women with endometriosis. Improvement later plateaus and remains stable, allowing patients to experience the beneficial effects over a period of years., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life., Materials and Methods: A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210)., Results: A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients., Conclusion: For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales., Competing Interests: The authors have declared that no competing interests exist.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: Endometriosis symptoms may have a negative effect on health-related quality of life (HRQoL). Analyses of open comments are known to be a key source of information and support. The authors aimed to analyse open comments associated with a validation scale study, in order to ascertain whether the questionnaires allowed an adequate exploration of patient preoccupations and in so doing define important quality of life themes not assessed in HRQoL scales., Material and Methods: Analysis of open comments, following two questionnaires (SF-36 and EHP-30) as part of a national study evaluating the EHP-30, was performed. Questionnaires were distributed online, via a link to the RedCap Internet platform. The association EndoFrance, a support group for endometriosis patients, notified women of the launching of the study. Women were asked to complete the questionnaire and had the opportunity to comment. Comments were gathered, coded systematically, and categorised by theme., Results: Of the 1156 women who responded to the questionnaire, 913 (79.0%) declared having a confirmed surgical diagnosis of endometriosis, and 265 comments were analysed. Comments were classified in 20 themes. Correspondence between the themes and items for both questionnaires and the open comments was investigated for all topics, including those non-addressed by the questionnaires. 8 themes are not mentioned in both questionnaires, 9 themes are covered by EHP-30, two by SF-36 and only one by both., Conclusion: Anonymous data collection and subsequent analysis proves to be an effective and practical way of obtaining patient opinion on their pathology. Analysis of comments may provide additional and useful information to the classical HRQoL Scale., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objective: To report and visually demonstrate the feasibility of using indocyanine green (ICG) in endometriosis surgery and to discuss potential benefits., Design: ICG fluorescent imaging has been validated to assess tissue perfusion with clinical use in many medical fields, including gynecology and digestive surgery, but has not described in endometriosis surgery for bowel assessment. To our knowledge, there is no validated, objective, intraoperative method to assess the vascularity of the operated bowel in endometriosis surgery, a potentially good indicator for postoperative fistula formation. Our center is conducting a registered clinical trial examining the use of ICG to evaluate the bowel vascularization after endometriosis rectal shaving surgery, and the potential role in reducing fistula rates (Institutional Review Board no 2016-002773-35)., Setting: Tertiary university hospital., Patient(s): Three patients undergoing laparoscopic surgery for deep infiltrating endometriosis (DIE) with the use of a rectal shaving procedure., Interventions(s): Patients undergoing laparoscopic surgery for DIE with a rectal shaving procedure were injected with ICG intravenously at the end of endometriosis resection., Main Outcome Measures: Visual assessment of the rectal shaving area was assessed as fluoresced or not with the use of a Likert-type scale (0 = no fluorescence; 4 = very good fluorescence)., Result(s): After ICG injection, all three patients have showed very good fluorescence levels at the rectal shaving area with no adverse reactions. Other uses of ICG are demonstrated throughout the video (vaginal cuff, ureter, and ovary assessment)., Conclusion(s): ICG fluorescent imaging is feasible in endometriosis surgery, and there is an ongoing trial to determine if its use reduces postoperative fistula formation., Clinical Trial Registration Number: NCT03080558., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS)., Methods: We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach., Results: The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III-V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013)., Conclusion: Our results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

In this chapter we have examined the possibilities of screening endometriosis, both in the general population as well as in the target population. We then proposed decision trees, for primary and secondary care. Currently, there is not enough data in the literature to develop or organize a screening test for endometriosis. Screening for endometriosis is not recommended in the general population (level A). There is also no evidence to support systematic screening in a population with genetic risk factors (endometriosis in a relative), or with other clinical risk factors (increased menstrual volume, short cycles, early menarche) (level A). However, it is possible to propose a decision tree for the management of chronic pelvic pain symptoms (dysmenorrhea, dyspareunia, non-menstrual pelvic pain). The search for symptoms suggestive of endometriosis (intense dysmenorrhea [visual analogue scale >7/10, frequent abstention, resistance to level 1 analgesics], infertility) should be systematic. The search for localizing symptoms of deep endometriosis (deep dyspareunia, cyclic defecation pain, cyclic urinary signs) enables to orient the patient to second line evaluation. We propose a decision tree for second and third line evaluations, according to the suspicion and/or the discovery of deep lesions with specific locations, or the suspicion of superficial lesions., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: To evaluate the feasibility and functional urinary and digestive results of nerve sparing techniques in endometriosis surgery., Methods: A research on the medline/pubmed database using specific keywords (nerve sparing, endometriosis, pelvic nerves) identified 7 publications among about 50 whose purpose was to describe the feasibility, the techniques and the functional results of nerve preservation in this indication. Among them there are: 2 uncontrolled retrospective studies, 3 prospective non-randomized studies, a meta-analysis and a review of the literature., Results: Nerve preservation requires a perfect knowledge of the anatomy of the pelvic autonomic system. The laparoscopic approach is preferred by the different authors due to its anatomical advantage. The feasibility of this technique seems to be demonstrated despite certain limitations in the different studies and depending of the retroperitoneal extension of the lesions. When feasible, it is likely to significantly improve postoperative urinary function (urinary retention) compared to a conventional technique. It is observed no difference regarding digestive function., Conclusions: Nerve sparing in this indication is a technique the feasibility of which has been demonstrated and is subject to the topography and extent of the disease. In the absence of invasion or entrapment of pelvic autonomic nerves by endometriosis, this technique improves postoperative voiding function (NP3). During pelvic surgery for endometriosis, it is recommended to identify and preserve autonomic pelvic nerves whenever possible (GradeC)., (Copyright © 2018. Published by Elsevier Masson SAS.)

Based on the best evidence available, we have provided guidelines for clinical practice to target the nature of endometriosis as a disease, the consequences of its natural history on management, and the clinical and imaging evaluation of the disease according to the level of care (primary care, specialized or referral). The frequency of endometriosis is unknown in the general population; endometriosis requires management when it causes symptoms (pain, infertility) or when it affect the function of an organ. In the absence of symptom, there is no need for follow-up or screening of the disease. Endometriosis may be responsible for various pain symptoms such as severe dysmenorrhea, deep dyspareunia, painful bowel movements or low urinary tract signs increasing with menstruation, or infertility. A careful evaluation of the symptoms and their impact on the quality of life should be made. The first-line examinations for the diagnosis of endometriosis are: digital examination and pelvic ultrasound. The second-line examinations are: the pelvic exam by an expert clinician, the pelvic MRI and/or the transvaginal ultrasound by an expert. MRI and ultrasound carrying different and complementary information. Other examinations may be considered as part of the pre-therapeutic assessment of the disease in case of specialized care. Diagnostic laparoscopy may be suggested in case of clinical suspicion of endometriosis whereas preoperative examinations have not proved the disease, it must be part of a management plan of endometriosis-related pain or infertility. During management, it is recommended to give comprehensive information on the different therapeutic alternatives, the benefits and risks expected from each treatment, the risk of recurrence, fertility, especially before surgery. The information must be personalized and take into account the expectations and preferences of the patient, and accompanied by an information notice given to the patient., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: Optimal surgical treatment of rectovaginal endometriosis remains a controversial topic. The objective of this study was to evaluate long-term postoperative outcomes after rectal shaving or colorectal resection for rectovaginal endometriosis., Material and Methods: 195 patients underwent surgery (172 managed by shaving, 23 by colorectal resection) between January 2000 and June 2013 for rectovaginal endometriosis (>2 cm) involving at least the serosa of the rectum. Primary outcome measures were pain and fertility. Secondary outcome measures were complications, recurrence rates and quality of life., Results: Mean follow-up was 60 ± 42 months in the shaving group and 67 ± 47 months in the resection group. The mean VAS score for pelvic pain between the pre and postoperative period decreased from 5.5 ± 3.5 (shaving group) and 7.3 ± 2.9 (resection group) to 2.3 ± 2.4 (p < 0.001) and 2.0 ± 1.8 (p < 0.001), respectively. For dysmenorrhea, the mean baseline VAS score fell postoperatively from 7.7 ± 2.8 (shaving group) and 8.2 ± 2.6 (resection group) to 3.3 ± 2.9 (p < 0.001) and 2.7 ± 2.7 (p < 0.001), respectively. Pregnancy rates were 73% for shaving and 69% for resection. Major complications occurred in 4% of patients in the shaving group and in 26% in the resection group (p = 0.001). Thirteen patients (7.6%) from the shaving group and none from the resection group were reoperated for suspicion of endometriosis recurrence (p = 0.37). Postoperative quality of life scores revealed no differences between the two groups., Conclusion: Our study demonstrates that rectal shaving, when feasible for rectovaginal nodule (>2 cm) infiltrating the digestive serosa, has equal impact on pain and pregnancy rates compared with colorectal resection at long-term follow-up, with low complication and favorable pregnancy rates., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Preoperative evaluation: clinical examination, and research for associated lesions. Laparoscopic approach. Cystectomy: gold standard, conformed to the endometrioma pathophysiology (3 zones). Laser CO 2 Plasmajet ® vaporisation: important data lead to legitimate utilisation. Haemostasis: be patient! Use of bipolar energy sparingly. Look for other endometriotic lesions, and systematic treatment. Preoperative medical treatment not always useful. Postoperative treatment: decrease recurrence. Especially for patients with no immediate pregnancy desire., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objective(s): To compare the most used types of surgical techniques, for peritoneal lesions management, to Plasmajet® (PJ), in term of healing and post-operative adhesion., Study Design: Prospective, experimental animal study. Female pigs (Landrace/Large White-Pietran) weighing 20-25kgs were used for the experiments. Eleven areas of 2cm 2 were treated on each lateral side of the peritoneal wall. Two areas of control, 2 of surgical resection with scissors, 2 of bipolar coagulation, 2 of Plasmajet® 10 low (PJ10L, adjustment of the Plasmajet®) used in contact with the peritoneum, 2 of PJ10L used at 3-5mm from the peritoneum, 2 of PJ10L used at 10mm, 2 of PJ used at 10 High (PJ10H) close to the peritoneum, 2 of PJ10H used at 3-5mm, 2 of PJ10H used at 10mm, 2 of PJ used at 40 Low (PJ40L) used at 3-5mm, 2 of PJ40L used at 10mm from the peritoneum., Results: For each 2 areas, one was removed immediately for histological analysis. All animals were reoperated 14days later to evaluate macroscopic healing, adhesion score, histological inflammation and mesothelialization. Immediate histological analysis shows that in every treated area the peritoneum was completely vaporized, coagulated or removed. After resection, the healing was macroscopically perfect and there was no adhesion, as in the control area. After bipolar coagulation in half of cases there was adhesion. There was no adhesion after treatment by Plasmajet® 10 low used at 10mm from the peritoneum., Conclusion: Surgical resection leads to perfect healing, and no adhesion formation. The use of Plasmajet® 10 low used at 10mm from the peritoneum could be an alternative to resection, because it allows complete superficial destruction, with a low rate of adhesion. Further study is required to explore and assess fully the potential of this device., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: The objectives were to evaluate the acceptability, reliability and validity of the cross-cultural adaptation of the Endometriosis Health Profile-30 instrument into French., Methods: This cross-sectional study was conducted between July and October 2015. We created an online link (REDCap platform) with the questionnaires. An endometriosis patients association spread the link on its website and with social networks. The translation and cultural adaptation of the EHP-30 was performed according to guidelines. Psychometric evaluation included data completeness, score distributions, floor and ceiling effects, factor analysis, internal consistency, item-total correlations corrected for overlap, convergent validity and test-retest reliability., Results: The study included 913 women with endometriosis. In our results, data completeness was excellent. No floor effects were found and one ceiling effect was observed for the 'Infertility' scale. The highest means scores were found for 'Control and powerlessness' and 'Infertility' scales. Factor analysis confirmed the structure of the original EHP-30 questionnaire. Internal consistency was good (Cronbach's α range=0.72-0.96). The correlations of similar scale scores between EHP-30 and SF-36 were all significant (Spearman correlation coefficients ranging from -0.52 to -0.75). Test-retest reliability was good (intraclass correlation coefficients range=0.51-0.98)., Conclusion: The French version of the EHP-30 is an acceptable, reliable and valid instrument for measuring health-related quality of life in women with endometriosis., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objective: The study was performed to evaluate whether trauma is an initial event of development of endometriosis., Method: Using Medline database from January 1960 up to December 2014, a systematic review was made of all published studies using the keywords trauma, healing, injury, infection, hyperperistaltism, stretch and endometriosis, adenomyosis and trauma. Studies and review articles written in French and/or in English related to the topic were included and reviewed independently by two authors., Results: The role of trauma is well-established for endometriotic lesions diagnosed in surgical scars. Various traumas including delivery, uterine curettage or incision, intraperitoneal hemorrhage, or occult pelvic inflammatory diseases could be involved to explain other localizations of the disease. Many data suggested that the healing process, particularly growth factors and the associated estrogen production, may facilitate the implantation and the growth of ectopic endometrial cells. After the initial, a traumatic event, the phenotype of the disease would depend on the tissue in which the endometriotic lesion grows., Conclusions: The present literature review may support a potential role of a trauma as an initial event of endometriosis., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

The Purpose of the Study: To study preoperative thresholds of the SF-36 components above which we can predict a high risk of failure in order to improve the quality of life after surgery for patients with minimal endometriosis., Material and Methods: Design: prospective and multicenter observational study between February 2004 and 2011., Patients: 167 patients with operated minimal endometriosis., Setting: for the Physical Component Summary (PCS) or the Mental Component Summary (MCS) subscales of the SF-36 questionnaire, an improvement defined by an increase of 5 points., Intervention: evaluation by the SF-36 questionnaire the week before and one year after surgery., Measurement and Main Results: Success of surgery measured by an improvement in both components. We found significantly different initial variables between patients with improvement and those without: initial MCS score (P=0.0003), initial PCS score (P<0.0001) and dyspareunia (P=0.004). Multivariate analysis revealed only two significant variables. Initial MCS higher than 40 (OR=4.6) and initial PCS higher than 50 (OR=10.6) are risk factors for failure of improvement after surgery., Conclusion: Surgery is seldom a good treatment for improving QOL in minimal endometriosis. We set two thresholds for SF-36, 50 for PCS and 40 for MCS: above there is a very high risk of failure (86% of failure in our population). Under, the risk of failure remains high (54.3%)., Canadian Task Force Classification of Study Design: Evidence obtained from well-designed cohort or case-control studies, preferably from more than one center or research group., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Study Objective: To assess the outcomes and complications of laparoscopic ureteroneocystotomy in gynecologic surgery., Design: We retrospectively reviewed all medical records of patients who underwent ureteroneocystostomy between April 2008 and May 2012., Design Classification: Retrospective case series study., Setting: A university tertiary care hospital., Patients: Nine patients underwent ureteroneocystostomy: 3 patients had ureteral endometriosis stenoses; and 6 patients had iatrogenic ureter injuries., Interventions: All procedures were performed laparoscopically. The ureterovesical re-implantation was unilateral in 8 cases and bilateral for 1 patient., Measurements and Main Results: The mean operating time was 226.7 min (range, 120-480). Average blood loss was 114.4 mL (range, 30-400). The mean duration of the in-dwelling catheter was 10.4 days (range, 7-21); the average hospital stay was 12.6 days (range, 6-26). The mean duration of the ureteral double J stent was 7.8 weeks (range, 6-16). One patient was re-operated for vaginal and laparoscopic drainage of a pelvic abscess on the sixth postoperative day. The median follow-up time was 20.8 months (range, 9-36), No patient had stenosis or breakdown of a suture line., Conclusions: Our series confirms the feasibility and the effectiveness of laparoscopic ureteroneocystostomy. This minimally invasive approach, which avoids laparotomy, requires a multidisciplinary team., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain., Methods: A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336)., Results: A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID., Conclusions: When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response., (© The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Benign ovarian tumors can be separated in three groups: teratoma, unilocular cyst and endometrioma. Laparoscopy should always be preferred for the surgical approach. Before menopause, conservative treatment should be preferred apart from previous oncologic history (breast and ovary). After menopause, the surgical approach (conservative or radical) should be discussed on case-by-case basis. Concerning teratoma, follow-up is one of the options for small cyst (less than 4 to 6 cm). For larger cyst, surgery seems to be justified but there is no definitive argument for this attitude. Concerning unilocular cyst, hormonal treatment or ultrasound-guided puncture are not recommended. For symptomatic patient, laparoscopic surgery is the gold standard. For asymptomatic patient, there is no definitive argument for systematic surgery. There is no justification for systematic ultrasound follow-up. For cyst larger than 10 cm, the data in the literature are very poor and surgery can be proposed. Concerning endometrioma, there isn't strong data that allows preferring one treatment (surgical, medical, follow-up) over another. Preoperative medical treatment is not recommended. Stripping technique is the gold standard. Hormonal postoperative treatment is recommended (if there is no desire for pregnancy)., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Study Objective: To assess recurrence and pregnancy rates in women with ovarian endometrioma treated via ablation using plasma energy., Design: Retrospective non-comparative pilot study including 55 patients treated during 28 months, with prospective recording of data (Canadian Task Force classification II-2)., Setting: Tertiary referral center., Patients: Fifty-five consecutive women with pelvic endometriosis in whom ovarian endometriomas were managed solely via ablation using plasma energy. The minimum follow-up was 1 year., Intervention: Endometrioma ablation using plasma energy., Measurements and Main Results: Information was obtained from the database of the North-West Inter Regional Female Cohort for Patients with Endometriosis, based on self-questionnaires completed before surgery, surgical and histologic data, and systematic recording of recurrences, pregnancy, and symptoms. Recurrences were assessed using pelvic ultrasound examination. Mean (SD) follow-up was 20.6 (7.2) months (range, 12-39 months). In 75% of patients, deep infiltrating endometriosis was treated, and 40% had colorectal involvement. Preoperative infertility was recorded in 42% of patients. The rate of postoperative recurrence was 10.9% for the entire series. Of 33 women who wished to conceive, 67% became pregnant, spontaneously in 59%. Time from surgery to the first pregnancy was 7.6 (4.3) months. After discontinuation of postoperative hormone therapy, the probability of not conceiving at 12 months was 0.36 (95% confidence interval, 0.19-0.53), and at 24 months was 0.27 (95% confidence interval, 0.12-0.44)., Conclusions: Recurrence and pregnancy rates are encouraging in that they seem comparable to the best reported results after endometrioma cystectomy. Plasma energy may have an important role in the management of ovarian endometrioma in women seeking to conceive. Patients most in need of surgical procedures that can spare ovarian parenchyma, such as those with bilateral endometriomas or a history of ovarian surgery, may particularly benefit from ablation using plasma energy., (Copyright © 2013 AAGL. Published by Elsevier Inc. All rights reserved.)

The surgical treatment of deep infiltrating endometriosis is challenging and complex. Currently, the gold standard for patient care is the referral to tertiary centers with a multidisciplinary team including gynecologists, colorectal surgeon and urologist with adequate training in advanced laparoscopic surgery. The surgical technique is essential to adequately manage the disease and to minimize the risk of complications; however, the technique is rarely taught and described in details. This paper reviews our current technique and all the tricks to allow the reproduction and even the improvement of this technique by other surgeons.

Objective: To evaluate in infertile women the benefit of laparoscopic surgical treatment of endometriosis., Patients and Methods: All infertile patients aged 18 to 43 years old, operated between February 2004 and March 2008, with a minimal follow-up of 18 months, coming from the Auvergne cohort of endometriosis has been, were included. The primary end point was the achievement of a pregnancy., Results: One hundred and twenty-three patients have been included. Global pregnancy rate was 48%, which 47% was spontaneous with a mean postoperative delay of 6±4.5 months. Sixty-three patients had benefited from Assisted Reproductive Technology (ART) and 25 pregnancies were obtained (pregnancy rate: 39.7% with a mean delay of 10±3.8 months). Eighty-one percent of spontaneous pregnancies were obtained during the first 12 postoperative months. Duration of preoperative infertility and tubal involvement were significantly associated with lower spontaneous pregnancy rate. No significant differences were found between endometriosis stage I and II compared to stage III and IV, and between patient under 34 years old compared to older., Discussion and Conclusion: With this first study on infertility from the Auvergne cohort of endometriosis, we are confirmed that surgery is one of the central issues in the treatment of infertile endometriosis patient. The postoperative delay to obtain a spontaneous pregnancy requires a quick management by ART after 6 to 12 postoperative month and an immediate management by ART in case of tubal involvement or former infertility., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: The aim of our study was to assess ovarian tissue loss related to endometrioma cystectomy by 3D-ultrasonography., Patients and Methods: We have retrospectively included 15 women with no previous ovarian surgery who benefited from cystectomy of an unilateral endometrioma the diameter of which was superior to 30mm. Cystectomy has been performed using an ovarian tissue-sparing procedure with no incision of the ovarian cortex. Patients underwent ultrasonography at least 9 months after the surgery. Several ovarian parameters, such as the area on longitudinal cross-section, the volume and the antral follicles count (AFC), were measured on both operated and contra lateral ovary, and then were compared using Mann and Whitney test. The relationship between the reduction of operated ovary volume and preoperative endometrioma diameter was evaluated by multiple regression., Results: Operated ovary presented a significant reduction in area (mean reduction 229.8mm(2)±47.6; P<0.0001), volume (mean reduction 5.8cm(3)±1.16; P<0.0001) and AFC (mean reduction 5.1±3.8, P=0.002). No statistically significant correlation was found between operated ovary volume reduction and preoperative endometrioma diameter., Discussion and Conclusion: Endometrioma cystectomy leads to significant reduction in ovarian parenchyma volume and AFC, when compared to contra lateral ovary. This event must be taken into account in the choice of treatment strategy, especially in the case of enlarged, bilateral and recurrent endometriomas, recurrence, as well as in women presenting with other risk factor for ovarian failure., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: To use postoperative examination by three-dimensional (3D) ultrasound to compare loss of ovarian parenchyma after ovarian endometrioma ablation with the use of plasma energy versus cystectomy., Design: Retrospective "before and after" comparative study., Setting: University tertiary referral center., Patient(s): Thirty women with no previous history of ovarian surgery managed for unilateral ovarian endometrioma >30 mm in diameter., Intervention(s): Endometrioma ablation using plasma energy and ovarian tissue-sparing cystectomy., Main Outcome Measure(s): 3D ultrasound assessment of postoperative reduction in ovarian volume and antral follicle count (AFC)., Result(s): Fifteen women with comparable baseline characteristics were managed by each technique. Those who underwent cystectomy showed a statistically significant reduction in ovarian volume and AFC when compared with women who underwent ablation using plasma energy. Multivariate analysis showed that the relationship between the decrease in ovarian volume and AFC and the use of cystectomy remained statistically significant after adjustment for age, previous pregnancy, and cyst diameter., Conclusion(s): When compared with plasma energy ablation, cystectomy is responsible for a statistically significant decrease in ovarian volume and a statistically significant reduction in AFC. This data should be taken into account in therapeutic decision-making concerning women attempting pregnancy, especially where there are other risk factors for postoperative ovarian failure., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Good knowledge of physiopathology, surgical techniques and of the literature allows for an adequate treatment of ovarian endometrioma. Preoperative medical treatment has not shown to be efficient and might be adapted to each patient (continuation or initiation of hormonal treatment in case of symptomatology, will for contraception, association with functional cyst). Laparoscopy is the mandatory surgical approach. Cystectomy is the surgical technique of choice but may affect normal ovarian tissu. Surgical technique should be meticulous in particular with respect to the hilum of the ovary. Exclusive coagulation using bipolar is not recommended. A hybrid technique associating both cystectomy and vaporization (laser or Plasmajet(©)) at the level of the hilum of the ovary could be interesting. Hemostasis should be spontaneous or obtained with bipolar coagulation with parcimony. Ovarian suture is a solution. Extra-ovarian lesions should be carefully searched for and treated. Anti-adhesion products should be applied. Postoperative medical treatment decreases recurrence and should be systematic for patients who do not want to conceive. Multidisciplinary approach is essential., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: This study was designed to compare the surgical outcomes of standard and reverse laparoscopic techniques for the treatment of rectovaginal endometriosis., Methods: A retrospective study was conducted in a teaching and research hospital (tertiary center), which included 75 women subjected to laparoscopic treatment of rectovaginal endometriosis that required both vaginal resection and rectal surgery. Standard and reverse laparoscopic techniques were compared in 35 and 40 women, respectively. Student's t test, Mann-Whitney test, and Fisher's exact test were performed to compare groups when needed; p < 0.05 was considered statistically significant., Results: There was no statistically significant difference in operating time, blood loss, conversion rate, major intraoperative complications, length of hospital stay, and minor postoperative complications between the two techniques. The rate of major postoperative complications for the standard technique was 22.9%, whereas only 5% for the reverse technique (p = 0.02). The rate of postoperative rectovaginal fistula was the same for both techniques., Conclusions: Major postoperative complications were reduced by using the reverse technique.

We performed a retrospective three-dimensional ultrasound evaluation of the ovarian features in ten women with no previous ovarian surgery who benefited from ablation by plasma energy for unilateral endometriomas greater than to 30 mm in diameter. Values of ovarian volume and antral follicle count in operated ovaries were decreased by an average 12% and 18%, respectively, suggesting that endometrioma ablation using plasma energy spares the underlying ovarian parenchyma., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Abdominal wall endometriosis is unusual and mostly occurs in scars following Cesarean section. Although malignant transformation is rare, it must be recognized in order to benefit from radical resection. We report a very rare case of mixed endometrioid and serous carcinoma developing in a Cesarean section endometriosis scar and the way we managed it using surgery and chemotherapy. 18-FDG PET-CT imaging was performed to correctly stage the disease.

In ten ovarian endometriomas of diameter exceeding 30 mm, managed by complete vaporization of the inner surface using plasma energy followed by cystectomy, we performed histologic evaluation of the depth of necrosis and the effectiveness of endometrial tissue ablation. We observed that plasma energy allows the ablation of endometrial tissue with minimal damage to the ovarian parenchyma, which suggests that this technique might be of particular interest for women with risk factors of postoperative ovarian reserve impairment, such as recurrent and bilateral endometriomas., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)