C.Y. Liu, MD
I can only speak to you about my clinical experience of endometriosis and my assignment is to talk about the surgical treatment for deep, infiltrating endometriosis. As I said, from my point of view, endometriosis is not all the same and it behaves differently. Until we have a certain way of telling us what type of endometriosis we are dealing with in our individual patients I will have to go by my own clinical judgment. My judgment is based on two things. One is by the location of endometriosis and the other one is simple, by histological appearance. There are basically three locations: one is the peritoneal, one is the ovarian and one is the endometriosis involving the endopelvic fascia, or the pelvic floor, namely retrocervical rectovaginal septum, going down to involve the vagina anteriorly, posterior into the rectosigmoid colon, lateral and superiorly to the uterosacral ligament, _ ligament and the perimetrium, which could involve the ureter and the pubocervical fascia, endometriosis involves even that area and can involve the bladder. All these three locations behave differently.
Ovarian endometriosis is going to behave differently from the peritoneal. Peritoneal is different from the fascia of the pelvic floor. Histological appearance is based on glandular appearance, whether it is in more high proliferative phase or not, and stromal appearance is more disorganized, and the ____ of degree of fibrosis also tells us a lot. Back in 1989 we started to call some of the endometriosis that looked like adenomyosis of the uterus, deep infiltrating endometriosis, and what Harry likes to call deep infiltrating fibrotic endometriosis, which I think is more descriptive.
Here is superficial peritoneal endometriosis. These types of endometriosis are superficially implanted and most patients do not have really bad symptoms, they may have some, and they usually respond to hormonal therapy. Adenomyosis or also called deep infiltrating fibrotic endometriosis is less common. It tends to have a deeper invasion into the pelvic floor and much more simple matter, almost 100 percent symptomatic, including infertility. It usually does not respond to hormonal therapy.
This is what we are going to talk about this afternoon – endometriosis, which involves the fascia of the pelvic floor. This is the rectovaginal septum. We will also talk about the bladder and the ureter. The treatment for deep infiltrating fibrotic endometriosis right now is surgical. There is no medicine for it. What are the main goals for established surgery? One is the total excision of all the visible endometriosis. If we do not excise it all clean the patient will continue to have the symptoms. And even if you do excise it all cleanly, and you think it is complete, we are not able to guarantee they will not have any more pain. And as Dr Meana mentioned about surgery not being enough, they will still need counseling.
Number two of course is to restore the anatomy to promote fertility. Here is endometriosis involving the cul-de-sac, it can look like this, to a different degree and it can go even down to involve the rectal wall. This kind of endometriosis, the difficult part is that deep inside the structure when you look laparoscopically from here, or open surgery, you do not see much. For example, this patient here you only see an endometrium implant here. And you think well, that is not much. If you use an AFS classification it is really a low score. But, when you start to excise it, the tube and ovary look perfectly normal by the way in this case if you look there, when you start to excise it you feel a nodule, you feel fibrotic tissue right there. I am speeding it up a little bit. The more you cut the deeper you go. This kind of endometriosis when you are doing excision they do not bleed because it is all fibrotic. When you are doing this type of surgery you need to put a rectal probe in to guide you a little for where the rectum is. See right here, when you cut it you see some of the chocolate fluid coming up, which means you have not cut deep enough. He had to excise ____ and you get into the healthy tissue. It looks like the excision is a big hole but it is not enough. There it is clean, when you touch it, it is kind of nice and soft but here again, it still feels hard and there is a nodule. During this kind of surgery you need to do frequent rectovaginal exam to make sure you do not miss out because sometimes by looking at it you may not be able to tell. By touching it you can tell a little bit, but the best way still is to do a rectovaginal exam in the middle of the surgery. Look there, all the lesions. Again, that kind of chocolate, like a fluid, leaking out, it is not cut enough and you have to cut more. The key is that it does not matter where this endometriosis is, on the bowel, on the bladder or on the ureter, if it is there you need to excise it. If you do not it is going to give the patient trouble and the chances of another surgery will be high. We just keep on cutting all the fibrotic tissue until it is completely clean. Lo and behold, here is some fecal material leaking out. We have entered into the bowel already. But we cannot stop here, we still need to continue to excise all the endos. Here is some more. Is the picture clear enough to see the white fibrotic material? You can tell this is another nodule right there. It is right on the anterior rectal wall. This is a rectal probe. You see that why you see inside the rectum, the rectal probe is really helpful for us to do the surgery. When you start to have some bleeding it is a good sign, it means you are near to the healthy tissue. This part is at the end of it. At this point I put my finger in again and do the rectovaginal exam and make sure I do not feel any more nodules. If there are still nodules I will have to excise it and go back. A bit of hole on the rectum is not a big deal, you just sew it back up usually with two layers with the muscularis mucosa and then, just two layers and they are doing very well. You can feel them as soon as they pass gas which usually happens within the first 24 hours.
Doing endometriosis surgery does require a certain kind of suturing skill because you are going to get into the bowel, get into the bladder and get into the ureter. I am going to speed this up. Do the two layers and then continue to close it. I thought I had 50 minutes to talk and then I found out I only had 40 minutes, so I am speeding this up a little bit. Then reconstruct to cover up this hole and this will be at the end of the surgery. Looks like a new cul-de-sac and excise all the endo. This patient did very well.
Endometriosis can move down even further and get into the vagina. Every time, almost 100 percent in my own experience, when I see the endometriosis in the vagina this will always involves the rectum for this patient. The cul-de-sac is always obliterated. This is the same case here the endometriosis on the vagina. This area is always completely obliterated and always involves the rectum that is my experience. I cannot speak for other people. Here you see the endometriosis, the key of doing surgery for endometriosis in the vagina is you have got to start vaginally because you can see the lower margin of the endometriosis in the vagina and make an incision. Otherwise, when you start from above and get into the vagina you do not know where to start. If you make a marker first vaginally it is so much easier to excise the whole thing. In _ some tracing to reduce the bleeding and then just mark the lower margin of the endometriosis and cut directly into the rectovaginal septum. This is a laparoscopic deal now, you can see some endometrial implants on the bowel, always on the _ of the surface of the bowel. Here you can see the bowel stuck to the ovary, which we anticipated. Every time we see endometriosis in the vagina we know it is a big mess. Here you can see the endometrioma ruptured and we try to get into the cul-de-sac. You can see all the anatomy totally distorted. Endometriosis surgery actually is one of the most difficult surgery in gynecology. I think it is the worse than cancer surgery because simply the anatomy is so distorted, so much scarring and you must identify the ureter. The ureter, you can dissect it out or sometimes you have to put the ureter catheter in to help you to identify the ureter. With the rectal probe inside the rectum you know exactly where the ureter is, you are practically home free. You just start to cut it. Usually you do not have to use electrosurgery, you are not sure with the _____ cut, and sometimes it is just so hard. With the anatomy being so distorted a lot of times you will over cut it or you will come across heavy bleeding because you cut the inferior rectal artery or something like that. That is okay. You can see all the fibrosis of this endometriosis. With the rectal probe in the rectum here I cut into the rectal artery. This is in a very deep pelvic area. Make sure you know how to stop this kind of bleeding by first grasping the bleeder first before you try to coagulate the bleeding. It is just a lot of cutting, it looks like we are doing it blindly but we are not. In our minds we are thinking about the anatomy and here continue here, you see exosurgery we use a very high-powered density – you see the chocolate coming out again. We use 100 watts per cut and so the thermal damage or thermo sp____ is really minimal. Now we are getting into the vagina right here. This is under the anterior part of the vagina. In the posterior part of the vagina I would make a marker so I will know where to – here is the vagina cut in already – I will know the extent that I am excising. Both of these are nodules - that is not the cervix. The key is if you do a marker then you know - here is the endometriosis you can see all those – and here is the lower margin, which we made prior to the surgery. That is a very important part of the surgery for the vaginal endometriosis. If you do not do that you will probably get lost, and here we do not know how deep we go down. We resected the whole nodule in the cul-de-sac and you see the rectal probe coming out, which means you have got into the rectum already, which we anticipated. Then there is some more infiltrating endometriosis right on the anterior rectal wall. We have to excise that. Then we can suture, I want you to pay attention to how clean it is right here, the anterior rectal wall. It is completely clean. If you do not clean up all the infiltrating fibrotic endometriosis the patient is not going to get better. So it is very important to do that, look at how clean it is. All the endo has been excised and that is absolutely normal. We continue to close it up and make sure to do what we call a colon patency test. We want to do a water tight closure on the rectum. And you see, very, very clean, all the endo has been excised. In the end all the endometrioma was excised and adhesions were lysed.
Endometriosis of the bladder is endometriosis that involves pubocervical fascia. And here are cystoscopic findings, this patient has a hematuria every time she appeared and she also had a lot of pelvic pain. And this is what the cysto you see here, a big endometriosis right there. This kind of patient is quite involved so usually it would be a good idea to put the iridio of stain first before you start to excise endometriosis of the bladder because you do not want to injure the ureter without knowing it. Sometimes you have to cut through it, sometimes it is inevitable. Look right here the cul-de-sac is also obliterated and this you can bet is invading probably into the rectal area too. We try to take care of the bladder endometriosis first. Here is the anterior part, the bladder. Here is the endometriosis and here is the anterior wall of the uterus close to the cervix. Here the round ligament and anticipate the bladder is tightly adherent to the anterior cervix and low _ segment. Of course, during the dissection, there will be endometriotic fluid coming out, so just keep on dissecting and if you get into the bladder it is okay, you will get into the bladder anyway. You want to free the bladder completely of the uterus. In the end you excise that endometriosis of the bladder. This is all still scarring, dissected and here you see the healthy tissue. This is superiorly. Here is the endometriosis of the bladder. That whole thing here is all fibrotic endo. Here is the healthy tissue now. At this point the bladder is free from the uterus, here the superior part of the bladder. The whole thing needs to be excised and you will try to save as much healthy bladder tissue as possible. The bladder is very, very forgiving. Even if you remove one third to one half of the bladder the bladder capacity can be recovered within about two to three months. But you want to try to save as much healthy bladder tissue as possible. During the process of excising the endometriosis you want to look at the ureter all the time and make sure you do not come close to it. Here the ureter is stained that is a good thing and you can actually see urine coming out from the ureter orifice. The whole thing here is endometriosis. We try to save all the healthy bladder tissue as much as possible.
When you are using electrosurgery for deep infiltrating fibrotic endometriosis you really have to use a high power otherwise it will take forever. The endometriosis has been excised and here the remaining bladder. The ureter seems to be okay. Then we just close it. I like to use zero chromic catgut just with the two layers and then try to make sure it is a water tight closure. So the first area is the muscularis mucosa just like the bowel. Okay, two layers – a lot of suturing. The second layer I use Vicryl you can use chromic if you want to. It really does not make a difference but make sure it is water tight. Make sure you inflate the bladder at the end of the surgery, make sure there are no leaks and you can reperitonize it. This patient got instant relief. No more hematuria during the period, no more pain in that area. Another bladder endometriosis, I think I am going to skip this one. Again, you just have to excise them all in principle.
Talking about ureteral endometriosis, when endometriosis involves the ureter there are two types: one is the limited infiltration to the capsule or the ureter. In that case you can shave it off and you do not have to do any kind of segmental resection. But if the endometriosis is already infiltrated, or invaded it into the muscularis then you will have to excise the whole endometriosis, doing a segmental resection and do a reanastomosis. Here you can see severe endometriosis. The left ovary was stuck to the left pelvic side wall and the sigmoid colon is all there. I am going to move up a little bit here. Here after you separate the ovary and separate the sigmoid colon then you identify the ureter above the lesion. The ureter, you can see it here and here is all the fibrotic endo. You can use electrosurgery or use a CO2 laser. In this case I used a CO2 laser it was hard to excise the endometriosis. This is where the uterine artery crosses over the ureter apparently the whole thing was scarred in. I can see the uterine artery right here so I am going to try to separate it as much as possible. This patient is only 27 years old and never had any children so I do not want to sacrifice her uterine artery. I do not know what the implication of damage to the uterine vessel or to ligate the uterine vessel will do to her future fertility, so I am trying to conserve her uterine artery even others right here. This is all scarring. With a CO2 laser or electrosurgery doing this kind of surgery you just have to be very patient. You cannot be in a hurry. If you are in a hurry you will get into trouble right away. You can see with a small cut that the uterine artery actually grew to the ureter right here. It is very close. Since we want to save the uterine artery we had to separate the uterine artery away from the ureter. If this patient had had a couple of kids already I would probably have ligated the uterine artery over here before I did this part. At this part, at any point, I can damage the uterine artery and then will come across very heavy, heavy bleeding. After I have separated the uterine artery from the ureter I was lucky that I did not damage the uterine artery. Then I could see some of the adhesive bands around the ureter. Let us see now, can you see the band here? If I cut that band the ureter will be freed. So for this patient we do not need to do a segmental resection but the only way you will be able to know that is by setting out and excising all the endometriosis there. In that case this patient will be happy because I do not have to do anything and she can go home the same day or next day without having reanastomosis. We just cut the adhesive bands and the patient was okay. It was a great work experience, she was having some hydroneph ureter already, hydroneph process because of that and we just left it.
The next case is the last case. This is a 29 year old G-0, unfortunately we are dealing with a lot of patients that never had any children and they have extensive disease. She had a history of endometriosis and actually I did surgery on her about four years prior to this surgery. She was complaining of some left loin pain and went to see her primary care physician. He did a CT scan, IVE and he found out this patient had left hydronephrosis and hydroureter on the left side. She was referred to a urologist. The urologist heard that she had had endometriosis before and the urologist referred her back to me. This is the surgery when we first went in. We identified the ureter. This is some _____ structure here, what is it? Is it an artery or what? It is pretty big but you can see movement from superior to inferior. The only organ that moves like that is the ureter, so this is a hydroureter. We kept on dissecting down and followed the ureter toward the deep pelvis. By the way, her pelvis was clean. I had cleaned her out four years prior to this surgery and she had remained clean, there was no evidence of endometriosis, except for this area. We continued to dissect the ureter toward the deep pelvis and lo and behold came across something right here. This is where the problem was. In the patient obviously the endometriosis already had invaded into the muscularis. You cannot just shave it off. We had to do a segmental resection. We decided to proceed with that and started to dissect it in order to do a tension free reanastomosis we had to dissect the ureter all the way to about the pelvic rim. Gynecologists are always afraid of cutting the ureter but now this is a chance for us to cut the ureter on purpose, so to give you a good feeling about when you cut through the ureter. Laparoscopic surgery is micro surgery, so cut. The ureter is actually very heavy too and you can cut it and get instant relief. When you cut you can do a tangential cut or you can just cut 90 degrees, it does not matter because laparoscopic surgery is microsurgery. The key is that you have to excise all the endometriosis. If you do not do that you will not help the patient at all. From this point on you can do a reanastomosis so we put the ureter capsule in and did a reanastomosis. The reanastomosis exactly is a _ taught me years ago with microsurgery for the tubal reanastomosis, 6:00, 12:00. With the ureter I put two, four, eight and the ten, so a total of six stitches in. When you try to do a reanastomosis you need to have a big bite but when you tie the knot you do not want to tie too tight. You need to tie it with dulled tension so the tissue will not – how do you say that? It can reattach very well without tenting up. With 6:00 and 12:00 cut suture long so it can move back and forth and facilitate for you to put the two, four, eight and ten sutures. I do not know if you need six sutures, maybe only four will be enough. After you have reanastomosed it then you put the double J in and leave for about four to six weeks and then the urologist will remove the double J stent in their office.
This is just a very quick overview but I hope and I am pretty sure you can appreciate the difficulties of doing this type of deep infiltrating fibrotic endometriosis. Thank you very much for your attention.