Endometriosis Foundation of America
Endometriosis of the Retroperitoneum: Bladder, Ureter and Pelvic Floor
Dr. Tamer Seckin
Thank you very much for all of you staying here. I would like to take a nice shot from here, you all look gorgeous. Maybe I should take my iPhone and do this shot.
Really, today I am going to be talking about things you probably will like because I like to take photographs and this is a testimony of it (taking photo) and Dr. Buterman – thank you. I do like photographs and I like to look at things very closely. I get really passionately involved, addicted. I am really addicted to this from somebody very special here. You all know it is Harry Reich. Harry is special to everybody and he has been to me too. Through Harry I really learned how to control capillary style oozing. He does very patiently after every case, he controls bleeding with the micro bipolar. Apart from that he cuts. He waits, whatever stops, stops. Those patients that you control bleeding heal so well. I know it because I have been following because they are the ones that call me at night, right?
I chose this topic, I assigned this topic to myself, retroperitoneum because you know, hey, all endometrium is actually retroperitoneum otherwise it would not be a disease, right? But it is the organ that is most commonly attacked by endometriosis and endometriosis destroys peritoneum. Peritoneum is an organ, not just a lining, it is an organ. It functions, it has layers. Once peritoneum is destroyed the endo takes over and causes effacement of this organ’s surfaces and all those things that Harry mentioned, deep fibrotic endometriosis takes place maybe, and he is right really. Endometriosis really does not infiltrate like cancer, it is really an inclusionary cyst. It buries itself. It dives in, it covers and the mesothelium covers.
I have to move a little fast because our time is limited. Lone is on my left side and she is going to be yelling at me.
A lot of things happen in the female pelvis. Not only the period you see every month, 400 of them a woman gets, also intraperitoneal there is always ovulation, bleeding, ovulation, bleeding every month, right side, left side. The female pelvis is not an easy ground, there is always something happening. There is a potential sensitivity there. But when the periods are rather eventful, excessive retrograde bleeding, in some women there is more than necessary bleeding. I do believe there is an element of retrograde bleeding in the etiology of endometriosis. Not as much as I used to, my opinion changes also. And I will tell you why.
Peritoneum, here you see multiple layers really, supra mesothelial, intraperitoneal, sub-peritoneal and even that black slide is retroperitoneal where the organs are. Anything that happens on that peritoneal surface interests us. This peritoneum is not really unique to the pelvis. It is all over, it is from Battery Park City all the way to Buffalo. And everything that happens is not only in the pelvis. That is why I picked the topic peritoneum today.
In this woman you see something in the vagina. The same woman; the lesion is all the way up. But there is something special about this particular group of cells which is more aggressive in this woman thank in another woman. This is the thoracic cavity. A couple of weeks ago we did probably, I do not know what anybody else did at Lenox Hill, but with Dr. Stavropolous we did the first elective, proactive ______ resection on a possible endo patient. I have good videos of it but this is not the place to go into those now.
There is one more interesting observation this is again peritoneum being lift up. After I took this peritoneum out I saw this incredible shiny fibrotic material down there, it looked like endometriosis. I marked it specially. I told my fellow. We sent it to pathology, and as usual, no offense Dr. Rogers but, there is no endo there obviously. I was very upset. I called again. I said, “Exhaust the tissue”, “Are you nuts we’ve got to cut 80 more specimens”, “Please do so, I am just looking at something”. Yes, it was endo. It was endometriosis, those things, those little things were endometriosis. So even in early endometriosis we think there is something happening subperitoneally. It does not get from nothing, the older cases that Dr. Reich saw all these end cases. They start somewhere.
Ladies and gentlemen this disease starts at the age of 13/14 and we are catching it very, very late. We have a responsibility. We really do, that is what we are doing here and I really appreciate you are all here. This disease is teaching us.
Again, another model the peritoneum, epithelium separates the vessels go up. Here is my Seckin animation. All the elements of supra mesothelial events that go all the way to the oxidative stress stage where repetitive blood with obviously genetic disturbance in it marinates these supracervical supra mesothelial tissue and separates the cell. What this is trying to say to you, this animation, the vessels go up, spikes up, all these cells signaling, there are all the narrative parts of it but it is the stem cells which are represented by the blue and green. What I am trying to say is that it is not all supra mesothelial, it is also submesothelial. There is significant dialogue between submesothelial blood vessels and the supra mesothelial blood vessels. This crying for oxygen, at one point these cell mass with glands are rescued and oxygenated. And it survives. Then it buries itself and goes on and on.
I will pass the molecular stuff, you can read them. There are a lot of them.
Basically, this is an example of these spiking, very close under blue water. I examined them because it gives me great contrast. I eliminate the yellow and red, personal choice, does it really make me recognize endo more? Maybe not, but I think the pictures are great. These are micro bleeders. Again, bleeding subperitoneally and bleeding again. Then fibrosis; these small fibrosis and linear fibrosis, micro fibrosis and it advances slowly. On the blue this white area is, as Harry said, endo. Rectum ________ and posterior vagina, vesicular junction, and with the rectal probe you see the nodule. Many of these lesions, if you stain them specially, the nerves area always there, even if they are early lesions. They are not crying for nothing. They have some surface tension direct or indirect nerve stimulation.
It is always important to recognize what cautery does, increases surface tension, distorts and contracts the tissue. Rather than therapeutic, it makes the patient worse. There is no pathology, nothing. You do not know what you are really doing, you do not know how far you should burn. How can you burn those lesions? Laser nice, ablation, however it uniformly discolors the base, again, you cannot tell the base if you have endo or not below. Everything is ablated, no pathology and, again, the surface tension on the tissue stays. But here, on an excision with no power, basically the rim, really the corners of the rim, are not sealed. You can see the underlying tissue, you can feel it. There is a feedback, you have pathology, and you know how far you can go down, whether it is rectum or ureter. If the disease is there, you go there and you fix it.
This is another sample of how the excision is done, simply with Wolff scissors. How proximal? This is the uterine vein – you cannot burn in these areas much. This is a Finer, with the tip you can elegantly snip it, snip it and follow the fibrotic material being excised.
I am just going to show you a couple of cases. This is a 35-year-old nurse with 10 years of birth control pills, severe symptoms of pain and infertility – this is an example of cul de sac lateral wall excision. This is how it was. What I do in these cases the ovary usually is freed first. Then I suspend the ovary with GraNee needle like this. This is the other side but it is an example, this is the other side. I hooked them up through the case - I keep them in certain cases 24 hours then I go subperitoneally, inject the methylene blue and give that contrast to my vision. I excise meticulously around the ureter and this whole thing slowly…in the end the idea is basically go subperitoneally and use bipolar direction and excise it here. Let’s move on.
On the other side, again, the same thing. You see how the contrast is giving us the… Great, so you see how the honeycomb peritoneum is not only that lesion you see, it is more than that. It is wider. That really gives us a wide area of excision almost to the peritoneum rectum area.
We will move on to another case. This is the ureter of the same case. This is the same case we just did, I think with Dr. Ansari. We are a team, I have two very good general surgeons willing to work with me. In one case we did a discoid rectal excision and segmental at the same time with bilateral endometrioma. Twenty percent of the time if there is a deep rectal nodule you should be looking somewhere else, there is somewhere else in the sigmoid or sacral area, there is more endometriosis. This is how this case started. This is the inside of the endometrioma, this is an endometrioma cyst and this is the nodule on the right lateral wall. This is how we basically proceed in a case like this. Again, the same scissors. I used harmonic because my general surgeon friend likes it and I do not mind. It is pretty nice in certain cases and I find it practical also. The feedback I get with the scissors is better I think. In this case there was a wide opening in the rectum like 5 cm. We excised this. Rectally we put a bag from the rectum like this, put everything in the bag and pulled it out and stitched this area with two layers with silk. As Harry said we check it with methylene blue, in fact we have to, there is so much denudation between knots it may be air tight but that air tightness could be fake. If there is mucosa it is transparent and we need to put sutures there. Same patient, pathology report.
We are moving on another vaginal patient with similar complaints with vaginal cyst removal in the past appendectomy. This is her MRI. You see a large mass between the rectum and uterus. Cystoscopy, this is the vaginal masses all the way to the liver. Liver nodule – this is how it looked. This is the vagina, you see the layer like a Napoleon cake, as you cut you can see the layer of endometriosis around. This is the vaginal wall posteriorly stitched and we did it with a mini-lap. The lesion and the sigmoid was brought up and put together. This is a patient with four laparoscopies in the past. We were told a reanastomose of the tube. The dictation of the OR was there in fact the urologist in this case could not get into the left ureter. We excised the endo and the obstruction was relieved but we could not put a stent in. I had to put the stent abdominally through the scope. Then we learned that in fact the patient had ureteral bladder anastomosis. So she had two orifices, one was fake, and that was why the urologist struggled. We applied the stent from above like this. It is not easy. So the protective sheet is passed with 4-0 monocryl. We interrupt the stitching on the ureter.
This is another patient who was operated on in the Mayo Clinic, two laparotomies and one hysterectomy. She had BSO later, diffuse pain, bilateral hydronephrosis, not totally obstructed. This is a case after resection which was also stented this is the other side. I think there was some excessive denuding of the ureter. It was rather iatrogenic on the right side. As we repaired it we noticed in this case there was also bladder defect so we closed the bladder also. In this case there were old pelvic specimens showing excessive nerve tissue with hemosiderin and foreign body giant cells.
Moving on…this is another patient, a 26 year old, with a two bowel resection history. Her __________ was removed with the appendix and she had also small bowel resection. She came severely symptomatic for bowel disease. In this case 29 specimens were removed with lymph nodes positive for endometriosis. This is the dilated sigmoid, the uterus and ovary and this is what it is at the end of the case where discoid sigmoid resection was removed. In this case basically this is how the lesion on the sigmoid is with frank excision. The mass was removed. Again, the back was brought to the rectum and the defect was repaired primarily.
My last, maybe not the last…this is a 34-year-old patient who had four surgeries including total hysterectomy and bilateral partial salpingo-oophorectomy. This patient was so symptomatic with leg pain, back pain and dyspareunia with painful bowel movements. This was an interesting case. I will just go to the left side, you will see the ureter. You see as we go down deep in the hypogastrics you see the endometrioma deep chocolate material popped out – you saw that, right? This was interesting it was so deep in this case. Again, there is no guidance here. The hypogastric nerve is right lateral to my scissors underneath the ureter on the left side – you see. This is the lesion. In this case we excised more area. I had the opportunity of looking back to this patient again. She came back. I do not have that video, however, at pelvic exam she continued to have paravaginal mass, parametrial mass. We went back and we excised an exact similar lesion that you saw here where chocolate cysts popped up in the deep hypogastric. This patient is doing very well compared to how she was. She could be one of the persons who may speak today in the “Doctors, Do You Hear Me” session.
This is my last case. This lady is had hydronephrosis, loss of kidney function by 80 percent; and four times laser treatments for superficial endometriosis. During her last laparoscopy procedure her surgeon described the area with superficial endometriosis over the right ureter evaporate. This was the fourth time this was being evaporated. The lesson here is, you know, superficial evaporation does the trick really in this case. She has stents for almost ten years. Parametrial endometriosis blocking the ureter and extending all the way to obturators. Obviously it does not look like…you may think there is nothing here other than the laser, carbon charcoal view here but this is how it looked. As we went in, obviously, again, chocolate deep material popped out with fibrotic again, with chocolate fibrosis around. This is the content of that cystic appearance. As we went deep, Dr. Romoff is not there, but these cases are not point blank ureter peristalsis and everything, they are very bloodied, it is very difficult to identify the tissue. This is all ureter but this is all endo. As we go forward – all the way to the bladder in this case to the obturators and this was also, additionally, cleaned.
The good thing about this patient is she was…when I presented this case in Japan, she was 24 weeks pregnant. I was there in December, and actually she just had the baby last week in Long Island.
I think I am going to cut here. There is one more case but the bottom line here is the disease, even though we do excessive advanced cases we have to be vigilant about the early endo that has fibrotic elements to it. We have to really look for it, scan these patients in close up. Look everywhere. These patients do come back – one out of three patients, some stay symptomatic and some of them are incomplete surgery that we cannot see. You cannot technically do it. Some of those patients also have other problems including prescription drug excess use, very common in New York. We have learned how to watch those patients. I think early diagnosis is the key. Early diagnosis, early intervention is the key to prevention of infertility, prevention of hysterectomy and of having a good quality of life.
I thank you for your attention. Thank you very much.
Endometriosis Foundation of America