Extragenital endometriosis

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Extragenital endometriosisDr. Bulent UrmanKoc University School of MedicineDepartment of Obstetrics and GynecologyAmerican Hospital of Istanbul

Extragenital endometriosisEndometriosis involving other organsRectovaginal septum or retrocervicalIntestinalBladderAbdominal wallDiaphragmThoracic

Diagnosis is difficultCyclic symptoms may give a clue

Bowel endometriosisBowel 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 endometriosisEndometriosis of the small bowel is rare

SymptomsChronic abdominal pelvic painDyschezia (pain during defecation during menstrual period)DysmenorrhoeaDyspareuniaTenesmus,Constipation or diarrheaRectal bleeding

Innervation of DIEFrom 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

TreatmentAysmptomatic patient-Watchful waitingSymptomatic patient-SurgeryShaving of superficial lesionsDiscoid resection/anterior rectal wall excisionSegmental colorectal resection-anastomosis

Surgical treatment of DIE with colorectal involvementBowel surgeryN (%)Previous surgeriesIndicationHistological confirmationMixed Procedures17 studies 1791 patientsResection/ anastomosis737 (39.9%)58.8%Pain (62.9%)83.2%Full thickness disc excision375 (20.3%)Shaving/ superficiaal excision679 (36.8%)Only resection and anastomosis32 studies 2039 patients59%Pain 75.2%Pain and infertility 24.8%99.2%

From Meuleman HR Update 2011

A-Complete segmental resectionB-Residual diseaseC-No bowel endoFrom Stepnievska et al. F&S 2010Long 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)ProcedureNumberDissection of the culdesac+resection or shaving of the uterosacral ligaments26Dissection of the culdesac+deep endometriosis nodule excision37Dissection of the culdesac+shaving of rectal and sigmoid endometriosis lesions8Dissection of the culdesac and+rectal resection11Dissection of the culdesac+nodule excision and rectal resection10Dissection of the culdesac+sigmoid colon resection7Dissection of the culdesac+nodule excision+rectal resection+partial cyctectomy2

American Hospital Data (unpublished)

Complications (Bowel endometriosis-mixed surgery n=38)ComplicationNumberFistula formation0Temporary voiding problems2Infection0Follow-up1-38 moRecurrence of bowel lesions2/38Recurrence of pain21 (20.8%)

Abdominal wall endometriosis-a review of 445 casesFrom Horton et al. Am J Surg 2008

From Horton et al. Am J Surg 2008

DiagnosisPalpationUSMRI-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; 32:20312043)Fine needle aspiration biopsy (Journal of Cytology / January 2015 / Volume 32 / Issue 1)

Differential diagnosis

TreatmentMedical treatment is not successful (Hensen et al. AJR 2006)Wide surgical excision is necessary

Other sites of extragenital endometriosisBowelBladderSkinDiaphgramLungKidneyLiverCNS and the spinePericardiumLegEyes, nose, ears

Liver

Brain

Lung and diaphgram

Eyes

ConclusionsExtragenital endometriosis is relatively commonAlmost all organs are affectedA high index of suspicion is necessary to make the diagnosisSurgical resection is often necessary and curative