Combined vaginal-laparoscopic approach vs. laparoscopy alone for prevention of bladder voiding dysfunction after removal of large rectovaginal endometriosis.

STUDY OBJECTIVE: To assess whether the combined vaginal-laparoscopic route may reduce the risk of postoperative bladder atony, when compared to an exclusively laparoscopic approach, in patients presenting with deeply infiltrating rectovaginal endometriosis with extensive vaginal infiltration. DESIGN: Retrospective comparative cohort study using data prospectively recorded in the CIRENDO database. SETTING: Academic Tertiary Care Centre. PATIENTS: One hundred and thirty-two consecutive patients who underwent surgery of rectovaginal endometriosis with vaginal infiltration measuring greater than 3cm diameter. INTERVENTIONS: Combined vaginal-laparoscopic versus laparoscopic approach. MEASUREMENT AND MAIN RESULTS: Sixty-two patients underwent excision of endometriosis via a combined vaginal-laparoscopic approach (study group, or cases), while 71 patients underwent surgery via an exclusively laparoscopic route (controls). Rates of preoperative cyclical voiding difficulty and sensation of incomplete bladder emptying were comparable between the two groups. Preoperative urodynamic assessment was carried out in 18% of cases and 38% of controls, with abnormal results in 27.3% and 11.1% of cases and controls respectively. Early postoperative voiding difficulty (post-void residual>100mL) occurred in 14.7% and 24.3% of cases and controls respectively. There was a significant reduction in risk of intermittent self-catheterisation of 13% at time of discharge in the study cases. Three months postoperatively, one case and 6 controls had persistent voiding dysfunction requiring prolonged self-catheterisation. CONCLUSION: The combined vaginal-laparoscopic approach for large rectovaginal endometriotic nodules could reduce the risk of postoperative bladder dysfunction, when compared to an exclusively laparoscopic approach, most likely due to a reduced risk of damage to the pelvic splanchnic nerves at the paravaginal level.

Improvement of digestive complaints in women with severe colorectal endometriosis benefiting from continuous amenorrhoea triggered by triptorelin. A prospective pilot study.

OBJECTIVE: To assess the impact of therapeutic amenorrhoea triggered by triptorelin in the digestive complaints of women with deep endometriosis infiltrating the rectum. DESIGN: Prospective series of consecutive patients with deep endometriosis of the rectum enrolled over a period of 17 consecutive months. SETTING: University tertiary referral center. PATIENTS: Seventy patients. INTERVENTIONS: Medical therapy (triptorelin 11.25 mg and add-back therapy using estradiol) administered for 3.4±1.8months before surgery. MAIN OUTCOME MEASURES: Gastrointestinal standardised questionnaires before beginning medical treatment and the day before surgery. RESULTS: The most frequent digestive complaints at baseline were: defecation pain in 77.1% of patients, bloating in 60%, diarrhoea in 54.3% and constipation in 50%. The largest diameter of the rectal area infiltrated by the disease was <1cm in 12.2% of women, 1 to 2.9 cm in 34.3% and ≥3cm in 51.4%. Multiple colorectal nodules were found in 32.9%. Medical treatment led to disappearance of cyclic defecation pain in 78.6%, dyschesia in 58.3%, diarrhoea in 58.3% and bloating in 50%. Relieving digestive complaints was not significantly related to either length of triptorelin administration or size of rectal infiltration by deep endometriosis. CONCLUSION: Therapeutic amenorrhoea averaging 3 months allowed complete improvement of various cyclic digestive complaints in more than half of patients. In selected patients, continuous therapeutic amenorrhoea could compensate for the lack of complete resection of deep infiltrating endometriosis of the rectum, when this latter is likely to result in a high rate of postoperative morbidity.