Extragenital endometriosis

EXTRAGENITAL ENDOMETRIOSISDr. Bulent UrmanKoc University School of MedicineDepartment of Obstetrics and GynecologyAmerican Hospital of Istanbul

Extragenital endometriosisEndometriosis involving other organs

Rectovaginal septum or retrocervicalIntestinalBladderAbdominal wallDiaphragmThoracic

Diagnosis is difficultCyclic symptoms may give a clue

Bowel endometriosis• Bowel endometriosis is reported to be present in 5-40% of

patients with pelvic endometriosis • Rectum and sigmoid are the most common sites (up to

95% of cases)• 5-20% of the cases have appendix endometriosis• Endometriosis of the small bowel is rare

Symptoms• Chronic abdominal pelvic pain• Dyschezia (pain during defecation during menstrual

period)• Dysmenorrhoea• Dyspareunia• Tenesmus,• Constipation or diarrhea• Rectal bleeding

Innervation of DIE

From Wang et al. HR 2010

From Bazot et al. F&S 2009

From Bazot et al. F&S 2009

Evaluation of DIE with bowel involvement

From Saccardi et al. Ultrasound Obstet Gynecol 2012

Treatment• Aysmptomatic patient-Watchful waiting• Symptomatic patient-Surgery

• Shaving of superficial lesions• Discoid resection/anterior rectal wall excision• Segmental colorectal resection-anastomosis

Surgical treatment of DIE with colorectal involvementBowel surgery N (%) Previous

surgeriesIndication Histological

confirmation

Mixed Procedures

17 studies 1791 patients

Resection/ anastomosis

737 (39.9%) 58.8% Pain (62.9%) 83.2%

Full thickness disc excision

375 (20.3%)

Shaving/ superficiaal excision

679 (36.8%)

Only resection and anastomosis

32 studies 2039 patients

59% Pain 75.2%Pain and infertility 24.8%

99.2%

From Meuleman HR Update 2011

A-Complete segmental resectionB-Residual diseaseC-No bowel endo From Stepnievska et al. F&S 2010

Long term follow-up of patients who underwent LS surgery for colorectal endometriosis

Recurrence

From de Cicco et al. BJOG 2010

Laparoscopic procedures performed for deep infiltrating endometriosis (n=101)Procedure Number

Dissection of the culdesac+resection or shaving of the uterosacral ligaments

26

Dissection of the culdesac+deep endometriosis nodule excision

37

Dissection of the culdesac+shaving of rectal and sigmoid endometriosis lesions

8

Dissection of the culdesac and+rectal resection 11Dissection of the culdesac+nodule excision and rectal resection

10

Dissection of the culdesac+sigmoid colon resection 7Dissection of the culdesac+nodule excision+rectal resection+partial cyctectomy

2

American Hospital Data (unpublished)

Complications (Bowel endometriosis-mixed surgery n=38)Complication Number

Fistula formation 0Temporary voiding problems 2Infection 0Follow-up 1-38 moRecurrence of bowel lesions 2/38Recurrence of pain 21 (20.8%)

Abdominal wall endometriosis-a review of 445 cases

From Horton et al. Am J Surg 2008

From Horton et al. Am J Surg 2008

Diagnosis• Palpation• US• MRI-the presence of blood products in an anterior abdominal wall

mass at magnetic resonance (MR) imaging with no other explanation is strongly suggestive of scar endometriosis (RadioGraphics 2012; 32:2031–2043)

• Fine needle aspiration biopsy (Journal of Cytology / January 2015 / Volume 32 / Issue 1)

Differential diagnosis

Treatment• Medical treatment is not successful (Hensen et al. AJR

2006)• Wide surgical excision is necessary

Other sites of extragenital endometriosis

• Bowel• Bladder• Skin• Diaphgram• Lung• Kidney• Liver• CNS and the spine• Pericardium• Leg• Eyes, nose, ears

Liver

Brain

Lung and diaphgram

Eyes

Conclusions• Extragenital endometriosis is relatively common• Almost all organs are affected• A high index of suspicion is necessary to make the

diagnosis• Surgical resection is often necessary and curative