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Preferred Treatment for Rectovaginal Endometriosis: Surgery versus Medical Therapy
Karl-Werner Schweppe, Endozone Advisory Board member
infiltrating, retroperitoneale endometriosis is considered as a special entity
of endometriosis with respect to the histological characteristics. The nodules
are containing glands, stroma,and muscle cells resembling adenomyotic foci
(1,2). For the clinician the question is of importance, whether this
endometriotic nodules react to hormonal therapy or surgery is the only option of
choice as known from adenomyosis of the uterus.
performed a retrospective analysis of 78 cases treated in our clinic between
1988 and 1998 for rectovaginal endometriosis, of which we have follow up data
between two and thirteen years, with a mean follow up period of 5,2 years. Four
different treatment options were performed:
Medical treatment with Danazol or GnRH-agonists for 6 months;
permanent medical therapy i.e. low dose progestins or GnRH-agonists with add
back medication -continuously or intermittent (3),
primary surgical treatment, i.e. resection of the nodule with disc resection of
the rectum, or rectum resection with anastomosis (4), and
preoperative medical therapy with GnRH-agonists for reduction of the implants
and the blood supply for 3 to 6 months followed by surgery.
patients were treated medically (8 with Danazol 600 mg/d and 16 with
GnRH-agonists for 6 months); 22 reported reduction of symptoms and improvement
of their quality of life despite of different side effects. But all claimed
recurrence of the disease within 3 to 12 months after cessation of therapy. Of
these group 16 were than put on GnRH-agonists with add back medication for
permanent medical treatment; all responded again. Two were lost of follow up,
two relapsed and had surgery but 14 are still on this therapy.
surgical treatment were performed in 19 cases and in the 6 women with recurrence
after medical therapy. Resection of the tumor was sufficient in 4 cases, disc
resection of the rectum was necessary in 9 cases and resection of the bowl with
anastomosis was done in the remaining 12 patients. During the follow up period
we observed 7 recurrences (2 after resection of the nodule, 3 after resection
of the anterior wall of the bowl, and 2 after resection and anastomosis of the
rectum). The last group of preoperative medication contains 35 patients; 6 of
them received 6 months of danazol 600 mg/d, 9 patient were pre-treated with
GnRH-agonists for 6 months (7 of them with add-back medication) and 20 were
operated after 3 months of GnRH-Agonist medication. During the follow up period
the following recurrences were observed: 1 of 3 cases with resection of the
tumor only; 0 of 7 cases with resection of the nodule including resection of the
anterior wall of the rectum; and 2 of 27 patients with bowl resection and
case of rectovaginal endometriosis sufficient radical surgery is the preferred
treatment. It is necessary to remove all nodules completely and preoperative
medical treatment with GnRH-Agonists seems to reduce the recurrence rates.
Medical treatment is insufficient with a 100 percent recurrence rate.
Permanent medication however is an alternative to surgery, if the patient
accepts that treatment has to last until menopause.