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Long-term follow-up after conservative surgery for bladder endometriosis
REPRODUCTIVE SURGERY Long-term follow-up after conservative surgery for bladder endometriosis Luigi Fedele, M.D.,a Stefano Bianchi, M.D.,b Giovanni Zanconato, M.D.,c Valentino Bergamini, M.D.,c Nicola Berlanda, M.D.,a and Luca Carmignani, M.D.d a
Departments of Obstetrics and Gynecology and d Urology, Ospedale San Paolo, and b Department of Obstetrics and Gynecology, Clinica “Luigi Mangiagalli,” University of Milan, Milan; and c Department of Maternal and Child Health, Biology and Genetics, University of Verona, Verona, Italy
Objective: To describe the long-term outcome of surgical conservative treatment of bladder endometriosis. Design: Descriptive study. Setting: Tertiary referral center for the treatment of endometriosis. Patient(s): Forty-seven patients with symptomatic bladder endometriosis. Intervention(s): Partial cystectomy by laparoscopy or laparotomy. Main Outcome Measure(s): Rates of recurrence at a 36-month follow-up. Result(s): All 14 patients with isolated bladder dome lesions remained symptom-free. Among the 33 patients with lesions involving the vesical base and vesicouterine septum, cumulative recurrence rates at 36 months were 24.7% and 15.5% for recurrence of symptoms and of clinical-instrumental evidence of lesion, respectively. The only factor influencing rate of recurrence was the extent of surgical excision. When the resection included both the vesical lesion and a 0.5- to 1-cm deep portion of the adjacent myometrium, recurrence was significantly less frequent compared to the removal of the bladder lesion only (7% vs. 37% for symptom recurrence and 0% vs. 26% for clinical-instrumental recurrence, respectively). Conclusion(s): Conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality. (Fertil Steril威 2005;83:1729 –33. ©2005 by American Society for Reproductive Medicine.) Key Words: Bladder endometriosis, adenomyosis, deep endometriosis, laparoscopic surgery
Endometriosis involving the bladder is a rare condition, associated to heterogeneous anatomopathological findings (1), whose pathogenetic mechanisms remain controversial. According to the three major etiopathogenetic theories proposed, vesical endometriosis may develop from mullerian remnants in the vesicouterine septum (2), or as an extension of an adenomyotic nodule of the anterior uterine wall (3), or from implantation of regurgitated endometrium (4, 5). Treatment of this condition consists of surgical ablation of endometriotic nodules (6), which has traditionally been performed by laparotomy. However, several investigators have reported the feasibility and efficacy of the laparoscopic approach (7–9), although most previously published articles on surgical treatment of bladder endometriosis included small series or single patients and did not evaluate long-term outcome. As a consequence reliable data are needed, based
Received August 5, 2004; revised and accepted December 2, 2004. Reprint requests: Luigi Fedele, M.D., Clinica Ostetrico-Ginecologica dell’Università di Milano, Ospedale “San Paolo,” Via Di Rudinì n. 8, 20142 Milano, Italy (FAX: 39-02-50323062; E-mail: [email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.12.047
on a larger series of patients and with an adequate period of follow-up. In this article we report the long-term outcome of surgical conservative treatment for bladder endometriosis, based on a 15-year period, with the aim of defining its success rate and to identify prognostic factors affecting the rate of recurrence. MATERIALS AND METHODS In the present study patients who were diagnosed with vesical endometriosis at the referral Centre for Endometriosis, directed by Prof. Luigi Fedele at the University Hospital of Milan from 1989 to 1994, and from 1995 to 2001 at the University Hospital of Verona. Due to the descriptive nature of the study, Institutional Review Board approval was not requested. Clinical symptoms suggesting vesical endometriosis were urgency, frequency, suprapubic pain, urge incontinence, and catamenial hematuria. Instrumental workup included urine microscopy and culture, transvaginal ultrasound and cystourethroscopy; in a minority of patients, magnetic resonance imaging (MRI) provided the final diagnosis (10). Surgical treatment was offered to a total of 49 patients with
Fertility and Sterility姞 Vol. 83, No. 6, June 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
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symptoms as well as sonographic or MRI evidence suggesting bladder endometriosis. Two of these patients had an intraoperative diagnosis of a retrovesical uterine fibroid and were subsequently left out of the study. Clinical characteristics of the patients are described in Table 1. In 18 patients the surgical approach was by laparoscopy; the remaining 29 were treated by laparotomy.
FIGURE 1 (A) Transvaginal ultrasound showing an endometriotic nodule of the bladder dome. E ⫽ endometriotic nodule; B ⫽ bladder lumen. (B) Surgical specimen of an endometriotic nodule of the bladder dome.
The decision for the surgical approach was made as a result of the extension of the vesical nodule as ascertained instrumentally before surgery and according to the intraoperative finding. Site of the lesion was another factor influencing the surgeon’s decision. In the presence of a solitary endometriotic nodule affecting the vesical dome (Fig. 1), a partial transparietal cystectomy was performed, by laparotomy until 1995, with a subsequent switch to the laparoscopic approach. Cystoscopic transillumination was used to better define the edges of the lesion and to maximize sparing of unaffected mucosa. The vesical incision was repaired with a double layer of continuous 3-0 Vicryl sutures. When the endometriotic lesion involved the vesical base (Fig. 2), the procedure was as follows: [1] cystoscopy and bilateral catheterization of the ureters, [2] complete dissection of the uterovesical space with separation of the bladder from the isthmic region, [3] partial cystectomy with maximum sparing of the unaffected mucosa, [4] a 0.5- to 1-cm-deep myometrial resection of the uterine wall adjacent to the vesical nodule to remove any adenomyotic focus lying under the vesical lesion, and [5] vesical repair as already described and closure of the anterior uterine wall with interrupted Vicryl 2-0 sutures. Surgical step number 4 has been systematically carried out since 1995. Any other endometriotic lesion was treated before being staged according to the American Fertility Society (AFS) classification (11). Before surgery and at each follow-up visit all patients were requested to complete a questionnaire for the evaluation of the severity of urgency, frequency, and pain at micturition during
TABLE 1
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
Characteristics of 47 patients who underwent surgery for bladder detrusor endometriosis. Age (mean ⫾ SD) 30.5 ⫾ 3.2 Previous surgery for endometriosis 17 (36.2%) Parous 10 (21.3%) Other endometriotic localizations 30 (63.8%) Surgical approach Laparotomy 29 (61.7%) Laparoscopy 18 (38.3%) Follow up (months, mean ⫾ SD) 33.5 ⫾ 20.1 Localization Base 33 (70.2%) Dome 14 (29.8%) Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
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Fedele et al.
menstruation. These symptoms were considered as mild if reported less than once in five micturitions; as moderate if reported more than once in five and less than once in two; as severe if reported more than once in two micturitions. A follow-up was planned for all patients and visits were scheduled every 6 months. At each visit, pain symptoms and urinary complaints were assessed, a pelvic examination and ultrasound evaluation performed; pregnancy was also ruled out. Hypergonadotropic amenorrhea of ⱖ3 months’ duration and need for a medical or surgical treatment implied exclusion from the study. We calculated the estimated proportion of patients with anatomical progression of disease or appearance of pain symp-
Conservative surgery for bladder endometriosis
Vol. 83, No. 6, June 2005
FIGURE 2 (A) Transvaginal ultrasound showing an endometriotic nodule involving the vesical base. E ⫽ endometriotic nodule; B ⫽ bladder lumen; U ⫽ uterus. (B) Surgical specimen of an endometriotic nodule involving the vesicle base.
had an endometriotic nodule of the vesical dome, whereas in 33 patients the vesical base was affected with the involvement of the vesicouterine septum. Thirty patients were also surgically treated for concomitant ovarian or peritoneal endometriosis, a last group of 7 patients received surgical treatment for bowel or rectovaginal septum endometriosis. No intraoperative complications were recorded, but eight patients had postoperative fever. In three cases, the detrusorial nodule reached the vesical trigone close to the ureteral openings; a double-J ureteral catheter had to be left in place for 30 days. The mean follow-up was 33.5 ⫾ 20.1 months (range 24 –108 months). Seventeen women went on a combined pill regimen of variable duration, for contraceptive reasons only. During the follow-up 11 women became pregnant, 9 of them delivered at term and 2 had spontaneous miscarriage. In no case was suppressive hormonal treatment prescribed. One patient became menopausal 6 years after surgery and another one underwent total hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids 5 years later. Recurrence of at least one symptom (urgency, frequency, pain at micturition) of moderate-to-severe intensity occurred in eight women, with a cumulative recurrence rate of 17.5% at 36 months. Clinical and instrumentally proven recurrence was observed in five women, with a cumulative recurrence rate of 10.9% at 36 months. Among the eight patients with symptomatic recurrence, two had previously undergone laparoscopy and were re-treated by laparotomy, in three cases a levonorgestrel-releasing intrauterine device (IUD) was inserted and another three patients were given oral contraceptives (OC) on a continuous regimen. Recurrences were all observed among the patients who had vesical base involvement, whereas all patients treated for a lesion of the vesical dome remained asymptomatic. The cumulative recurrence rates at 36 months were 24.7% and 0% (P⬍.05) for recurrence of symptoms and 15.5% and 0% (P ⫽ not significant) for recurrence of clinical-instrumental evidence of lesion in the former and latter group, respectively.
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
toms attributable to bladder endometriosis by means of survival analysis using the Kaplan-Meier method (SPSS 11.5; SPSS Inc., Chicago, IL). Student’s t-test for continuous data, Fisher’s and 2 test for nominal data, as appropriate, were used to evaluate factors associated with symptom recurrence or objective signs of disease. Univariate analysis has taken into account the time variable with the log-rank test applied to the survival curves obtained with the Kaplan-Meier method. RESULTS All the 47 women included in the study complained of one or more moderate-to-severe urinary symptom(s) during menstruation in the 6 months before surgery. Fourteen patients Fertility and Sterility姞
Tables 2 and 3, which relate only to patients with endometriosis of the vesical base, summarize the relationship between specific factors and recurrence of symptoms or evidence of lesion. Extent of the surgical procedure has been the aspect most significantly associated with recurrence. When resection had included both the myometrium adjacent to the vesical lesion and the vesical wall, recurrence was less frequent than that associated with cases treated less radically. The limited number of cases prevents further stratification of the analysis. DISCUSSION Our results support the conclusion that conservative surgical treatment for vesical endometriosis provides long-term relief of symptoms in more than 80% of patients. In endometriosis affecting the vesical dome, the success rate was in 100% of cases. On the other hand, when the vesical base and the vesicouterine septum were involved, recurrence rate of symptoms was 25% at 3 years; for this specific localization, 1731
TABLE 2 Association between potential prognostic factors and symptoms recurrence in 33 women with base bladder endometriosis lesions. Symptoms recurrence
Age (y) Type of operation Type 1a Type 2b Surgical approach Laparotomy Laparoscopy Previous surgery for endometriosis No Yes Parous No Yes Pregnancy after operation No Yes a b
No
Yes
P value
30.7 ⫾ 0.5
29.4 ⫾ 31.7
NS
12 (63.2%) 13 (92.9%)
7 (36.8%) 1 (7.1%)
.04
22 (81.5%) 3 (50%)
5 (18.5%) 3 (50%)
NS
15 (75%) 10 (76.9%)
5 (25%) 3 (23.1%)
NS
22 (78.6%) 3 (60%)
6 (21.4%) 2 (40%)
NS
19 (73.1%) 6 (85.7%)
7 (26.9%) 1 (14.3%)
NS
Partial cystectomy only (see text for details). Partial cystectomy and resection 0.5- to 1-cm-deep of the myometrium adjacent to the vesical nodule.
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
a radical surgical excision including the endometriotic nodule and a portion of the adjacent myometrium was associated with a lower recurrence rate. Our surgical approach for bladder endometriosis has changed with time, inasmuch as laparoscopy has been applied more frequently to treat lesions of the vesical dome whereas open surgery has been systematically used for lesions of the vesical base. Such rationale has a pathogenetic basis along with an empirical origin. In some cases the vesical lesion appeared to be the result of an infiltrating adenomyotic nodule of the anterior uterine wall (3). Cleavage of the vesical nodule from the uterine wall has always been difficult, with no distinct separation between detrusorial and myometrial fibers. Such technical setback has also been observed by Vercellini and coworkers (5), although they do not share the same pathogenetic view as in our study relating adenomyosis to bladder endometriosis. In our series, histology of the excised myometrium has in all cases shown a diffuse reactive fibrosis and muscle fiber hyperplasia surrounding endometrial glands and stroma. Laparotomy has been the standard surgical approach when dealing with lesions of the vesical base as it allows manual exploration of the detrusor and of the involved myometrium. Extension of the deepest lesions and integrity of the ureters in their intravesical tract can also be ascertained manually. Such information cannot be obtained by any means through 1732
Fedele et al.
laparoscopy, even when the ureters have been previously catheterized. With regard to endometriosis involving the vesical dome, laparoscopy may be as effective as laparotomy, as such lesions can be clearly visualized and adequately defined by concomitant cystoscopic transillumination. Both approaches require a vesical catheter to be left in place for at least 7 days. In our opinion, two factors are responsible for the higher recurrence rate associated with lesions of the vesical base. The first is a surgical aspect implied in the close connection between the lesion, the detrusor, and the openings of the ureters, obviously limiting extension of the surgical resection around the nodule. Second, we believe recurrence may originate from adenomyotic foci of the anterior uterine wall. This idea is supported by the observation that recurrences are less frequent in those patients in whom the anterior myometrium is excised. Our analysis has undoubtedly the intrinsic limitation of an observational study based on a relatively small affected population. However, bladder endometriosis is a rare condition, and our follow-up was reasonably long. Previous articles based on individual cases and small series have focused mainly on feasibility and efficacy of the laparoscopic approach (8, 9) or on pathogenesis of the disease (1) with just one article providing data on long-term follow-up in a series of 15 treated patients (7).
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TABLE 3 Association between potential prognostic factors and base bladder endometriosis lesions recurrence. Base bladder endometriosis recurrence
Age (y) Type of operation Type 1a Type 2b Surgical approach Laparotomy Laparoscopy Previous surgery for endometriosis No Yes Parous No Yes Pregnancy after operation No Yes a b
No
Yes
P value
30.7 ⫾ 1.2
30.5 ⫾ 0.5
NS
14 (73.7%) 14 (100%)
5 (26.3%) 0
.03
24 (88.9%) 4 (66.6%)
3 (11.1%) 2 (33.3%)
NS
18 (90%) 10 (76.9%)
2 (10%) 3 (23.1%)
NS
23 (82.1%) 5 (100%)
5 (17.9%) 0
NS
21 (80.8%) 5 (100%)
5 (19.2%) 0
NS
Partial cystectomy only (see text for details). Partial cystectomy and resection 0.5- to 1-cm-deep of the myometrium adjacent to the vesical nodule.
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
Our observed recurrence rate is low when compared with the accepted rate of recurrence for endometriomas (12, 13) and lesions of the rectovaginal septum (14, 15). Having observed the inverse correlation between extent of surgery and frequency of symptomatic recurrences we believe that the latter should be considered as persistence of the disease rather than a true recurrence. Accordingly, the vesical detrusor is not a likely site of recurrence if surgery was radical in the first place. Our findings, including the fact that none of our patients had gone through adnexectomy, question the idea of transtubal reflux of endometrial cells as the only cause of this type of lesion. In conclusion, conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality. REFERENCES 1. Chapron C, Boucher E, Fauconnier A, Vieira M, Dubuisson JB, Vacher-Lavenu MC. Anatomopathological lesions of bladder endometriosis are heterogeneous. Fertil Steril 2002;78:740 –2. 2. Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 2000;74:1175– 81. 3. Fedele L, Piazzola E, Raffaelli R, Bianchi S. Bladder endometriosis: deep infiltrating endometriosis or adenomyosis? Fertil Steril 1998;69:972–5.
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4. Vercellini P, Meschia M, De Giorgi O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: clinical and pathogenetic implications. J Urol 1996;155:84 – 6. 5. Vercellini P, Frontino G, Pisacreta A, De Giorgi O, Cattaneo M, Crosignani PG. The pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol 2002;187:538 – 42. 6. Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002;29:625–35. 7. Nezhat CH, Malik S, Osias J, Nezhat F, Nezhat C. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002;78:872–5. 8. Chapron C, Dubuisson JB. Laparoscopic management of bladder endometriosis. Acta Obstet Gynecol Scand 1999;78:887–90. 9. Seracchioli R, Mannini D, Colombo FM, Vianello F, Reggiani A, Venturoli S. Cystoscopy-assisted laparoscopic resection of extramucosal bladder endometriosis. J Endourol 2002;16:663– 6. 10. Fedele L, Bianchi S, Raffaelli R, Portuese A. Pre-operative assessment of bladder endometriosis. Hum Reprod 1997;12:2519 –22. 11. American Fertility Society. Revised American Fertility Society classification of endometriosis. Fertil Steril 1985;43:351–2. 12. Ahmed MS, Barbieri RL. Reoperation rates for recurrent ovarian endometriomas after surgical excision. Gynecol Obstet Invest 1997;43:53– 4. 13. Busacca M, Marana R, Caruana P, Candiani M, Muzii L, Calia C, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Am J Obstet Gynecol 1999;180:519 –23. 14. Ford J, English J, Miles WA, Giannopoulos T. Pain, quality of life and complications following the radical resection of rectovaginal endometriosis. BJOG 2004;111:353– 6. 15. Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotch F. Long term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 2004;190:1020 – 4.
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Departments of Obstetrics and Gynecology and d Urology, Ospedale San Paolo, and b Department of Obstetrics and Gynecology, Clinica “Luigi Mangiagalli,” University of Milan, Milan; and c Department of Maternal and Child Health, Biology and Genetics, University of Verona, Verona, Italy
Objective: To describe the long-term outcome of surgical conservative treatment of bladder endometriosis. Design: Descriptive study. Setting: Tertiary referral center for the treatment of endometriosis. Patient(s): Forty-seven patients with symptomatic bladder endometriosis. Intervention(s): Partial cystectomy by laparoscopy or laparotomy. Main Outcome Measure(s): Rates of recurrence at a 36-month follow-up. Result(s): All 14 patients with isolated bladder dome lesions remained symptom-free. Among the 33 patients with lesions involving the vesical base and vesicouterine septum, cumulative recurrence rates at 36 months were 24.7% and 15.5% for recurrence of symptoms and of clinical-instrumental evidence of lesion, respectively. The only factor influencing rate of recurrence was the extent of surgical excision. When the resection included both the vesical lesion and a 0.5- to 1-cm deep portion of the adjacent myometrium, recurrence was significantly less frequent compared to the removal of the bladder lesion only (7% vs. 37% for symptom recurrence and 0% vs. 26% for clinical-instrumental recurrence, respectively). Conclusion(s): Conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality. (Fertil Steril威 2005;83:1729 –33. ©2005 by American Society for Reproductive Medicine.) Key Words: Bladder endometriosis, adenomyosis, deep endometriosis, laparoscopic surgery
Endometriosis involving the bladder is a rare condition, associated to heterogeneous anatomopathological findings (1), whose pathogenetic mechanisms remain controversial. According to the three major etiopathogenetic theories proposed, vesical endometriosis may develop from mullerian remnants in the vesicouterine septum (2), or as an extension of an adenomyotic nodule of the anterior uterine wall (3), or from implantation of regurgitated endometrium (4, 5). Treatment of this condition consists of surgical ablation of endometriotic nodules (6), which has traditionally been performed by laparotomy. However, several investigators have reported the feasibility and efficacy of the laparoscopic approach (7–9), although most previously published articles on surgical treatment of bladder endometriosis included small series or single patients and did not evaluate long-term outcome. As a consequence reliable data are needed, based
Received August 5, 2004; revised and accepted December 2, 2004. Reprint requests: Luigi Fedele, M.D., Clinica Ostetrico-Ginecologica dell’Università di Milano, Ospedale “San Paolo,” Via Di Rudinì n. 8, 20142 Milano, Italy (FAX: 39-02-50323062; E-mail: [email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.12.047
on a larger series of patients and with an adequate period of follow-up. In this article we report the long-term outcome of surgical conservative treatment for bladder endometriosis, based on a 15-year period, with the aim of defining its success rate and to identify prognostic factors affecting the rate of recurrence. MATERIALS AND METHODS In the present study patients who were diagnosed with vesical endometriosis at the referral Centre for Endometriosis, directed by Prof. Luigi Fedele at the University Hospital of Milan from 1989 to 1994, and from 1995 to 2001 at the University Hospital of Verona. Due to the descriptive nature of the study, Institutional Review Board approval was not requested. Clinical symptoms suggesting vesical endometriosis were urgency, frequency, suprapubic pain, urge incontinence, and catamenial hematuria. Instrumental workup included urine microscopy and culture, transvaginal ultrasound and cystourethroscopy; in a minority of patients, magnetic resonance imaging (MRI) provided the final diagnosis (10). Surgical treatment was offered to a total of 49 patients with
Fertility and Sterility姞 Vol. 83, No. 6, June 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
1729
symptoms as well as sonographic or MRI evidence suggesting bladder endometriosis. Two of these patients had an intraoperative diagnosis of a retrovesical uterine fibroid and were subsequently left out of the study. Clinical characteristics of the patients are described in Table 1. In 18 patients the surgical approach was by laparoscopy; the remaining 29 were treated by laparotomy.
FIGURE 1 (A) Transvaginal ultrasound showing an endometriotic nodule of the bladder dome. E ⫽ endometriotic nodule; B ⫽ bladder lumen. (B) Surgical specimen of an endometriotic nodule of the bladder dome.
The decision for the surgical approach was made as a result of the extension of the vesical nodule as ascertained instrumentally before surgery and according to the intraoperative finding. Site of the lesion was another factor influencing the surgeon’s decision. In the presence of a solitary endometriotic nodule affecting the vesical dome (Fig. 1), a partial transparietal cystectomy was performed, by laparotomy until 1995, with a subsequent switch to the laparoscopic approach. Cystoscopic transillumination was used to better define the edges of the lesion and to maximize sparing of unaffected mucosa. The vesical incision was repaired with a double layer of continuous 3-0 Vicryl sutures. When the endometriotic lesion involved the vesical base (Fig. 2), the procedure was as follows: [1] cystoscopy and bilateral catheterization of the ureters, [2] complete dissection of the uterovesical space with separation of the bladder from the isthmic region, [3] partial cystectomy with maximum sparing of the unaffected mucosa, [4] a 0.5- to 1-cm-deep myometrial resection of the uterine wall adjacent to the vesical nodule to remove any adenomyotic focus lying under the vesical lesion, and [5] vesical repair as already described and closure of the anterior uterine wall with interrupted Vicryl 2-0 sutures. Surgical step number 4 has been systematically carried out since 1995. Any other endometriotic lesion was treated before being staged according to the American Fertility Society (AFS) classification (11). Before surgery and at each follow-up visit all patients were requested to complete a questionnaire for the evaluation of the severity of urgency, frequency, and pain at micturition during
TABLE 1
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
Characteristics of 47 patients who underwent surgery for bladder detrusor endometriosis. Age (mean ⫾ SD) 30.5 ⫾ 3.2 Previous surgery for endometriosis 17 (36.2%) Parous 10 (21.3%) Other endometriotic localizations 30 (63.8%) Surgical approach Laparotomy 29 (61.7%) Laparoscopy 18 (38.3%) Follow up (months, mean ⫾ SD) 33.5 ⫾ 20.1 Localization Base 33 (70.2%) Dome 14 (29.8%) Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
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Fedele et al.
menstruation. These symptoms were considered as mild if reported less than once in five micturitions; as moderate if reported more than once in five and less than once in two; as severe if reported more than once in two micturitions. A follow-up was planned for all patients and visits were scheduled every 6 months. At each visit, pain symptoms and urinary complaints were assessed, a pelvic examination and ultrasound evaluation performed; pregnancy was also ruled out. Hypergonadotropic amenorrhea of ⱖ3 months’ duration and need for a medical or surgical treatment implied exclusion from the study. We calculated the estimated proportion of patients with anatomical progression of disease or appearance of pain symp-
Conservative surgery for bladder endometriosis
Vol. 83, No. 6, June 2005
FIGURE 2 (A) Transvaginal ultrasound showing an endometriotic nodule involving the vesical base. E ⫽ endometriotic nodule; B ⫽ bladder lumen; U ⫽ uterus. (B) Surgical specimen of an endometriotic nodule involving the vesicle base.
had an endometriotic nodule of the vesical dome, whereas in 33 patients the vesical base was affected with the involvement of the vesicouterine septum. Thirty patients were also surgically treated for concomitant ovarian or peritoneal endometriosis, a last group of 7 patients received surgical treatment for bowel or rectovaginal septum endometriosis. No intraoperative complications were recorded, but eight patients had postoperative fever. In three cases, the detrusorial nodule reached the vesical trigone close to the ureteral openings; a double-J ureteral catheter had to be left in place for 30 days. The mean follow-up was 33.5 ⫾ 20.1 months (range 24 –108 months). Seventeen women went on a combined pill regimen of variable duration, for contraceptive reasons only. During the follow-up 11 women became pregnant, 9 of them delivered at term and 2 had spontaneous miscarriage. In no case was suppressive hormonal treatment prescribed. One patient became menopausal 6 years after surgery and another one underwent total hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids 5 years later. Recurrence of at least one symptom (urgency, frequency, pain at micturition) of moderate-to-severe intensity occurred in eight women, with a cumulative recurrence rate of 17.5% at 36 months. Clinical and instrumentally proven recurrence was observed in five women, with a cumulative recurrence rate of 10.9% at 36 months. Among the eight patients with symptomatic recurrence, two had previously undergone laparoscopy and were re-treated by laparotomy, in three cases a levonorgestrel-releasing intrauterine device (IUD) was inserted and another three patients were given oral contraceptives (OC) on a continuous regimen. Recurrences were all observed among the patients who had vesical base involvement, whereas all patients treated for a lesion of the vesical dome remained asymptomatic. The cumulative recurrence rates at 36 months were 24.7% and 0% (P⬍.05) for recurrence of symptoms and 15.5% and 0% (P ⫽ not significant) for recurrence of clinical-instrumental evidence of lesion in the former and latter group, respectively.
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
toms attributable to bladder endometriosis by means of survival analysis using the Kaplan-Meier method (SPSS 11.5; SPSS Inc., Chicago, IL). Student’s t-test for continuous data, Fisher’s and 2 test for nominal data, as appropriate, were used to evaluate factors associated with symptom recurrence or objective signs of disease. Univariate analysis has taken into account the time variable with the log-rank test applied to the survival curves obtained with the Kaplan-Meier method. RESULTS All the 47 women included in the study complained of one or more moderate-to-severe urinary symptom(s) during menstruation in the 6 months before surgery. Fourteen patients Fertility and Sterility姞
Tables 2 and 3, which relate only to patients with endometriosis of the vesical base, summarize the relationship between specific factors and recurrence of symptoms or evidence of lesion. Extent of the surgical procedure has been the aspect most significantly associated with recurrence. When resection had included both the myometrium adjacent to the vesical lesion and the vesical wall, recurrence was less frequent than that associated with cases treated less radically. The limited number of cases prevents further stratification of the analysis. DISCUSSION Our results support the conclusion that conservative surgical treatment for vesical endometriosis provides long-term relief of symptoms in more than 80% of patients. In endometriosis affecting the vesical dome, the success rate was in 100% of cases. On the other hand, when the vesical base and the vesicouterine septum were involved, recurrence rate of symptoms was 25% at 3 years; for this specific localization, 1731
TABLE 2 Association between potential prognostic factors and symptoms recurrence in 33 women with base bladder endometriosis lesions. Symptoms recurrence
Age (y) Type of operation Type 1a Type 2b Surgical approach Laparotomy Laparoscopy Previous surgery for endometriosis No Yes Parous No Yes Pregnancy after operation No Yes a b
No
Yes
P value
30.7 ⫾ 0.5
29.4 ⫾ 31.7
NS
12 (63.2%) 13 (92.9%)
7 (36.8%) 1 (7.1%)
.04
22 (81.5%) 3 (50%)
5 (18.5%) 3 (50%)
NS
15 (75%) 10 (76.9%)
5 (25%) 3 (23.1%)
NS
22 (78.6%) 3 (60%)
6 (21.4%) 2 (40%)
NS
19 (73.1%) 6 (85.7%)
7 (26.9%) 1 (14.3%)
NS
Partial cystectomy only (see text for details). Partial cystectomy and resection 0.5- to 1-cm-deep of the myometrium adjacent to the vesical nodule.
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
a radical surgical excision including the endometriotic nodule and a portion of the adjacent myometrium was associated with a lower recurrence rate. Our surgical approach for bladder endometriosis has changed with time, inasmuch as laparoscopy has been applied more frequently to treat lesions of the vesical dome whereas open surgery has been systematically used for lesions of the vesical base. Such rationale has a pathogenetic basis along with an empirical origin. In some cases the vesical lesion appeared to be the result of an infiltrating adenomyotic nodule of the anterior uterine wall (3). Cleavage of the vesical nodule from the uterine wall has always been difficult, with no distinct separation between detrusorial and myometrial fibers. Such technical setback has also been observed by Vercellini and coworkers (5), although they do not share the same pathogenetic view as in our study relating adenomyosis to bladder endometriosis. In our series, histology of the excised myometrium has in all cases shown a diffuse reactive fibrosis and muscle fiber hyperplasia surrounding endometrial glands and stroma. Laparotomy has been the standard surgical approach when dealing with lesions of the vesical base as it allows manual exploration of the detrusor and of the involved myometrium. Extension of the deepest lesions and integrity of the ureters in their intravesical tract can also be ascertained manually. Such information cannot be obtained by any means through 1732
Fedele et al.
laparoscopy, even when the ureters have been previously catheterized. With regard to endometriosis involving the vesical dome, laparoscopy may be as effective as laparotomy, as such lesions can be clearly visualized and adequately defined by concomitant cystoscopic transillumination. Both approaches require a vesical catheter to be left in place for at least 7 days. In our opinion, two factors are responsible for the higher recurrence rate associated with lesions of the vesical base. The first is a surgical aspect implied in the close connection between the lesion, the detrusor, and the openings of the ureters, obviously limiting extension of the surgical resection around the nodule. Second, we believe recurrence may originate from adenomyotic foci of the anterior uterine wall. This idea is supported by the observation that recurrences are less frequent in those patients in whom the anterior myometrium is excised. Our analysis has undoubtedly the intrinsic limitation of an observational study based on a relatively small affected population. However, bladder endometriosis is a rare condition, and our follow-up was reasonably long. Previous articles based on individual cases and small series have focused mainly on feasibility and efficacy of the laparoscopic approach (8, 9) or on pathogenesis of the disease (1) with just one article providing data on long-term follow-up in a series of 15 treated patients (7).
Conservative surgery for bladder endometriosis
Vol. 83, No. 6, June 2005
TABLE 3 Association between potential prognostic factors and base bladder endometriosis lesions recurrence. Base bladder endometriosis recurrence
Age (y) Type of operation Type 1a Type 2b Surgical approach Laparotomy Laparoscopy Previous surgery for endometriosis No Yes Parous No Yes Pregnancy after operation No Yes a b
No
Yes
P value
30.7 ⫾ 1.2
30.5 ⫾ 0.5
NS
14 (73.7%) 14 (100%)
5 (26.3%) 0
.03
24 (88.9%) 4 (66.6%)
3 (11.1%) 2 (33.3%)
NS
18 (90%) 10 (76.9%)
2 (10%) 3 (23.1%)
NS
23 (82.1%) 5 (100%)
5 (17.9%) 0
NS
21 (80.8%) 5 (100%)
5 (19.2%) 0
NS
Partial cystectomy only (see text for details). Partial cystectomy and resection 0.5- to 1-cm-deep of the myometrium adjacent to the vesical nodule.
Fedele. Conservative surgery for bladder endometriosis. Fertil Steril 2005.
Our observed recurrence rate is low when compared with the accepted rate of recurrence for endometriomas (12, 13) and lesions of the rectovaginal septum (14, 15). Having observed the inverse correlation between extent of surgery and frequency of symptomatic recurrences we believe that the latter should be considered as persistence of the disease rather than a true recurrence. Accordingly, the vesical detrusor is not a likely site of recurrence if surgery was radical in the first place. Our findings, including the fact that none of our patients had gone through adnexectomy, question the idea of transtubal reflux of endometrial cells as the only cause of this type of lesion. In conclusion, conservative surgical treatment of bladder endometriosis seems effective in ensuring long-term relief in almost all cases of endometriosis affecting the vesical dome, whereas success rates for deeper lesions involving the vesical base and the vesicouterine septum are lower, depending on the degree of surgical radicality. REFERENCES 1. Chapron C, Boucher E, Fauconnier A, Vieira M, Dubuisson JB, Vacher-Lavenu MC. Anatomopathological lesions of bladder endometriosis are heterogeneous. Fertil Steril 2002;78:740 –2. 2. Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril 2000;74:1175– 81. 3. Fedele L, Piazzola E, Raffaelli R, Bianchi S. Bladder endometriosis: deep infiltrating endometriosis or adenomyosis? Fertil Steril 1998;69:972–5.
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4. Vercellini P, Meschia M, De Giorgi O, Panazza S, Cortesi I, Crosignani PG. Bladder detrusor endometriosis: clinical and pathogenetic implications. J Urol 1996;155:84 – 6. 5. Vercellini P, Frontino G, Pisacreta A, De Giorgi O, Cattaneo M, Crosignani PG. The pathogenesis of bladder detrusor endometriosis. Am J Obstet Gynecol 2002;187:538 – 42. 6. Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002;29:625–35. 7. Nezhat CH, Malik S, Osias J, Nezhat F, Nezhat C. Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma. Fertil Steril 2002;78:872–5. 8. Chapron C, Dubuisson JB. Laparoscopic management of bladder endometriosis. Acta Obstet Gynecol Scand 1999;78:887–90. 9. Seracchioli R, Mannini D, Colombo FM, Vianello F, Reggiani A, Venturoli S. Cystoscopy-assisted laparoscopic resection of extramucosal bladder endometriosis. J Endourol 2002;16:663– 6. 10. Fedele L, Bianchi S, Raffaelli R, Portuese A. Pre-operative assessment of bladder endometriosis. Hum Reprod 1997;12:2519 –22. 11. American Fertility Society. Revised American Fertility Society classification of endometriosis. Fertil Steril 1985;43:351–2. 12. Ahmed MS, Barbieri RL. Reoperation rates for recurrent ovarian endometriomas after surgical excision. Gynecol Obstet Invest 1997;43:53– 4. 13. Busacca M, Marana R, Caruana P, Candiani M, Muzii L, Calia C, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Am J Obstet Gynecol 1999;180:519 –23. 14. Ford J, English J, Miles WA, Giannopoulos T. Pain, quality of life and complications following the radical resection of rectovaginal endometriosis. BJOG 2004;111:353– 6. 15. Fedele L, Bianchi S, Zanconato G, Bettoni G, Gotch F. Long term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol 2004;190:1020 – 4.
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