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Laparoscopic diagnosis and treatment of urinary tract endometriosis in a referral center

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Laparoscopic diagnosis and treatment of urinary tract endometriosis in a referral center

Maria Manzone1, Matteo Ceccarello1 – Orcid, Francesco Bruni1, Giovanni Roviglione1 – Orcid, Roberto Clarizia1 – Orcid, Daniele Mautone1 – Orcid, Giuseppe Caleffi1 – Orcid Alberto Molinari1 – Orcid Marcello Ceccaroni1 – Orcid

1 – Department for the Protection of Women’s Health and Quality of Life, ISSA International School of Surgical Anatomy, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona

Corresponding Author: Maria Manzone

maria.manzone@sacrocuore.it

DOI: 10.53146/lriog1202133

Abstract

The diagnosis of extra-genital Deep Endometriosis is very frequent in referral centers. The urinary tract represents the second most affected extra-genital site. Bladder Endometriosis is defined as Deep Endometriosis infiltrating the detrusor muscle, partially or fully. Ureteral endometriosis is subdivided into intrinsic and extrinsic form, with an obstruction to the spread of parametric Deep Endometriosis. Patients often come to a referral center after a long period of lack of medical therapy and / or several incomplete surgeries. While patients with Bladder Endometriosis are symptomatic, Ureteral Endometriosis is more often low / asymptomatic, leading to progressive and silent renal failure. Having a systematic model of pre-operative diagnosis, an intra-operative evaluation plan using the cooperation of a multi-disciplinary team in a referral center, represents the solution able to reducing the consequences of late diagnosis and offer precise surgical treatment. A complete ultrasound scan (pelvic and abdominal) performed by an experienced operator could allow the diagnosis; second level exams (Magnetic Resonance Imaging, CT urograhy, scintigraphy) can help to confirm and define it. The treatment of Bladder Endometriosis depends on various factors (symptoms, extent of the disease, age of the patients, childbearing desire). In cases of refractory to medical therapy, laparoscopic surgery is the treatment that leads to more complete cure, long-term relief of symptoms and low relapse rates. Any ureteral stenosis caused by an intrinsic lesion requires a ureteral resection. Ureterolysis is the procedure for removing extrinsic ureteral lesions that do not cause direct stenosis, preventing disease progression. An intraoperative evaluation of the ureters after ureterolysis is mandatory to determine the surgical outcome. The laparoscopic nerve-sparing eradication of Deep Endometriosis of the urinary tract is the way to provide good results in terms of symptoms’ control and relapses, an improvement of quality of life with a low post-operative complications rate. The possibility in a reference center to make use of a multidisciplinary team is essential to be the best surgical strategy before and intraoperatively.

Keywords: deep endometriosis; bladder endometriosis; ureteral endometriosis; partial cystectomy; uretero-neocystostomy.

Available in LRIOG Nr.3 – 2021

e-ISSN: 1824-0283

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Adnexal surgery “fertility sparing” in deep endometriosis

Editor , , , , , , ArticlesLRIOG 2021-3 , , , .
Adnexal surgery “fertility sparing” in deep endometriosis

Anna Katarzyna Stepniewska1 – Orcid, Giulia Mantovani1, Chiara Signori1, Maria Manzone1, Silvia Baggio1 – Orcid, Paola De Mitri1 – Orcid, Marcello Ceccaroni1 – Orcid

1 – Department for the Protection of Women’s Health and Quality of Life, ISSA International School of Surgical Anatomy, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona

Corresponding Author: Anna Katarzyna Stepniewska

stepniewska.anna@gmail.com

DOI: 10.53146/lriog1202132

Abstract

Adnexal surgery in deep endometriosis represents a significant clinical problem because the patients who suffer from it are typically of childbearing age and often, in addition to aiming for the improvement of painful sym- ptoms, have a desire for pregnancy. Endometriosis can cause infertility and the surgical removal of the disease implies a good chance of conception; at the same time surgery, in particular of endometriomas, involves the risk of a reduction in the ovarian reserve, up to its extreme consequence represented by premature menopause. For this reason, the indications for surgery must be evaluated very carefully and accompanied by an appropriate instrumental study that allows for an adequate surgical procedure; all this, in order to radically remove the disease and not expose the patient to a high risk of recurrence resulting in subsequent surgical gestures and a consequent further reduction of the ovarian reserve. Histological, anatomical aspects and hints on surgical instrumentation are presented, all useful for choosing the most appropriate surgical approach. The various traditional and innovative surgical techniques are also discussed and other additional procedures useful to reduce the risk of decreased ovarian reserve and postoperative adhesions are described.

Keywords: deep endometriosis; laparoscopic surgery; ovarian reserve; fertility.

Available in LRIOG Nr.3 – 2021

e-ISSN: 1824-0283

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Role and evolution of nerve-sparing surgery for the treatment of deep infiltrating endometriosis

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Role and evolution of nerve-sparing surgery for the treatment of deep infiltrating endometriosis

Marcello Ceccaroni1 – Orcid, Roberto Clarizia1, Giovanni Roviglione1, Francesco Bruni1, Daniele Mautone1 – Orcid, Giacomo Ruffo2 – Orcid

1 – Department of Obstetrics and Gynecology, Gynecological Oncology and Mini – Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS “Sacro Cuore – Don Calabria” Hospital, Negrar di Valpolicella, Verona

2 – Department of General Surgery, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona

Corresponding Author: Marcello Ceccaroni

marcello.ceccaroni@sacrocuore.it

DOI: 10.53146/lriog1202140

Abstract

Nerve-Sparing (NS) surgery is a technique which, in the last decades, has shown to be highly effective in order to significantly reduce intestinal, vesical and sexual dysfunctions without reducing surgical results in eradicating Deep Infiltrating Endometriosis (DIE). Following a correct and standardized anatomo-surgical approach, NS technique for DIE can be reproducible by the pelvic surgeon who desires to face surgery for DIE and can lead, for what is possible in severe cases, to an optimal preservation of the majority of the visceral nerve fibers of the pelvis. This approach has shown not to have a negative impact over recurrence rates, which are similar to those related to the classical technique, such as the rates of efficacy over chronic pelvic pain.

Keywords: deep infiltrating endometriosis; laparoscopy; nerve-sparing; radical surgery; surgical anatomy.

Available in LRIOG Nr.3 – 2021

e-ISSN: 1824-0283

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The role of a reference center in the multidisclipinary and interdisciplinary treatment of pelvic endometriosis

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The role of a reference center in the multidisclipinary and interdisciplinary treatment of pelvic endometriosis 

Daniele Mautone1 – Orcid, Simone Orlandi1 – Orcid, Giuseppe Caleffi1 – Orcid, Giuseppe Deledda1 – Orcid, Giovanni Foti1– Orcid, Elena Rossato1– Orcid, Stefano Cavalleri1, Giacomo Ruffo1 – Orcid, Luca Garriboli1 – Orcid,  Marcello Ceccaroni1– Orcid

1 – IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona

Corresponding Author: Daniele Mautone

daniele.mautone@sacrocuore.it

DOI: 10.53146/lriog1202130

Abstract

Endometriosis is a chronic hormone-dependent disease affecting approximately 25-30% of women in the third and fourth decade. Despite its frequency, it is often detected late. The aim of this article was to present a standardized treatment algorithm for an interdisciplinary endometriosis consultation considering medical and surgical approaches. Despite the frequency of endometriosis and a high number of publications dealing with the disease there is a lack of evidence in literature for standardized treatment algorithms allowing a rational diagnostic, medical, multiprofessional and therapeutic approach. The diagnosis includes a structured medical history with the identification of endometriosis-typical symptoms and a gynecological rectovaginal examina- tion, if necessary additional examinations. The treatment algorithm is essentially divided into the phase of diagnosis and the phase of therapy as well as the prevention of recurrence or long-term treatment. A multi-professional team of gynaecology, visceral surgery, vascular surgery ,urology, nutritional medicine, physiatry, gastroenterology, physiotherapy, psychology and psychiatry can be consulted for support. The treatment of endometriosis should be multiprofessional, standardized and reproducible during specialized consultations at certified centers.

Keywords: endometriosis; referral center; endometriosis unit; interdisciplinary approach.

Available in LRIOG Nr.3 – 2021

e-ISSN: 1824-0283

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Ultrasound diagnostic criteria for ovarian and deep endometriosis

Editor , , , , , , , ArticlesLRIOG 2021-3 , , , .
Ultrasound diagnostic criteria for ovarian and deep endometriosis

Mara Albanese1 – Orcid, Carlotta Zorzi1, Anna Katarzyna Stepniewska1 – Orcid, Paola De Mitri1 – Orcid, Giamberto Trivella1, Silvia Baggio1– Orcid, Mariangela Fornalè, Marcello Ceccaroni1– Orcid

1 – Department of Obstetrics and Gynecology, Gynecological Oncology and Mini-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS “Sacro Cuore – Don Calabria” Hospital, Negrar di Valpolicella, Verona

Corresponding authors: Mara Albanese, Carlotta Zorzi

mara.albanese@sacrocuore.it, carlotta.zorzi@sacrocuore.it

DOI: 10.53146/lriog1202129

Abstract

Transvaginal ultrasonography is considered the first-line imaging technique for the diagnosis of endometriosis because it allows accurate exploration of the pelvis. In the evaluation of ovarian disease, ultrasonography is useful in recognizing endometrioma and distinguishing it from other diseases. The “typical” endometrioma is a unilocular cyst with “ground glass” echogenicity. The ultrasound features of endometriotic cysts change during pregnancy due to decidualization and with advancing age. In particular, the presence of vascularized solid component should raise suspicion of malignant formation. In the evaluation of extra-ovarian disease, ultrasound is useful to identify and evaluate the extention of DIE in the pelvic structures. The transvaginal evaluation is a dynamic and interactive exam. It is essential to identify the “sliding sign” of the anterior and posterior compartments, the tenderness of the tissues and organs, the“pain mapping” that means pain induced by the probe. Transvaginal ultrasonography allows for an accurate evaluation of the vagina, particularly the areas of the posterior and lateral vaginal fornixes, the retrocervical area, the uterosacral ligaments, and the rectovaginal septum. The slightly filled bladder allows to evaluate the bladder walls and the presence of endometriotic nodules that appear as linear or spherical hypoechoic lesions protruding towards the lumen, affecting the serosa, the muscle or the (sub) mucosa of the bladder. Deep rectal nodules appear as hypoechoic lesions with regular or irregular borders, poorly or non-vascularized on Color Doppler, which infiltrate the intestinal wall distorting its normal structure. An adequate ultrasound diagnosis is essential to perform adequate patient management.

Keywords: pelvic ultrasound; endometrioma; deep endometriosis; ovarian cyst.

Available in LRIOG Nr.3 – 2021

e-ISSN: 1824-0283

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Diaphragmatic endometriosis: diagnosis and laparoscopic treatment

Editor , , , , , , ArticlesLRIOG 2021-3 , , , , .
Diaphragmatic endometriosis: diagnosis and laparoscopic treatment

Giovanni Roviglione1 – Orcid, Roberto Clarizia1, Daniele Mautone1 – Orcid, Francesco Bruni1, Matteo Ceccerello1,  Alberto Claudio Terzi2 – Orcid, Marcello Ceccaroni1 – Orcid

1 -Department of Obstetrics and Gynecology, Gynecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS “Sacro Cuore – Don Calabria” Hospital, Negrar di Valpolicella, Verona

2 – Thoracic Surgery Division, IRCCS “Sacro Cuore – Don Calabria” Hospital, Negrar di Valpolicella, Verona

Corresponding Author: Giovanni Roviglione

giovanni.roviglione@sacrocuore.it

DOI: 10.53146/lriog1202135

Abstract

Diaphragmatic endometriosis (DE) is a rare and often misdiagnosed condition. Most of the times it is asymptomatic and due to the low accuracy of diagnostic tests, it is almost always detected during surgery for pelvic endometriosis. Its management is challenging and, until now, there are not guide-lines about its treatment. In fact, Literature reports a plenty of single-center small series or case-reports about case treated for DE, thus, still nowadays a general consensus for diagnosis or treatment of DE does not exist. However, Our Institution has collected the largest case-series of patient treated for DE, reporting high-effective surgical results and proposing laparoscopy as its ideal tool, for its high cost-benefits relationship and its low morbidity.
A proposal of algorithm for diagnosis and treatment of DE has recently been published by Our Institution with the aim to standardize the surgical appro- ach according to the type of lesion, and finally reducing the rate of under- or over-treatments and intra or post-operative complications.
Conclusions: this kind of surgery should be performed in a Referral Center by a gynecologic surgeon with onco-gynecologic expertise and skills, with the eventual support of a laparoscopic general surgeon, a specialized thoracic surgeon and a trained anesthesiologist.

Keywords: diaphragmatic endometriosis; thoracic endometriosis; extrapelvic endometriosis; laparoscopy; radical surgery.

Available in LRIOG Nr.3 – 2021

e-ISSN: 1824-0283

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