The Surgical Management of Deep Rectovaginal Endometriosis
Endometriosis Zone News
The Surgical Management of Deep Rectovaginal Endometriosis
Charles H. Koh, M. D., Associate Clinical Professor, Medical College of Wisconsin
Co-Director, Reproductive Specialty Center
Grace M. Janik, M. D., Associate Clinical Professor, Medical College of Wisconsin
Co-Director, Reproductive Specialty Center
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In the past few years there has been considerable interest in elucidating the nature of deep and rectovaginal endometriosis in patients with pain, and in clarifying the appropriate surgical management to obtain prolonged amelioration of symptoms or cure.  Medical suppressive therapy has been found to be either ineffective  or temporary with recurrence as high as 76%  whereas surgical excision is effective in relieving pain and dyspareunia symptoms. [4, 5, 6] The concept of adenomyotic nodules was advanced by Cullen in 1920 , while infiltrating endometriosis of the rectovaginal area was described by Sampson in 1927 , and Novak in 1974  verified that the lesion was a combination of fibromuscular tissue within which resided the glands and stroma of endometriosis. Currently there is lack of agreement on the extent of resection that is necessary for this disease especially when present in the rectovaginal area, and this may be influenced as much by each author’s surgical resources as belief in disease pathology. However, the age old rationale of performing hysterectomy with bilateral salpingo-oophorectomy as the “definitive” treatment of the disease is now increasingly recognized as being indiscriminate, unduly severe, and often ineffective in the presence of extensive, deep endometriosis of the rectovaginal and uterosacral-cardinal areas. This is often because much of the deep disease is left behind in laparotomy techniques like retrograde hysterectomy.  The persistence and recurrence of symptomatology in patients after hysterectomy with bilateral salpingo-oophorectomy is significant and probably underreported. 
The encouraging trend that is clearly emerging recently is the employment of radical resection of deep disease without the automatic inclusion of hysterectomy or oophorectomy as part of the treatment. Expert laparoscopic surgery has been the main stimulus of this paradigm shift because of the enhanced access to the retroperitoneal and rectovaginal space with magnification allows great accuracy in delineation of the disease from normal tissue with its concomitant complete excision. Over the past few years as laparoscopic surgical prowess - gynecological, general surgical and urological - has caught up with this enhanced visibility there has been an increasing number of reports addressing this issue. [12, 13, 14, 15] What is currently still controversial is the extent of rectal wall resection necessary to affect a cure in women with rectovaginal endometriosis.
The argument over laparoscopy versus laparotomy for the best approach to deep and advanced endometriosis is specious and detracts from the real issue-the ability of the surgeon to completely excise deep disease by whichever method. In our experience, we cannot achieve the same degree of radicality by laparotomy as we do by laparoscopy because of the following:
- Laparotomy visualization of peritoneal endometriosis and retroperitoneal access is poor and does not allow radical microsurgery, which is the key to achieving radicality even in the ‘frozen pelvis’.
- Resection and repair of bowel, bladder, and ureter has been a part of our routine laparoscopic armamentarium since 1992 and there has been only one conversion to laparotomy since then.
Definition of Deep Rectovaginal Endometriosis and Limitations
Deep endometriosis is defined as any lesion exceeding 5 mm and is most commonly found on the uterosacral cardinal ligaments, bladder peritoneum and occasionally the pelvic sidewall and ovarian fossa.  There was a higher proportion of patients with pain with deep lesions.  We consider deep rectovaginal endometriosis to be present when a bulky lesion is present in the cul de sac or has invaded the muscularis of the vagina or rectum or both. Cul-de-sac obliteration is a poor surrogate measurement for incidence of true rectovaginal endometriosis as Redwine  found that 27% of women with total cul-de-sac obliteration did not need any rectal treatment.
The revised AFS classification for endometriosis is not useful in categorizing deep endometriosis for pain. This is mainly because of loading of the scores by ovarian and tubal adhesions, and ovarian endometrioma. For comparability in ongoing research an accurate anatomical description of the location and infiltration of deep endometriosis is more valuable.
Sites and Topography of Deep Endometriosis
The understanding of the frequent location and extension of the lesions in deep endometriosis allow for a logical and consistent approach to its resection with a high degree of success. The most common area of involvement of deep endometriosis is the uterosacral ligament. With increasing infiltration laterally the cardinal ligament and the proximate periureteral tissue become involved leading to constriction of the ureter. It is very rare for the ureteral muscularis to be part of this process. Medial extension begins to incorporate the serosa and later the outer muscularis of the adjacent rectum, but infrequently to rectal mucosa. Anterior extension involves posterior cervix and vagina ipsilaterally.
Central lesions occur in the cul-de-sac between rectum and vagina and it is
debatale whether these arise from the rectovaginal septum or in fact represent obliterative disease in the cul-de-sac that is covered over by rectum. [18, 19] The concept that the rectovaginal septum ends at the trough of the cul-de-sac peritoneum is questionable  as this would mean that every woman has an enterocele (absence of fascia between peritoneum and posterior vaginal epithelium). Cadaveric dissection has firmly established that the rectovaginal septum (Fasciae Denonvilliers) is attached to the uterosacral-cardinal complex and forms the posterior part of the pericervical ring. 
The rectovaginal lesion may extend to the superficial muscularis or deeper up to the mucosa of the rectum or vagina. In the coronal plane this lesion extends laterally and may merge with the uterosacral lesion described as above. When this occurs bilaterally there is true cul-de-sac obliteration by a continuous sheet of fibrotic endometriosis.
Anterior to the uterus, the bladder peritoneum and muscularis may be progressively involved until a lesion occupies full thickness and is visible at cystoscopy as dark spots on the bladder mucosa. Mucosal lesions of the bladder, rectum, and vagina represent only the tip of the iceberg with the majority of the lesion being in the muscularis. Uterine adenomyoma may represent part of the spectrum of the same disease and we have seen one case where the bladder was fused to the anterior uterine wall by an adenomyoma that occupied the muscle of the uterus and bladder and involved the mucosa of the bladder and the endometrium of the uterus. The central lesions probably have their origins in the Mullerian remnants. The extensive presence of muscle in rectovaginal lesions may be adenomyomas  or represent metaplastic change of originally infiltrating endometriotic glands and stroma 
The need to diagnose the presence of deep endometriosis of the lateral pelvic sidewall or uterosacral ligament preoperatively is relatively unimportant as both diagnosis and treatment may be affected readily at the time of surgery. However the presence of severe ureteral involvement and/or rectal wall involvement if reliably diagnosed preoperatively would obviously aid in surgical preparation with regard to making available the urologist and bowel surgeon at the time of surgery. Our unit fortunately has surgeons experienced in laparoscopic colectomy available at any time; partial and full thickness resections of rectum are performed without the general surgeon. We generally perform the urological operations ourselves with a non-operative urologic consultation. Therefore the need for precise preoperative triage is less essential in our center.
Pelvic examination evaluating rectovaginal nodule size shows a correlation between the size of the nodule and risk of ureteral endometriosis with a nodule = 3 cm having a prevalence of ureteral stenosis and hydronephrosis of 11.2%.  Pelvic examination for nodules, however, often misses lesions in the upper uterosacral ligament and rectum.  Coronado evaluated patients who underwent colectomy by laparotomy for bowel endometriosis and found only two biopsy-positive lesions at proctosigmoidoscopy in 74 exams and extrinsic compression or non-specific abnormality in 18 of 73 barium studies.  Transrectal ultrasonography has recently been used in the assessment of rectovaginal endometriosis with a sensitivity and specificity of 97% and 96% respectively in the identification of rectal and vaginal wall infiltration. 
While the use of transrectal ultrasonography and MRI appear to be promising, the only way to validate its accuracy in diagnosing the extent of rectal involvement in endometriosis is by performing a segmental resection and histologically confirming the depth of invasion. In all the studies thus far the authors have employed the findings to determine which patients undergo colectomy by laparotomy and which patients have treatment of rectovaginal endometriosis without full or partial thickness rectal resection. Thus there is no confirmation that the untreated rectum in fact does not contain endometriosis or that segmental bowel resection was necessary.  Preoperative testing may be helpful in triaging patients to centers capable of radical endometriosis surgery, however the true extent of involvement cannot be determined until microdissection of the ureter and rectum are performed.
Surgical Technique-Radical Microsurgical Excision of Endometriosis
Our group focuses on the complete resection of deep endometriosis to normal tissue margins. This includes resection of ureter, bladder and rectum when indicated. The only exception to this rule is in the cases of deep endometriosis infiltrating lateral to the branches of the internal iliac vessels and the involvement of the obturator nerve.
The essential tools to initiate surgery are:
- The RUMI uterine manipulator, KOH cup, pneumo-occluder.
- Ring forceps and rectal probe to be placed in the rectum.
- Ring forceps for posterior vaginal fornix placed under the RUMI uterine manipulator handle.
- Laparoscopic tools: KTP laser with 300-micron sculptured tip, ureteric grasper, bowel grasper, dissecting forceps, micro-jaw and macro-jaw disposable bipolar, unipolar hook, serrated straight reusable scissors, 3 mm ultra micro graspers, Storz macro and micro needle holders.
Depending on the preoperative triage evaluation, standby of the general surgeon and the urologist may be needed. A bowel prep is used for all suspected rectovaginal disease. Except for full thickness bladder resection ureteral catheters are not placed. A preliminary cystoscopy with electrosurgical demarcation of the bladder mucosal lesion is useful to ensure complete excision at laparoscopy. The perimeter of the vaginal lesion may be marked with surgical ink.
We have a systematic approach and order of dissection that has allowed all rectovaginal disease to be successfully resected.
1. Mapping of Peritoneal Disease
We map the total outline of the bladder, cul-de-sac, and lateral pelvic wall
peritoneal disease at the start of surgery so that later ecchymoses does not distort the areas for en bloc peritoneal resection. If an ovarian endometrioma is adherent to the posterior uterus it is first deflated and the contents aspirated in order to create space for further dissection.
2. Sigmoid Take-down and Ureteral Dissection
This is the essential first step of the rectovaginal release operation with exposure
of the left common iliac artery and medial dissection to ultimately reveal the ureter crossing over. All investing layers of the ureter (up to the adventitia) are divided using a 3 mm ultra micro grasper as backstop. This step is essentially different from that in retroperitoneal dissection by oncologic surgeons as they tend to reflect the ureter with the peritoneum medially. Such an approach does not allow micro dissection of the overlying fibrosis from the ureter in the cardinal uterosacral area. The dissection continues down to the ureteric tunnel taking care not to divide the uterine artery accidentally at this stage. If there is a left ovarian endometrioma which is adherent to the ureteral peritoneum this step allows the safe mobilization of the ovary away from the ureter taking with it the ovarian fossa peritoneum. Dissection of the ovary from its adherence to the rectum may also be necessary at this stage and superficial rectal serosa or muscularis should be resected in order not to leave ovarian tissue on the rectum, which may later cause ovarian remnant syndrome. After mobilization of the ovarian cyst the ureter can be exposed down to the ureteric tunnel. The ovary is now sutured to the lateral abdominal wall peritoneum in order to keep it out of the way during the rest of surgery.
3. Ureter and Bladder Resection
For the ureter microdissection allows precise liberation of the ureteric adventitia from the surrounding fibrosis and this is possible even when the ureter is constricted. After liberation from the fibrosis in excising the fibrotic endometriotic tissue, we often find expansion of the stenotic segment so that ureteric resection and anastomosis is not needed. When there is extreme stenosis with no recovery after microureterolysis or when the actual ureteric muscularis is invaded, then segmental resection with ureteral ureterostomy or ureteroneocystostomy is performed laparoscopically. In the case of the bladder, full or partial thickness bladder wall resection is readily accomplished and ureteral stents are placed by the urologist to protect the trigone and ureteric orifices during this resection.
4. En bloc excision of anterior rectal, posterior cul-de-sac, and uterosacral disease
If the uterosacral ligaments are thickened we lateralize the ureters and divide the uterosacral ligaments medial to the ureter towards the central rectovaginal mass. With maximum antiflexion of the uterus afforded by the RUMI and with slight traction on the rectum, the KTP laser is used with magnification to release the rectum from the posterior uterus and vagina. At some point it will be possible to insert a grasper into the defined lateral rectovaginal space towards the central mass and to divide the overlying thick endometriotic tissue of the central mass towards the dissecting grasper. This has the effect of cutting into the rectovaginal disease leaving a portion of it on the rectum and a portion on the posterior vagina. Further dissection with the laser and dissector will enter the unaffected distal rectovaginal space where a ring forceps in the rectum identifies normal rectal muscularis. Thus before proceeding further to resect rectal disease the normal boundary is identified.
At this point the previously marked peritoneum is used as a guide and further
incision is performed with the KTP laser to include the uterosacral ligament pararectal tissue bilaterally in the dissection. A determination is now made of the depth of infiltration of the rectum by palpation with a bowel grasper. Partial thickness resection should only be performed when the outer longitudinal muscularis is involved and can be peeled mechanically from the inner circular muscularis. The inner muscularis cannot be peeled from the mucosa and any resection will be incomplete. We perform a full thickness disc resection when the inner muscularis or mucosa is involved and the lesion is less than 3-4 cm. With larger lesions or multifocal lesions a laparoscopically assisted
colectomy with end-to-end stapled anastomosis is performed by the general
With partial or full thickness anterior rectal resection 3-0 PDS on an SH needle is
used to approximate the outer longitudinal muscularis in one or two layers continuously with intracorporeal knotting. Test for leakage is performed by air introduced via a rectal proctoscope.
5. Excision of Vaginal Endometriosis
The pneumo-occluder which is attached to the RUMI is inflated and full thickness excision of the posterior fornix is facilitated by dissection against the RUMI rubber base or KOH cup using the mucosal marking for guidance. Following the removal of the vaginal lesion a single-layer continuous repair of the posterior vaginal epithelium is performed using 3-0 PDS continuously. The closure is transverse to avoid narrowing of the posterior fornix.
6. Ancillary Procedures
Ovarian cystectomy is now performed as necessary or peritubal adhesiolysis as
As with most surgical treatments, randomized controlled trials of radical excision of deep infiltrating endometriosis are not available, however observational comparative data and prospective clinical studies are encouraging. 
In a retrospective study of 21 patients with resection of deep uterosacral lesions, 84.2% had improvement of dysmenorrhea, 94.1% had improvement of deep dyspareunia, and 77.7% had improvement of chronic pelvic pain.  Donnez, et al, reported a series of 500 patients with rectovaginal nodules, of the 242 followed >2 years 3.7% had recurrence of severe pelvic pain and 1.2% had recurrence of deep dyspareunia.  Redwine and Wright evaluated 84 patients with obliterated cul-de-sac by a prospective study using a five-point questionnaire evaluating pre- and postoperative symptoms. Aggressive resection of endometriosis showed improvement in all symptomatology categories.  Postoperative fertility rate was 43%. No significant complications were noted, however, 16 patients were excluded from the study due to conversion to laparotomy for treatment of bowel disease.
We have evaluated over 400 cases of deep infiltrating endometriosis of the cul-de-sac. Of these, 105 had rectal disease; 22 required laparoscopic colectomy, 17 had full thickness anterior rectosigmoid resection, 56 had partial thickness resection. All cases were laparoscopic except for 1 colectomy early in the series. Postoperatively only 1 serious complication occurred of rectal perforation treated with diverting colostomy. A 48% fertility rate was achieved.
“First do no harm”. Causing iatrogenic sterility with no benefit to pain is
something we as a specialty cannot be proud of. With an increasing number of specialist endometriosis centers developing worldwide the patient with deep and rectovaginal endometriosis should be better served.
There is no controversy about the efficacy of complete resection of uterosacral or vaginal deep disease to disease-free margins. For rectal disease partial thickness resection may cause repeated surgeries [29, 30] and paradoxically does not decrease complication rates.  The safety and efficacy of segmental bowel resection at laparotomy is well established [32, 24] and also for laparoscopy [33, 13, 29, 6] as has been our experience. Many general surgeons assisting gynecologists are more comfortable doing laparoscopically assisted colectomy with low complication rates  than full thickness resection requiring suture repair. The management of rectovaginal endometriosis is best achieved laparoscopically and with an established multispecialty team of expert gynecologist, surgeon and urologist, and good theatre team. Currently only radical micro dissection can identify deep disease and next generation imaging may be promising in the future.
Management of deep infiltrating endometriosis has evolved from indiscriminate and often ineffective removal of uninvolved organs to radial excision all fibrotic endometriosis with disease free margins. This evolution has been greatly enhanced by the improved visualization of the rectovaginal space through laparoscopy, enabling ureterolysis and microdissection of the rectovaginal space. The outcome data for extensive resection, though not definitive, is continuing to confirm low morbidity and positive results. Further research is needed on optimal treatment of bowel involvement and positive predictive factors for pregnancy.
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- Fedele L, Bianchi S, Zanconato G, et al: Gonadotropin-releasing hormone agonist treatment for endometriosis of the rectovaginal septum. Am J Obstet Gynecol 2000; 183 (6): 1462-1467
- Shaw RW: Treatment of endometriosis. The Lancet 1992; 340: 1267-1271
- Anaf V, Simon P, El Nakadi I, et al: Impact of surgical resection of rectovaginal pouch of Douglas endometriotic nodules on pelvic pain and some elements of patients’ sex life. J Am Assoc Gynecol Laparosc 2001; 8 (1): 55-60
- **Redwine DB, Wright JT: Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril 2001; 76 (2): 358-365. Excellent contribution of the long term effects of extensive resection of cul-de-sac endometriosis in a large series. The article is also important in its elucidation of degrees of bowel involvement in cul-de-sac disease.
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- Chapron C, Dubuisson JB, Pansini V, et al: Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis. J Am Assoc Gynecol Laparosc 2002; 9 (2): 115-119
- Coronado C, Bailey HR, Franklin RR, et al: Surgical treatment of symptomatic colorectal endometriosis. Fertil Steril 1990; 53 (3): 411-416
- Fedele L, Bianchi S, Portuese A, et al: Transrectal ultrasonography in the assessment of rectovaginal endometriosis. Obstet Gynecol 1998; 91 (3): 444-448
- Chapron C, Dumontier I, Dousset B, et al: Results and role of rectal endoscopic ultrasonography for patients with deep pelvic endometriosis. Hum Reprod 1998; 13 (8): 2266-2270
- *Jacobson TZ, Barlow DH, Garry R, Koninckx P: Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2001; (4): CD001300. Review. Comprehensive review of randomized studies comparing laparoscopic surgery for endometriosis with other treatment modalities. Though only one trial qualified for inclusion, discussion of the topic is helpful.
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- Bailey HR, Ott MT, Hartendorp P: Aggressive surgical management for advanced colorectal endometriosis. Diseases of the Colon & Rectum 1994; 37 (8): 747-753
- Kockerling F, Rose J, Schneider C, et al: Laparoscopic colorectal anastomosis: risk of postoperative leakage. Surgical Endoscopy 1999; 13: 639-644
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