Surgical Outcomes after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the impact of type of surgery for colorectal endometriosis-rectal shaving or discoid resection or segmental colorectal resection-on complications and surgical outcomes. DATA SOURCES: We performed a systematic review of all English- and French-language full-text articles addressing the surgical management of colorectal endometriosis, and compared the postoperative complications according to surgical technique by meta-analysis. The PubMed, Clinical Trials.gov, Cochrane Library, and Web of Science databases were searched for relevant studies published before March 27, 2020. The search strategy used the following Medical Subject Headings terms: ("bowel endometriosis" or "colorectal endometriosis") AND ("surgery for endometriosis" or "conservative management" or "radical management" or "colorectal resection" or "shaving" or "full thickness resection" or "disc excision") AND ("treatment", "outcomes", "long term results" and "complications"). METHODS OF STUDY SELECTION: Two authors conducted the literature search and independently screened abstracts for inclusion, with resolution of any difference by 3 other authors. Studies were included if data on surgical management (shaving, disc excision, and/or segmental resection) were provided and if postoperative outcomes were detailed with at least the number of complications. The risk of bias was assessed according to the Cochrane recommendations. TABULATION, INTEGRATION, AND RESULTS: Of the 168 full-text articles assessed for eligibility, 60 were included in the qualitative synthesis. Seventeen of these were included in the meta-analysis on rectovaginal fistula, 10 on anastomotic leakage, 5 on anastomotic stenosis, and 9 on voiding dysfunction <30 days. The mean complication rate according to shaving, disc excision, and segmental resection were 2.2%, 9.7%, and 9.9%, respectively. Rectal shaving was less associated with rectovaginal fistula than disc excision (odds ratio [OR] = 0.19; 95% confidence interval [CI], 0.10-0.36; p <.001; I2 = 33%) and segmental colorectal resection (OR = 0.26; 95% CI, 0.15-0.44; p <.001; I2 = 0%). No difference was found in the occurrence of rectovaginal fistula between disc excision and segmental colorectal resection (OR = 1.07; 95% CI, 0.70-1.63; p = .76; I2 = 0%). Rectal shaving was less associated with leakage than disc excision (OR = 0.22; 95% CI, 0.06-0.73; p = .01; I2 = 86%). No difference was found in the occurrence of leakage between rectal shaving and segmental colorectal resection (OR = 0.32; 95% CI, 0.10-1.01; p = .05; I2 = 71%) or between disc excision and segmental colorectal resection (OR = 0.32; 95% CI, 0.30-1.58; p = .38; I2 = 0%). Disc excision was less associated with anastomotic stenosis than segmental resection (OR = 0.15; 95% CI, 0.05-0.48; p = .001; I2 = 59%). Disc excision was associated with more voiding dysfunction <30 days than rectal shaving (OR = 12.9; 95% CI, 1.40-119.34; p = .02; I2 = 0%). No difference was found in the occurrence of voiding dysfunction <30 days between segmental resection and rectal shaving (OR = 3.05; 95% CI, 0.55-16.87; p = .20; I2 = 0%) or between segmental colorectal and discoid resections (OR = 0.99; 95% CI, 0.54-1.85; p = .99; I2 = 71%). CONCLUSION: Colorectal surgery for endometriosis exposes patients to a risk of severe complications such as rectovaginal fistula, anastomotic leakage, anastomotic stenosis, and voiding dysfunction. Rectal shaving seems to be less associated with postoperative complications than disc excision and segmental colorectal resection. However, this technique is not suitable for all patients with large bowel infiltration. Compared with segmental colorectal resection, disc excision has several advantages, including shorter operating time, shorter hospital stay, and lower risk of postoperative bowel stenosis.

Predictive approach in managing voiding dysfunction after surgery for deep endometriosis: a personalized nomogram.

INTRODUCTION AND HYPOTHESIS: The aim was to develop a nomogram based on clinical and surgical factors to predict the likelihood of voiding dysfunction after surgery for deep endometriosis. METHODS: This was a retrospective study of 789 patients (training set) who underwent surgery for deep endometriosis with colorectal involvement from January 2005 through December 2017 at Tenon University Hospital. A multivariate logistic regression analysis of selected risk factors was performed to construct a nomogram to predict postoperative voiding dysfunction. The nomogram was externally validated in 333 patients (validation set) from Rouen University Hospital. RESULTS: Postoperative voiding dysfunction occurred in 23% of the patients (180/789) in the training set. Age, colorectal involvement/management, colpectomy and parametrectomy were the main factors associated with an increased risk of voiding dysfunction and were included in the nomogram. The predictive model had an internal concordance index of 0.79 (95% CI: 0.77-0.81) after the 200 repetitions of bootstrap sample corrections and showed good calibration. The ROC area related to the nomogram for external validation was 0.74 (95% CI: 0.72-0.76). CONCLUSIONS: The nomogram we present here, based on four clinical and imaging characteristics, could be useful in predicting postoperative voiding dysfunction for women undergoing surgery for deep endometriosis. Patients could thus be better informed about this postoperative risk and the surgical strategy adapted according to individual risk. The accuracy of the tool was validated externally but additional validation is required.

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis. DATA SOURCES: We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction. METHODS OF STUDY SELECTION: Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted. TABULATION, INTEGRATION AND RESULTS: Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I2 = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I2 = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I2 = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I2 = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I2 = 63%; p = .28). CONCLUSION: Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.

Prevesical peritoneum interposition to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: Results of a pilot study.

OBJECTIVE: To evaluate the risk of rectovaginal fistula after en bloc hysterectomy and colorectal resection (H-CR) for endometriosis using prevesical peritoneum interposition. STUDY DESIGN: A retrospective study conducted at Tenon University Hospital, expert center in endometriosis, from June 2016 to June 2018. Patients undergoing H-CR with prevesical peritoneum interposition without protective defunctioning stoma were included. RESULTS: Of the 160 patients who underwent surgery with colorectal resection for endometriosis during the study period, 27 had H-CR (15 with segmental and 12 with discoïd colorectal resection) and were included. The median age (range) was 45 years (41-47.5). Eight patients (13 %) were nulliparous. All procedures were performed by laparoscopy. Parametrial resection was performed in 14 cases (52 %). Associated bowel procedures were ileocecal resection (n = 5) and appendectomy (n = 2). Median follow-up (range) was 14.6 months (10.5-20.2). Nine (33.3 %) patients experienced intra- or postoperative complications including one grade I, four grade II, two grade IIIA and two grade IIIB complications (Clavien-Dindo classification). Seven patients (26 %) experienced postoperative voiding dysfunction. One suspicion of rectovaginal fistula associated with pelvic abscess was diagnosed 4 weeks after surgery but not confirmed during a second operation. CONCLUSION: Despite the small sample size, the present pilot study supports the practice of prevesical peritoneum interposition to limit the risk of rectovaginal fistula in patients who undergo H-CR for deep endometriosis.

Recurrence after Surgery for Colorectal Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: The recurrence rate after colorectal surgery for endometriosis is up to 50% at 5 years. The aim of the current review and meta-analysis was to assess recurrence associated with shaving, disc excision, and segmental resection for endometriosis with colorectal involvement. DATA SOURCES: A systematic review was performed by searching the PubMed, ClinicalTrials.gov, EMBASE, Cochrane Library, and Web of Science databases for publications before February 28, 2019, using the terms "colorectal endometriosis" and "recurrence" in English. The outcome measure was histologically proven recurrence 1 year after the index surgery. METHODS OF STUDY SELECTION: Studies rated as good or fair by a study quality assessment tool were included. Two reviewers independently assessed the quality of the studies; discrepancies were discussed, and if a consensus was not reached, a third reviewer was consulted. TABULATION, INTEGRATION, AND RESULTS: Of 156 relevant published trials, 41 were systematically reviewed and 4 were included in the meta-analysis. The risk of recurrence was higher after rectal shaving than after both segmental resection (odds ratio [OR], 5.53; 95% confidence interval [CI], 2.33-13.12; I2 = 0%; p = .001) and disc excision for histologically proven recurrence (OR, 3.83; 95% CI, 1.33-11.05; I2 = 0%; p = .01). This difference was not significant when comparing disc excision with segmental resection (OR, 2.63; 95% CI, 0.8-8.65; I2 = 0%; p = .11). CONCLUSION: The current analysis shows that the risk of recurrence is lower when segmental resection or disc excision is performed than when rectal shaving is performed. This finding is important when deciding the most appropriate surgical management.

How to perform a laparoscopic pelvic sentinel lymph node dissection using near-infrared fluorescence with indocyanine green in gynecological cancers.

The role of pelvic sentinel lymph node dissection (SLND) is increasing in oncological pelvic surgery, especially in the management of cervical and endometrial cancer.SLND using indocyanine green (ICG) is safe and effective, and its sensitivity is higher than with other detection methods. The advantages of ICG are its low toxicity, its confinement within the vascular compartment, its rapid excretion, and the rarity of allergic reaction. These advantages confer to this fluorescent dye a superiority over blue, which can cause anaphylactic reactions. Using ICG does not require advance planning involving nuclear protection and delayed surgery, as are mandatory when using 99Tc detection. ICG allows the surgeon to visualize the lymph nodes through the peritoneum and thus avoid wide dissection.According to European guidelines,1 the indications for SLND in cervical cancer are for patients with FIGO (International Federation of Gynecology and Obstetrics) IA1-IA2 disease, lymphovascular space involvement - positive status, without systematic pelvic lymphadenectomy - and patients with FIGO IB1-IIA1 disease, prior to systematic pelvic lymphadenectomy. Guidelines1 2 for endometrial cancer management state that SLND is indicated in cases of low-risk endometrial cancer (FIGO IA, grade 1-2), without systematic lymphadenectomy in cases of non-detection, with the technique being preferable to systematic lymphadenectomy in cases of intermediate-risk endometrial cancer (FIGO IB, grade 1-2, or FIGO IA, grade 3).2 Our objective is to review the technique of ICG injection and the real-time detection of pelvic SLNs using near-infrared imaging by means of a step-by-step explanation of the procedure using an instructional Video 1.

Laparoscopic uterine fixation to spare fertility before pelvic radiation therapy.

OBJECTIVE: To describe a surgical technique for laparoscopic uterine fixation (LUF) to decrease uterine radiation therapy side effects in case of rectal or anal cancer. DESIGN: This video article uses a surgical case to demonstrate the detailed technique. Institutional Review Board approval was not required for this video presentation. SETTING: University hospital. PATIENT(S): A 26-year-old nulliparous female patient diagnosed with rectal adenocarcinoma and liver metastases. After the completion of right hepatectomy and neoadjuvant chemotherapy with the use of the FOLFOX regimen, pelvic radiation therapy was applied before tumor excision. INTERVENTION(S): The patient underwent laparoscopic ovarian transposition. During the same intervention, we fixed the uterus with three late resorbable sutures into the fascia of the anterior abdominal wall as cranial as possible to remove the uterus away from the radiation field. MAIN OUTCOME MEASURE(S): Value and feasibility of LUF. RESULT(S): LUF was feasible and effective. Estimated isodoses demonstrated that this intervention may decrease uterine consequences of pelvic radiotherapy. The patient did not report any specific pain or complication in the postoperative period. Three months after the completion of pelvic concurrent chemoradiation therapy, the patient had normal menstrual periods. Hormonal blood tests were satisfactory. Ultrasound showed persistent ovarian function. CONCLUSION(S): Considering its simplicity of realization, LUF should be discussed for reproductive-age patients before undergoing pelvic radiotherapy for anal or rectal cancer. A close collaboration is required between surgeons and radiation oncologists to optimize the treatment and to decrease side-effects of radiotherapy. Intensity-modulated radiation therapy may contribute to enhance a multimodal fertility-sparing strategy in global management of young patients.