R.C. Falik

Pathophysiology and management of urinary tract endometriosis

Endometriosis predominantly affects the pelvic reproductive organs but can also affect the urinary tract. A number of theories for the pathogenesis of endometriosis have been suggested, but the exact mechanisms remain elusive. Endometriotic lesions can be found on both the ureter and bladder, and the optimal therapeutic approach depends on the extent, depth, and location of these lesions. Medical approaches, including hormonal therapies such as GnRH agonists and oral contraceptives, tend to be a temporary measure, but can be useful in a preoperative setting or if the patient is unsuitable for surgery, and are also useful as a postoperative treatment. If surgical resection is deemed appropriate, laparoscopic management with or without robotic assistance of urological endometriosis is feasible and advisable. Newer techniques, such as nerve-sparing surgery, might help to decrease the risk of urinary complications following resection of deeply infiltrating endometriosis.

Bowel Endometriosis: Diagnosis and Management

&NA; The most common location of extragenital endometriosis is the bowel. Medical treatment may not provide long‐term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert review we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5‐8 cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short‐ and long‐term complications.

Surgical management of niche, isthmocele, uteroperitoneal fistula, or cesarean scar defect: a critical rebirth in the medical literature

The rate of cesarean delivery is 30% or more across the United States, and an estimated one to three quarters of cesarean delivery patientsmaydevelop a defect in their uterine scar. Cesareandelivery scar defects—including uteroperitoneal fistula, niche, and isthmocele (1–3)—are currently underdiagnosed and may consequently be left untreated at a staggering rate. This defect comprises a thinning and indentation of the myometrium at the site of hysterotomy on the anterior uterine wall. In women who have undergone labor, the defect is distal, near the internal cervical os; in women who have had an elective cesarean delivery, the defect is typically found more proximal on the lower uterine segment. Wound healing may be compromised in a woman who smokes or has diabetes. Which may contribute to defect formation, as can surgical techniques such as low (cervical) hysterotomy, single-layer or endometrialsparing closure, multiple cesarean deliveries, or use of locking sutures (3). Although Morris first described ‘‘isthmocele’’ in 1995 and our group wrote of the first laparoscopic cesarean scar defect repair in 2003 (1), over a decade later there remains a paucity of quality literature on and attention given to the topic. In this day and age, the media spreads viral stories at an explosive pace, yet acceptance of medical and surgical treatments still lags decades behind their discoveries. As the rate of cesarean delivery worldwide increases, the incidence of cesarean scar defects and the associated symptoms and risks such as pain, bleeding, secondary infertility, and ectopic scar pregnancy are also likely to be on the rise. In 2000 we were teaching one of our routine postgraduate courses and were working alongside our esteemed colleague, Dr. Renee Charles, in the operating room and in the laboratory. He had performed laparoscopic lysis of adhesions twice on a woman who was experiencing secondary infertility, pelvic pain, andmenorrhagia ever since her cesarean delivery the year before. Dr. Charles referred this patient to us when her symptoms only continued to worsen. At laparoscopy, we discovered endometriosis on the bladder. As we carefully freed the uterus from its attachment to the anterior abdominal wall and bladder, we encountered a fistulous tract from the uterus to the peritoneum, which we described as a uteroperitoneal fistula. Laparoscopically, we resected the endometriosis and the fistula and repaired the defect. The patient subsequently had complete symptomatic relief, and spontaneously conceived and delivered a term baby the next year (1). Donnez et al. (4) have published the largest prospective study to date evaluating and treating patients with cesarean scar defects, and we commend the authors for their important contribution to the literature. The treatment of cesarean scar defects may finally be getting its much deserved moment in the medical literature, and not a moment too soon.