Marco Vieira

Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis

OBJECTIVE To investigate whether specific types of pelvic pain are correlated with the anatomic locations of deeply infiltrating endometriosis (DIE). DESIGN Retrospective data analysis. SETTING University tertiary referral center. PATIENT(S) Two hundred and twenty-five women with pelvic pain symptoms and DIE. INTERVENTION(S) During surgery, we recorded the anatomic locations of DIE implants and associated endometriosis. MAIN OUTCOME MEASURE(S) We studied the incidence of pelvic pain symptoms including severe dysmenorrhea, deep dyspareunia, noncyclic chronic pelvic pain, painful defecation during menstruation, urinary tract symptoms, and gastrointestinal symptoms as related to the location of DIE. RESULT(S) The frequency of severe dysmenorrhea increased with Douglas pouch adhesions and decreased with parity. The frequency of dyspareunia increased with a uterosacral ligament DIE location and decreased when it involved the bladder. The frequency of noncyclic chronic pelvic pain was higher when it involved the bowel and was lower for women who were treated for infertility. The frequency of painful defecation during menstruation was higher when DIE involved the vagina; lower urinary tract symptoms were more frequent when DIE involved the bladder and less frequent in women with a lower body mass index. Gastrointestinal symptoms were associated with bowel or vaginal DIE locations. CONCLUSION(S) The types of pelvic pain are related to the anatomic location of DIE. Knowledge of the characteristics of pelvic pain symptoms is important in the preoperative assessment of patients with suspected DIE.

Laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum

Background. Two aims: 1) To assess the results of laparoscopically assisted vaginal management of deep endometriosis infiltrating the rectovaginal septum (RVS); 2) to pinpoint the differences between this procedure and that used for deep endometriotic lesions located on the uterosacral ligaments (USL).

Magnetic Resonance Imaging and Endometriosis: Deeply Infiltrating Endometriosis Does Not Originate from the Rectovaginal Septum

The goal of this study was to describe the magnetic resonance (MR) imaging signs of deeply infiltrating endometriosis (DIE) lesions and above all to find out if MR imaging can pinpoint the location of these lesions. We made a retrospective study of 8 patients presenting with histologically proven DIE lesions. The MR imaging results were compared with intraoperative findings. Nodules revealed on T1-weighted images as isointense to myometrium with hyperintense spots remained visible on the fat-suppressed spin echo images. When there was no rectal involvement, the T1- and T2-weighted images showed a hypointense transition area between the nodule and the rectum. The DIE nodules were in identical locations in every case, lying below the torus uterinum, level with the posterior vaginal fornix and the upper third of the posterior vaginal wall. Without exception, the DIE nodules were located above the upper edge of the rectovaginal septum, with the latter appearing fine and regular with no image of any nodule. Our MR imaging results suggest that DIE lesions do not originate from the rectovaginal septum.

Histologic appearance of endometriosis infiltrating uterosacral ligaments in women with painful symptoms.

STUDY OBJECTIVE To describe the histologic appearance of deep endometriosis infiltrating the uterosacral ligaments (USL). DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS One hundred forty-nine women with pain due to endometriosis. INTERVENTION Resection of one or both USL. MEASUREMENTS AND MAIN RESULTS One hundred seventy-two USL were examined by histology after unilateral resection in 126 patients (84.6%) and bilateral resection in 23 (15.4%). Two-thirds of women (122, 70.9%) had a classic appearance of endometriosis. Lesions of myoproliferative endometriosis with a histologic appearance of so-called adenomyotic nodules were observed in 25 (14.5%). Associated fibrosis was most frequent in patients with positive compared with negative histology (85, 69.7% vs 18, 36.0%). CONCLUSION Anatomicopathologic lesions of deep endometriosis infiltrating the USL are heterogeneous. Adenomyotic nodules are not frequently observed.

Does deep endometriosis infiltrating the uterosacral ligaments present an asymmetric lateral distribution

Objective To investigate whether deeply infiltrating endometriosis occurs with equal frequency between left and right uterosacral ligaments.

Adhesion Formation after Laparoscopic Resection of Uterosacral Ligaments in Women with Endometriosis

STUDY OBJECTIVE To analyze the risk of postoperative adhesions in women who undergo laparoscopic surgical management of deep endometriosis infiltrating the uterosacral ligaments (USL). DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Forty-six women with deep endometriosis infiltrating the USL. INTERVENTION Laparoscopic resection of all USL with deep endometriotic lesions and excision of all other endometriotic lesions, followed by second-look laparoscopy. MEASUREMENTS AND MAIN RESULTS At second-look laparoscopy, 15 patients (32.6%) had no adhesions at the site where the USL had been resected, 24 (52.2%) had filmy avascular adhesions, and 7 (15.2%) had dense or vascular adhesions. No patient had adhesions of the binding type. Only two factors, the revised American Fertility Association (rAFS) score at initial laparoscopy and surgical modality (unilateral resection of the right USL, unilateral resection of the left USL, bilateral resection of USL) had a statistically significant influence on the risk of postoperative adhesions occurring. After adjustment, the relation with initial rAFS stage and surgical modality remained significant in the stepwise logistic regression model. CONCLUSION These encouraging results are particularly interesting for patients with infertility due to pelvic pain syndrome. Second-look laparoscopy should not be performed routinely after laparoscopic management of deep endometriosis infiltrating the USL. We propose that it be reserved for women with rAFS stages III and IV endometriosis, especially when lesions are located on the left side.