Full-Thickness Disc Excision in Deep Endometriotic Nodules of the Rectum: A Prospective Cohort.

BACKGROUND: To date, a majority of patients presenting with large endometriosis of the rectum are managed worldwide by colorectal resection. However, postoperative rectal function may be impacted by radical rectal surgery. OBJECTIVE: The purpose of this study was to assess the postoperative outcomes of patients with rectal endometriosis who are managed by full-thickness disc excision and to compare outcomes of the 2 procedures using a transanal approach. DESIGN: This was a prospective study. SETTINGS: The study was conducted at a university hospital. PATIENTS: Fifty patients with colorectal endometriosis that was managed by disc excision between June 2009 and November 2014 were included in the study. INTERVENTIONS: The procedure included laparoscopic deep shaving, followed by full-thickness disc excision to remove the shaved rectal area. Disc excision was performed using a semicircular transanal stapler (the Rouen technique) in 20 patients, an end-to-end anastomosis circular transanal stapler in 28 patients, and transvaginal excision in 2 patients. MAIN OUTCOMES MEASURES: Preoperative and postoperative assessments of pelvic symptoms and digestive function using standardized gastrointestinal questionnaires were the main measures. RESULTS: The largest diameter of specimens achieved was significantly higher using the Rouen technique (58 ± 9 mm) than the end-to-end anastomosis stapler (34 ± 6 mm). Two rectovaginal fistulas were recorded (4%), and 8 patients presented with transitory bladder voiding (16%). Median postoperative values for the Gastrointestinal Quality of Life Index and the Knowles-Eccersley-Scott-Symptom Questionnaire improved progressively 1 and 3 years after surgery. For patients intending to get pregnant, the cumulative pregnancy rate was 80%, and 63% of pregnancies were spontaneous. LIMITATIONS: The study sample size is small and the design is not comparative; however, direct comparison of patients managed by disc excision and colorectal resection would be inappropriate, because of differences regarding nodule localization and size. CONCLUSIONS: Disc excision is a valuable alternative to colorectal resection in selected patients presenting with rectal endometriosis, achieving better preservation of rectal function. The Rouen technique allows for successful removal of large nodules of the low and midrectum, with favorable postoperative outcomes. (See video abstract, http://links.lww.com/DCR/A208.).

Recurrences and fertility after endometrioma ablation in women with and without colorectal endometriosis: a prospective cohort study.

STUDY QUESTION: What are the recurrence and pregnancy rates in women managed for ovarian endometrioma by ablation using plasma energy with and without associated surgery for colorectal endometriosis? SUMMARY ANSWER: Concomitant management of colorectal endometriosis does not impact either risk of recurrences or probability of pregnancy in women managed for endometrioma ablation using plasma energy. WHAT IS KNOWN ALREADY: No consensus exists on how best to manage patients presenting with ovarian endometriomas and colorectal endometriosis, in terms of impact on fertility preservation and recurrence rates. STUDY DESIGN, SIZE, DURATION: A prospective series of consecutive patients managed for ovarian endometriomas by ablation using plasma energy, over a period of 48 consecutive months. The study included patients with associated colorectal endometriosis (n = 52) and those who were free of colorectal localizations of the disease (n = 72). No women were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS: The 124 women included in this study were managed for either unilateral or bilateral ovarian endometriomas using plasma energy at a university tertiary care center. Recurrences and pregnancy rate were compared in patients with and without colorectal endometriosis. The minimum length of follow-up was 1 year. Cyst recurrences were assessed using pelvic ultrasound and magnetic resonance imaging. Kaplan-Meier and actuarial life-table analysis were used to estimate the recurrence-free survival curve and the probability of pregnancy. The Cox model was used to assess independent predictive factors for recurrences. Pregnancy likelihood and independent predictors were estimated using a regression logistic model. MAIN RESULTS AND THE ROLE OF CHANCE: Mean follow-up was 32 ± 18 months. Forty-eight patients (40.3%) were presumed infertile and attended an assisted reproductive techniques (ART) center. Eighteen patients presented with a recurrence (14.5%). Bilateral localization of endometriomas was the only factor independently related to an increased risk of recurrences [hazard ratio 3.3, 95% confidence interval (CI) 1.2-9.4]. Of the 83 women wishing to conceive (66.9%), 51 became pregnant (61.4%) and 33 of these pregnancies were spontaneous (64.7%). The rates of pregnancy were 65.8% for the group of patients with associated colorectal endometriosis and 57.8% for controls (P = 0.50). Age over 35 years was the only independent factor for which association with pregnancy rates approached the significance threshold (adjusted odds ratio 0.35, 95% CI 0.12-1, P = 0.06). LIMITATIONS, REASONS FOR CAUTION: The study sample size may be insufficient to reveal statistically significant differences related to risk factors which have low impact on the probability of recurrence and pregnancy. Data on ovarian reserve before and after the procedure was not available in all patients, which would have added to our results and the discussion about treatment of endometrioma in general. WIDER IMPLICATIONS OF THE FINDINGS: Concomitant management of colorectal endometriosis does not impact either risk of recurrences or the probability of pregnancy in women having benefited from ovarian endometrioma ablation using plasma energy. Moreover, surgical management of colorectal and ovarian endometriosis may allow spontaneous conception in one out of three patients, thus reducing expenses related to ART management. STUDY FUNDING/COMPETING INTERESTS: No financial support was received for this study. Horace Roman reports personal fees for participating in a symposium and masterclass presenting his experience in the use of PlasmaJet.

Antimullerian hormone level and endometrioma ablation using plasma energy.

OBJECTIVE: To investigate the impact of ovarian endometrioma vaporization using plasma energy on antimullerian hormone (AMH) level. METHOD: We report a prospective, noncomparative series (NCT01596985). Twenty-two patients with unilateral ovarian endometriomas≥30 mm, with no surgical antecedent and no ongoing pregnancy, underwent vaporization of ovarian endometriomas using plasma energy during the period of November 29, 2010 to November 28, 2012. We assessed AMH levels before surgery, 3 months postoperatively, and at the end of follow-up. RESULTS: The mean length of postoperative follow-up was 18.2±8 months. AMH level significantly varied through the 3 assessments performed in the study, as the mean values±SD were 3.9±2.6 ng/mL before the surgery, 2.3±1.1 ng/mL at 3 months, and 3.1±2.2 ng/mL at the end of the follow-up (P=.001). There was a significant increase from 3 months postoperatively to the end of follow-up (median change 0.7 ng/mL, P=.01). Seventy-one percent of patients had an AMH level>2 ng/mL at the end of the follow-up versus 76% before the surgery (P=1). During the postoperative follow-up, 11 patients tried to conceive, of whom 8 (73%) became pregnant. CONCLUSIONS: The ablation of unilateral endometriomas is followed in a majority of cases by a significant decrease in AMH level 3 months after surgery. In subsequent months, this level progressively increases, raising questions about the real factors that impact postoperative ovarian AMH production.

Postoperative recurrence and fertility after endometrioma ablation using plasma energy: retrospective assessment of a 3-year experience.

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

Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive.

OBJECTIVE: To use postoperative examination by three-dimensional (3D) ultrasound to compare loss of ovarian parenchyma after ovarian endometrioma ablation with the use of plasma energy versus cystectomy. DESIGN: Retrospective "before and after" comparative study. SETTING: University tertiary referral center. PATIENT(S): Thirty women with no previous history of ovarian surgery managed for unilateral ovarian endometrioma >30 mm in diameter. INTERVENTION(S): Endometrioma ablation using plasma energy and ovarian tissue-sparing cystectomy. MAIN OUTCOME MEASURE(S): 3D ultrasound assessment of postoperative reduction in ovarian volume and antral follicle count (AFC). RESULT(S): Fifteen women with comparable baseline characteristics were managed by each technique. Those who underwent cystectomy showed a statistically significant reduction in ovarian volume and AFC when compared with women who underwent ablation using plasma energy. Multivariate analysis showed that the relationship between the decrease in ovarian volume and AFC and the use of cystectomy remained statistically significant after adjustment for age, previous pregnancy, and cyst diameter. CONCLUSION(S): When compared with plasma energy ablation, cystectomy is responsible for a statistically significant decrease in ovarian volume and a statistically significant reduction in AFC. This data should be taken into account in therapeutic decision-making concerning women attempting pregnancy, especially where there are other risk factors for postoperative ovarian failure.

Ultrasound ovarian assessments after endometrioma ablation using plasma energy.

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

Management of nonpuerperal uterine inversion using a combined laparoscopic and vaginal approach.

Although described as a postpartum complication, uterine inversion may also occur in nonpregnant women. We report a case of nonpuerperal uterine inversion, because of a large exteriorized submucous myoma in a 40-year-old woman, which was surgically managed by hysterectomy using a combined laparoscopic and vaginal approach.

Vaporization of ovarian endometrioma using plasma energy: histologic findings of a pilot study.

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