11 Laparoscopic surgery for intestinal and urinary endometriosis

11

Laparoscopic surgery for intestinal and urinary endometriosis DAVID B. R E D W I N E D E A N R. S H A R P E

Virtually every gynaecological surgical operation formedy performed by laparotomy has been accomplished laparoscopically. Laparoscopic techniques are still maturing as surgeons search for better techniques. Endometriosis is one of the most common diseases treated laparoscopically (Peterson et al, 1990, 1993; Levy et al, 1994), and it is arguably the most difficult to treat because superficial or deep disease can involve virtually any pelvic or extra-pelvic organ. Many gynaecologists feel uncomfortable treating bowel or urinary tract endometriosis. If such disease is encountered during surgery, an intra-operative consultant may be equally uncomfortable about the prospect of treating a 'gynaecological' disease in an unfamiliar patient without a bowel preparation or pre-operative imaging studies, therefore significant disease of the intestinal or urinary systems may escape treatment. Although medical therapy may be offered post-operatively, no medicine eradicates endometriosis, and in the long run the patient may suffer. It would be helpful for gynaecologists to understand the spectrum of intestinal and urinary tract endometriosis and to be able to anticipate its presence and plan accordingly.

INTESTINAL ENDOMETRIOSIS Pathology The colonic wall is composed of four layers: serosa, outer longitudinal muscularis, inner circular muscularis and mucosa. Beneath the cul-de-sac peritoneal reflection, no serosal layer exists. Intestinal endometriosis may be less than 1 mm in dimension, or may invade deeply into the muscularis with a resultant mass measuring up to 8 cm. The disease almost never penetrates the mucosa, even when large nodules are present (Figure 1). Muscularis involvement can be associated with fibromuscular proliferation leading to retraction and distortion of the bowel wall. A nodule may gather together a linear length of serosa which is four to five times the apparent diameter of the nodule, thus a very large surgical defect may result from Bailli~re's Clinical Obstetrics and Gynaecology775 Vol. 9, No. 4, December 1995 ISBN 0-7020-2008-7

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resection of a seemingly moderate sized nodule. The lower colon is involved most frequently, followed by the ileum, appendix and caecum (Table 1), a distribution previously noted (Weed and Ray, 1987). Lesions usually occur on the anti-mesenteric border of the intestine and may occur singly or in close proximity to one another. The mesentery of the bowel can also be involved by lesions which are usually superficial.

Figure 1. Endometriosis of wall of sigmoid colon. The muscularis exhibits a nest of glands and stroma of invasive endometriosis which encroaches on the submucosa. The rnucosa is intact.

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Table 1. Frequency of biopsy-proven intestinal endometriosis and surgical approach to treatment

among 1519 patients of Tile Endometriosis Institute of Oregon. Surgical approach (number of patients, %)

Patients Intestinal site

Number

%

Laparoscopy

Laparotomy

Rectum Sigmoid Ileum Caecum Appendix*

201 261 63 22 38

13.2 17.8 4.1 1.4 2.5

93 156 20 6 21

46,3 59,8 31,8 27.3 55.3

108 122 56 16 17

53.7 39.5 66.7 72.7 44.7

Total

402t

26.5

231

57.4

171

42.6

* Some patients had previous appendectomy, t Total number of patients exceeds 402 because some patients had more than one intestinal area involved.

Histologically, glands and stroma resembling native endometrium represent the gold standard for diagnosis of the disease. Because endometriosis has lower and varying levels of hormone receptors compared with native endometrium, it does not respond in a predictable fashion to hormonal influences. While native endometrium bleeds predictably and cyclically, this is not the case with endometriosis (Metzger, 1988). For this reason, the gross appearance may lack appreciable haemorrhagic colour, instead displaying a whitish, fibrotic colouration which appears inert, increasing the likelihood that even partially obstructing lesions may be overlooked. However, it should be recognized that these lesions are not 'burned out', but rather 'burned in'.

Symptoms Pelvic endometriosis

Pelvic pain is the most common and most specific symptom of pelvic endometriosis, although some patients may remain asymptomatic. Because the cul-de-sac, uterosacral ligaments and medial broad ligaments are the most common sites of disease (Redwine, 1987a), physiological events involving the pelvic floor are often painful, including painful defecation, dyspareunia, tenderness on pelvic examination, and lateral pain if endometrioma cysts are present. A dull pain may begin around ovulation and become sharp, stabbing and knifelike, increasing in a crescendo pattern toward menses. During menses, the pain may be much more intense and uterine cramping may become superimposed. Thus, upon careful questioning, 'dysmenorrhoea' may be more than just uterine cramping with menses and may include non-cramping types of pain which began well before the flow. Some patients may experience pain all month long. The intraperitoneal irritation associated with pelvic endometriosis may produce secondary intestinal symptoms, including intestinal cramping, diarrhoea, constipation and bloating. The frequency of such symptoms is similar in patients with or without intestinal endometriosis. Disease of the cul-de-sac and uterosacral ligaments may be associated with painful bowel movements during menses. Even in a refen'al centre, most patients with

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endometriosis do not have intestinal disease (Table 1), so non-specific intestinal symptoms are usually not due to intestinal involvement. Intestinal endometriosis Superficial endometriosis of the intestinal serosa may cause no symptoms. Invasive endometriosis results in retractive fibrosis which can distort the bowel wall and cause symptoms of partial obstruction, including intestinal cramping, alternating constipation and diarrhoea, and bloating. Significant fibrotic distortion of the bowel wall by nodular disease in specific intestinal sites can produce characteristic syndromes. A rectal nodule with obliteration of the cul-de-sac (Figure 2) may result in pain with each bowel movement throughout the month, rectal pain, rectal pain with flatus, rectal pain with sitting and dyspareunia with pain radiating to the rectum. Misshapen stools are occasionally mentioned.

Figure 2. Obliteration of the posterior cul-de-sac. While haemorrhagic lesions are visible on the right uterosacral ligament, white fibrosis along each ligament near its insertion into the posterior cervix gives evidence of invasive endometriosis, The rectum is adherent to the posterior cervix.

A sigmoid nodule of endometriosis may result in left lower quadrant intestinal cramping prior to or during passage of stools. Nodular disease of the ileum can produce cramping, fight lower quadrant pain which may become aggravated 30 to 60 minutes after eating. Because of the large diameter of the caecum, nodular disease here does not usually produce

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obstructive distortion or symptoms. Nodular disease of the appendix is usually asymptomatic. Even among patients eventually requiring fullthickness or segmental bowel resections, only 12% complain of rectal bleeding (Redwine, 1992a). The absence of rectal bleeding does not guarantee the absence of intestinal endometriosis (Gray, 1973).

Physical signs Tenderness or nodularity of the cul-de-sac, uterosacral ligaments or anterior rectal wall found during pelvic examination should immediately suggest endometriosis to the examiner. When focal tenderness alone is found on pelvic examination, 66% of the time endometriosis is found in that spot (Ripps and Martin, 1991). The more deeply invasive endometriosis becomes, the more likely it is to cause pain, (Koninckx et al, 1991) although younger patients can certainly suffer pain due to superficial lesions (Redwine, 1987b). Tenderness or nodularity of the cul-de-sac or uterosacral ligaments was present in 85% of an initial group of patients who were eventually found to have disease of the lower colon (Sharpe and Redwine, unpublished data). Signs of intestinal disease involving the sigmoid, ileum, appendix or caecum cannot be elicited on physical examination, although non-specific symptoms suggesting partial obstruction may be present. Most patients with sigmoid, ileal or caecal disease also had rectal disease, therefore the finding of a rectal nodule on physical examination implies the possible presence of other intestinal disease. Some patients will have endometriosis eroding into the posterior vaginal fornix, frequently extending from an invasive rectal nodule of endometriosis. This rather obvious sign can be hidden by the posterior blade of the speculum during office examination and it is therefore important to inspect this area routinely.

Pre-operative intestinal studies Among 402 patients with intestinal endometriosis undergoing surgery by the authors, only two have had full-thickness bowel wall endometriosis with disease extending to the mucosa. Accordingly, colonoscopy or sigmoidoscopy will be negative in most cases of intestinal endometriosis. In addition, many patients do not have sufficient distortion of the bowel wall to cause an abnormal barium enema. As a result, the false negative rate of intestinal studies is 82%. Simple pelvic examination alone is more predictive of intestinal disease in our and others' experience (Gray, 1973).

Surgical staging of intestinal endometriosis Because the revised American Fertility Society (rAFS) (American Fertility Society, 1985) classification system for endometriosis does not include intestinal disease as a factm, patients with intestinal endometriosis are not classified by this system. In fact, 13 patients have been seen with intestinal

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endometriosis who have been recorded as having stage 0 disease because they had no pelvic endometriosis. Because intestinal endometriosis is usually diagnosed surgically, severity of intestinal endometriosis must be gauged retrospectively by the number of intestinal areas involved, or by the extent of surgery necessary to remove the disease in an anatomic location (Table 2). Table 2, Severity of intestinal endometriosis-a surgically based system. Type of resection required

Grade

Superficial seromuscular Partial thickness to mucosa Full thickness Segmental

1 2 3 4

Among our patients with intestinal endometriosis, 70% had one intestinal area involved, 21% had two areas involved, 6.2% had three areas involved, and 2.8% had four areas involved, while one patient had all five areas involved. The number of geographically distinct intestinal areas correlated directly with the incidence of Grade 3 or 4 lesions (Table 3). Table 3. Incidence of Grade 3 or 4 intestinal lesions versus number of intestinal areas involved. Number of intestinal areas

Incidence of Grade 3 or 4 intestinal lesions

1 2 3 4

O.38 0.65 O.83 0.91

Patients with deeply invasive intestinal disease are significantly older (36.08 _+6.38 years of age, mean ± SD) than those with superficial intestinal disease only (32.74 _+5.97) or patients without intestinal disease (31.34 _+ 7.30). Endometriosis patients with intestinal disease had an average of 4.8 pelvic areas involved by endometriosis, while patients without intestinal endometriosis had only 2.9 pelvic areas involved. This observation persists even when corrected for the increased age of patients with bowel disease.

Pre-operative bowel preparation Mechanical bowel preparation is given to patients with known bowel disease or obliteration of the cul-de-sac, significant nodularity of the culde-sac or uterosacral ligaments, X-ray examination suggestive of bowel disease, or bowel symptoms, especially rectal pain with stool or flatus. In these patients, 4 litres of polyethylene glycol 3350 is taken orally the

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afternoon prior to surgery followed by two enemas the evening before surgery. If significant intestinal disease is encountered at surgery, patients receive 3 g of parenteral ampicillin/sulbactam, or if penicillin-allergic, 2 g ceftriaxone and 1 g metronidazole. Post-operatively, patients receive two to four doses of 1 g cefoxitin intravenously every 6 hours.

Surgical techniques The techniques described below can be performed most effectively with a triple-puncture technique using 3 mm scissors passed down the operating channel of a 10 mm operating laparoscope, using either sharp dissection or high current density electroexcision (Redwine, 1994a). Surgery for intestinal endometriosis is dictated by the depth of invasion and the geographic distribution of disease, therefore various techniques are necessary (Table 4), all guided in part by palpation for nodularity in the bowel wall. Table 4. Laparoscopic bowel surgery for endometriosis. Distribution of techniques by anatomic sites. Anatomic site

Total

Technique

Number of cases

Rectum

93

Segmental resection Full thickness Mucosal skinning Superficial

3 38 26 26

Sigmoid

156

Segmental resection Full thickness Mucosal skinning Superficial

3 27 33 93

20

Segmental resection Full thickness Mucosal skinning Superficial

0 9 3 8

6

Segmental resection Full thickness Mucosal skinning Superficial

0 2 1 3

Ileum

Caecum

Superficial lesions The scissors cut perpendicularly into the bowel wall adjacent to the lesion. The lesion is grasped and undermined, with the scissors working in a layer of muscularis. The dissection can proceed quickly beyond the lesion, therefore care must be taken to decide when to cut back out of the bowel wall. Although small lesions which are less than 1 cm in diameter and which do not penetrate the circular layer of muscularis do not need to be sutured, suture reinforcement of the bowel wall with 3-0 silk is wise. Valuable practice can be g~ned by suturing even small defects in the bowel wall. To make internal suturing easy, two points must always be kept in mind: 1. The long end of the suture must be held in order to form an arch pointing toward

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the port through which the tying instrument is passed. 2. The short end of the suture must be placed immediately beneath where the knot will be tied. This avoids reaching for the end of the suture, which pulls the suture through the tissue.

Mucosal skinning Occasionally, a larger lesion will require dissection down to the mucosa for complete removal. If there is no submucosal fibrosis, both layers of muscularis can easily be peeled off of the mucosa using sharp and blunt dissection (Figure 3), a technique termed mucosal skinning (Redwine, 1993a). Once the lesion has been completely undermined, the scissors are used to cut back out to the surface of the bowel. Interrupted 3-0 silk suture is used to close the serosa and muscularis in one layer. Antibiotic prophylaxis is optional.

Figure 3. A nodule of endometriosis has been removed by mucosal skinning from the wail of the lower sigmoid colon. Both layers of muscularis have been completely removed. Notice the cut edge of the distal muscularis, which resembles a cliff face. The mucosa remains intact.

Partial thickness ileum The part of the ileum most commonly involved is the terminal portion. A bulky mass effect nodule in the bowel wall may not be suggested by visible surface changes, but may be appreciated by palpation with graspers.

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Scissors are used to sharply excise the nodule within the muscularis by a mucosal skinning technique. With care, many nodules can be removed without penetrating the lumen. Most defects of the ileum should be closed with interrupted 3-0 silk suture because the bowel wall is thin.

Full thickness disc resection If submucosal fibrosis is present, or if the nodule is large, entry into the lumen of the bowel may be inevitable. Entry into the bowel lumen allows palpation of the lesion through the mucosa as well. This enables accurate determination of the point at which the dissection begins to exit the bowel wall. The mucosa can be closed with continuous 3-0 chromic suture and the seromuscularis can be closed with interrupted 3-0 silk suture. The pelvis is filled with irrigation fluid and air can be injected into the sigmoid colon through a sigmoidoscope to check for air leaks. If leakage occurs, it must be stopped with more sutures.

Appendectomy Monopolar appendectomy is simple and rapid. The appendiceal tip is grasped by one grasper, and the adjacent mesoappendix by another. These graspers pull the appendix off the mesoappendix as the 3 mm monopolar scissors with 50 W of coagulation current shave along the wall of the appendix where the vessels are quite small. This cuts and coagulates the vessels simultaneously until the caecum is reached. Three endoloops are applied around the bare appendix and the scissors cut between the suture. The scissors grasp the appendix and extract it from the 10 mm umbilical sheath.

Obliteration of the cul-de-sac Many clinicians view obliteration of the cul-de-sac as an adhesive process only: the colon is stuck to the back of the cervix and it must be unstuck. While this is partly true, the question must be asked 'what is the significance of the rectosigmoid adhering to the back of the the cervix and to the uterosacral ligaments in patients with endometriosis?' The answer to this question has two parts. First, because the cul-de-sac and uterosacral ligaments are among the pelvic areas most involved by endometriosis (Redwine, 1987a), it must be assumed that they are involved by invasive disease. Second, it must be recognized that invasive disease may exist in the wall of the adherent bowel. When these points are recognized, the clinician will realize the laparoscopic surgical treatment must be expanded to accomplish complete excision of disease in all of these areas, otherwise most patients will have persistent disease (Reich et al, 1991). The standard laparoscopic technique which will ensure comprehensive treatment of the obliterated cul-de-sac is reproducible and straightforward (Redwine, 1992a). Pure cutting current at 90 to 110 W is used to create lines of incision in normal peritoneum lateral and parallel to the uterosacral

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ligaments along the length of the ligament to be resected. This will expose the venous structures of the broad ligaments and isolates the pathology into the centre of the pelvis. By moving the scissors continuously and using high current density, there is very little lateral thermal spread, making it safe to operate on or around the bowel with electrosurgery. A blunt probe can be used to dissect behind the ligaments just below their insertion into the posterior cervix (Figure 4), isolating the ligaments away from the ureter and uterine vessels. The line of incision in normal peritoneum then leads around the base of each ligament toward the bowel wall, then up and over the bowel wall adjacent to the nodule, meeting the incision from the opposite side. A transverse incision is made across the cervix above the point of adherence of the bowel, then a slightly intrafascial dissection is carried down the posterior cervix toward the rectovaginal septum (Figure 5). Once the cervix is passed, the surgeon will encounter a thin layer of reddish areolar tissue. The yellow fat of the rectovaginal septum will be encountered just beyond this layer of reddish tissue. Once the rectovaginal septum has been dissected bluntly, the uterosacral ligaments now stand isolated on each side of the rectum. They can be transected at their insertions into the posterior cervix using monopolar scissors. The uterosacral ligaments are then dissected off the pelvic floor, working from the cervix posteriorly toward the line of peritoneal incision around the base

Figure 4. Laparoscopic treatment of obliteration of the cul-de-sac. A peritoneal incision has been created alongside the right uterosacral ligament, then across the posterior cervix above the point of adherent attachment of the rectum. The peritoneal incision lateral to the left uterosacral ligament is not visible in this view. A blunt probe is separating the right uterosacrat ligament from the vessels of the broad ligament.

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Figure 5. Laparoscopic treatment of the obliterated cul-de-sac. An intrafascial dissection has been carried down the posterior cervix, mobilizing the obliterated cul-de-sac posteriorly. Notice that the cul-de-sac remains obliterated, with the uterosacral ligaments fused to the lateral wall of the rectum.

of the ligaments. The now exposed fibrous attachments of the rectum to the lateral pelvic walls are progressively severed until sufficient mobility of the bowel has been achieved. All nodular disease of the cul-de-sac, uterosacral ligaments and rectal wail is now isolated in the centre of the pelvis attached to the anterior wall of the rectum. The cul-de-sac remains obliterated! The fatty tissue of the rectovaginal septum is stripped off the bowel to expose the longitudinal layer of outer muscularis distal to the mass. At this point, the decision is made either to perform a partial or full-thickness disc resection as discussed above, or to perform a segmental resection with end to end anastomosis. With full thickness resections, the surgical specimen can be retrieved transanally. After bowel closure or anastomosis, the bowel is checked for leaks as described above. Segmental colonic resection with end to end anastomosis

When the bowel lesion is large (> 3 cm) or when multiple bowel nodules are present, full thickness disc resection and repair may result in unacceptable bowel wall distortion. In such a case, resection of a segment of bowel may be necessary. The first reported technique for laparoscopic bowel resection was an intracorporeal technique (Redwine and Sharpe, 1991). While this demonstrated the feasibility of laparoscopic bowel resection,

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operating times were lengthy, and the use of the circular stapler fraught with potential problems (Sharpe and Redwine, 1992). This technique has been abandoned. Although transanal (Nezhat et al, 1992) and laparoscopically assisted abdominal bowel resections (Musser et al, 1994; Ye et al, 1994) are possible, the search for a simpler technique has led to a novel approach of laparoscopically assisted transvaginal bowel resection and anastomosis. In this technique, the abnormal bowel segment is mobilized laparoscopically, then the posterior vagina is opened, and the bowel is delivered through the vagina to the introitus (Figure 6). A segmental bowel resection with end-to-end hand sewn anastomosis can be performed under direct vision and control, providing a more positive anastomosis and avoiding an abdominal incision. This technique also works well for repairing partial or full thickness defects of the anterior rectal wall. In such cases, very little mobilization of the rectum is required in order to close the bowel.

Figure 6. A loop of colon involved by endometriosis has been separated from its mesentery and delivered transvaginally prior to segmental resection and anastomosis.

Conversion to laparotomy While many cases of intestinal endometriosis can be managed successfully laparoscopically, laparotomy can still play an important role in treating intestinal endometriosis if the surgeon lacks the necessary laparoscopic skills (Coronado et al, 1990). Because patients with intestinal endometriosis frequently have extensive pelvic disease, bowel surgery for endometriosis may follow 1-2 hours of pelvic surgery for removal of

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invasive endometriosis and mobilization of the bowel. As the length of laparoscopic surgery increases, the energy level of the surgeon decreases, and surgery seems interminably long. Laparotomy should be selected if a long surgery (i.e. over 4 hours) is anticipated. Also, laparotomy is far more efficient if two or more segmental resections are required in a single patient.

Complications One patient had a post-operative fever, following laparoscopic intracorporeal segmental resection of the sigmoid colon which responded to antibiotics. One patient undergoing a long (7 hours) procedure with multiple full-thickness bowel resections had bilateral peroneal nerve palsy which resolved after 6 weeks. Long cases like this no longer occur with the use of monopolar electrosurgery instead of sharp dissection (Redwine, 1993b). Late perforations have been rare. Prompt identification and treatment of perforations can avoid a fatal outcome (Soderstrom, 1993). One patient with partial thickness sigmoid resection without suture repair had a sigmoid perforation several days later. The perforation was repaired laparoscopically within 4 hours and the patient did well. One patient undergoing laparoscopically assisted full-thickness resection of the anterior rectal wall for endometriosis at the time of laparoscopic hysterectomy had a dehiscence of the suture line several days later, with resulting gross contamination of the lower abdominal cavity, fever and pain. Although integrity of the rectal suture line had been absolutely proven during surgery by underwater air injection, rectal injection of povidone iodine, and direct visualization with a sigmoidoscope, leakage had occurred from the right lateral corner of the suture line. The patient showed prompt improvement after a temporary colostomy was created. That patient has undergone colostomy closure and now has normal intestinal function.

Hormonal therapy for intestinal endometriosis Medical therapy for intestinal endometriosis has never been studied. It is known that medical therapy of endometriosis does not eradicate disease of any stage or location (Redwine, 1992b), and it has been shown in a randomized trial that medical therapy does not markedly improve pelvic pain in rAFS Stage III and IV (Parazzini et al, 1994). Accordingly, medical therapy has no place in the treatment of intestinal endometriosis. In endometriosis patients remaining symptomatic following removal of the uterus, tubes and ovaries but with retention of endometriosis, the intestinal tract is frequently found to be involved (Redwine, 1994b).

Results Relief of pain due to endometriosis consistently follows its removal. Even non-specific symptoms related to pelvic endometriosis frequently improve. Not all intestinal symptoms are due to endometriosis, however, and

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persistent symptoms following aggressive and complete surgery usually indicate another cause. URINARY TRACT ENDOMETRIOSIS

Pathology The urinary bladder is composed of two functional layers: mucosa and muscularis. Within the abdominal cavity exists a third layer, the serosa, which is the most common urinary site involved by endometriosis (Table 5). When muscularis involvement occurs, it is frequently adjacent to the uterovesical peritoneal fold and results in peritoneal rolling and nodularity. Within the muscularis, a criss-crossing web of muscle fibres gives the bladder the ability to contract centripetally to expel urine. As a result, this web of muscularis responds as one fairly thick surgical layer. For the surgeon, this means that wedge resection of bladder muscularis may be required for the rare case of invasive endometriosis of the bladder, rather than a peeling technique as can frequently be performed on the bowel. While some patients may have mucosal oedema overlying a vesical wall mass (Buka, 1988) in others, the mucosa may be involved by disease, with resultant discoloration (Oliker and Harris, 1971; Schwartzwald et al, 1992). When the muscularis is involved, urodynamic testing may reveal bladder irritability (Goldstein and Brodman, 1990). Nodular endometriosis of the trigone of the bladder may extend to involve the ureteral orifice.

Table 5. Urinary tract endometriosis: sites of occurrence. Site Bladder serosa Bladder full thickness Ureter full thickness

Total number of cases

Number treated laparoscopically

442 3 2

314 1 1

The ureter is rarely involved by endometriosis, although it can frequently be sheathed in retroperitoneal fibrosis extending from the vicinity of an adherent endometrioma cyst or from invasive endometriosis of the uterosacral ligament. This retroperitoneal fibrosis can sometimes constrict the ureter, resulting in hydroureter. Retroperitoneal fibrosis surrounding the ureter can always be dissected away using retroperitoneal ureterolysis employing sharp dissection, blunt dissection, electrosurgery and traction both on the ureter as well as on the abnormal tissue. When the muscular wall of the ureter is involved by invasive endometriosis, the dissection will eventually reveal a ureteral wall pockmarked by invasive disease, sometimes with associated hydroureter, hydronephrosis and hypertension (Davis and Schiff, 1988).

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Symptoms Most cases of endometriosis of the peritoneum overlying the bladder are asymptomatic, discovered during surgical investigation of pain originating in endometriosis of the posterior pelvis. In patients with deeper disease, pain with micturition and microscopic haematuria may be present (Schwartzwald et al, 1992) and more pronounced with menses. Gross haematuria is very rare (Oliker and Harris, 1971). Frequency and urgency are non-specific symptoms which can occur in endometriosis patients without involvement of the urinary system. If hydroureter results from constriction of the ureter by fibrosis, ipsilateral flank pain may result (Lucero et al, 1988), unless the constriction occurs very slowly.

Physical signs Physical examination will almost never reveal signs of urinary tract endometriosis. Among 442 patients with urinary tract involvement, one patient with invasive endometriosis of the posterior bladder wall and of the entire trigone was found to have tender nodularity of the anterior vaginal wall. Occasionally, a patient may display a palpable mid-line suprapubic mass (Aldridge et al, 1985; Hyler et al, 1994). Nodularity of the uterosacral ligament region may be associated with ureteral endometriosis.

Pre-operative imaging studies Because significant urinary tract disease is so rare, intravenous pyelogram (IVP) or ultrasound will rarely reveal hydroureter, hydronephrosis or decreased renal function (Figure 7). For the same reason, cystoscopy will rarely be helpful (Hyler et al, 1994). Like intestinal endometriosis, urinary tract endometriosis is usually a surgical diagnosis.

Surgical techniques Most cases of bladder serosal involvement are simple to treat by laparoscopic excision using sharp dissection, laser excision or electroexcision. Because of the nature of the bladder muscularis, deeper muscularis involvement will require wedge resection as discussed above. Rarely, fullthickness bladder resection will be required (Figure 8). This is simple when the resection is in the bladder dome and easily reached. The involved area of bladder wall is excised, then the mucosa is closed with 3-0 chromic suture and the seromuscularis closed with 2-0 chromic suture. Because urine is sterile, there is no need for a pre-operative preparation. A retention catheter is left in place for 7 to 10 days. Ureteral involvement may require resection of a portion of the wall of the ureter In such a case, a double-J stent (Figure 9) can be passed up the ureter by cystoscopy and the wall of the ureter repaired over the stent with interrupted 4-0 chromic suture (Figure 10). The stent is removed after 2 weeks.

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Figure 7. Anteropostefior nephrotomogmms showing delayed function and blunt calyces of left kidney resulting from endometriosis partially obstructing the left ureter.

Pre-operative IVP or placement of ureteral catheters to enhance intraoperative identification of the ureters has not been shown to make surgery safer and neither technique was used in any patient in this series. The surgeon must still positively identify the ureters visually and dissect them out of fibrosis regardless of their luminal contents or whether they have been exposed to pre-operative diagnostic radiation.

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Figure 8. A small nodule of endometriosis has been removed by full-thickness partial cystectomy from the bladder. Notice the tip of the retention catheter within the bladdel: The defect is closed in two layers.

Figure 9. Invasive endometriosis of the left ureter has been removed by resection of the involved ureteral wall. A double-J stent has been passed across the defect

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Figure 10. The ureteral

D. B. REDWINE AND D. R. SHARPE

defect is repaired over the stent using interrupted 4-0 chromic suture,

Medical therapy of ureteral endometriosis is controversial, some authors finding success (Gantt et al, 1981) and others finding failure (Jepsen and Hansen, 1988). Surgical treatment seems consistently successful.

Conversion to laparotomy In 4 I % of cases of urinary tract endometriosis, intestinal endometriosis is also found. It may be necessary to perform a Iaparotomy if lengthy surgery is anticipated or if the surgeon does not have adequate laparoscopic skills, particularly since invasive urinary tract endometriosis is often accompanied by significant disease elsewhere in the pelvis or intestinal tract. Even in expert hands, laparotomy has been necessary for a case of endometriosis of the bladder dome extending to the trigone with involvement of each ureteral orifice. Resection of the involved bladder dome and the trigone down to the urethra and repositioning of the ureters followed segmental bowel resection and en bloc resection of the pelvic floor for invasive endometriosis associated with obliteration of the cul-de-sac,

Complications There have been no complications resulting from treatment of urinary tract endometriosis in this series.

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Results Removal of the bladder dome and trigone in one patient with bladder pain with micturition resulted in normal, painless bladder function. One patient had invasion of the ureter by endometriosis with resultant hydronephrosis and decreased excretion of IVP dye (Figure 10). Resection of the wall of the ureter involved by endometriosis resulted in improvement of ipsilateral renal function as gauged by repeat IVP several months post-operatively. Review of the published work indicates consistent symptom improvement follows surgical resection of urinary tract disease.

SUMMARY Intestinal and urinary tract involvement by endometriosis may be symptomatic, particularly when invasive disease is present. Even in expert hands, complete excision of all invasive disease cannot be accomplished laparoscopically in every case. The practitioner must balance enthusiasm for the advantages of a laparoscopic approach with limitations of time and skill. Laparoscopy should be abandoned in a particular case if a better job can be performed by laparotomy. Hysterectomy with castration may not relieve symptoms due to invasive disease.

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