There is evidence that rectovaginal endometriosis requires excisional surgery performed by a skilled surgeon. While some studies find that a gynaecologist can perform a nodulectomy, other data suggests more extensive resection may be needed in some cases. Over time, the typical procedure performed has progressed from simple shaving to more complex wedge excisions and segmental resections. Whether this represents overtreatment in some cases remains unclear. Predicting the need for bowel involvement requires careful preoperative evaluation including laparoscopy, ultrasound and MRI. Overall, rectovaginal endometriosis is a challenging condition that may benefit from a collaborative surgical approach between gynaecology and colorectal surgery.

1. ENDOMETRIOSIS
and the Colorectal Surgeon
I J Adam
Consultant Colorectal Surgeon, Northern General Hospital, Sheffield
Dukes Club Annual Meeting, Chesford Grange Hotel, Kenilworth
9 March 2013

2. ENDOMETRIOSIS
A superficial peritoneal disease
caroline-overton.co.uk
gynaesafe.com/endometriosis

3. ENDOMETRIOSIS
A nodular peritoneal disease
gynaesafe.com/endometriosis
Human Reproduction 2004; 19: 760-68

4. A COLORECTAL SURGEON!
Location of infiltrating endometriosis
Cullen TS (1920). Arch Surg 1,215±283.

5. ENDOMETRIOSIS
gynaesafe.com/endometriosis
colorectalsurgeonssydney.com.au/wp-content

6. A GYNAECOLOGISTS DISEASE …..

7. …. THAT NEEDS A COLORECTAL SURGEON

8. OPTIMAL RECTOVAGINAL ENDOMETRIOSIS
SURGERY?
Dr D Redwine
Bend, Oregon
Fertil Steril 2001; 76: 358-65

9. OPTIMAL RECTOVAGINAL ENDOMETRIOSIS
SURGERY?
Dr D Redwine
St. Charles Medical Centre, Bend, Oregon
11 years
1149 patients presenting with endometriosis
100 patients with complete obliteration
of rectovaginal septum
84 required excisional surgery
Fertil Steril 2001; 76: 358-65

10. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY

11. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
J Am Assoc Gynecol Laparosc 2003; 10:182–89

12. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Incise normal peritoneum lateral and parallel to
uterosacral ligaments
Undermine the uterosacrals
Transverse incision across posterior cervix
Fertil Steril 2001; 76: 358-65
J Am Assoc Gynecol Laparosc 2003; 10:182–89

13. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Dissect between endometriotic mass and vagina
Fertil Steril 2001; 76: 358-65
J Am Assoc Gynecol Laparosc 2003; 10:182–89

14. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Dissect between endometriotic mass and vagina
Fertil Steril 2001; 76: 358-65
J Am Assoc Gynecol Laparosc 2003; 10:182–89

15. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Dissect between endometriotic mass and vagina
Fertil Steril 2001; 76: 358-65
J Am Assoc Gynecol Laparosc 2003; 10:182–89

16. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Dissect between endometriotic mass and vagina
Proceed down RV septum to clear tissue
Leaves endometriosis nodule on rectum
Fertil Steril 2001; 76: 358-65
J Am Assoc Gynecol Laparosc 2003; 10:182–89

17. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Finally remove endometriosis nodule from anterior rectum
Fertil Steril 2001; 76: 358-65
J Am Assoc Gynecol Laparosc 2003; 10:182–89

18. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Depth of invasion in rectovaginal endometriosis
- 1/10 through mucosa
- 1/3 through muscle
Human Reprod 2005; 20: 2317-20

19. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Finally remove endometriosis nodule from anterior rectum
Human Reprod. 2010;25:1949-1958

20. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Finally remove endometriosis nodule from anterior rectum
ANZ J Surg 2003; 73: 647-8

21. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Finally remove endometriosis nodule from anterior rectum
Human Reproduction 2003: 18; 1323-1327
Fertil Steril 2001; 76: 358-65

22. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
Finally remove endometriosis nodule from anterior rectum
St. Charles Medical Centre, Oregon
n = 84
Superficial shave 20%
Partial thickness shave 13%
Disc excision (nodulectomy) 31%
Anterior resection 8%
Fertil Steril 2001; 76: 358-65

23. RECTOVAGINAL ENDOMETRIOSIS EXCISIONAL
SURGERY
St. Charles Medical Centre, Oregon
n = 67
Percentage improved
Nonmenstrual pelvic pain 78%
Menstrual pelvic pain 68%
Dyspareunia 66%
Tenderness on examination 59%
Fertil Steril 2001; 76: 358-65

24. A NZ J Surg 2007; 77: 562-71

25. PREDICTING WHEN A COLORECTAL SURGEON
IS NEEDED

26. PREDICTING WHEN A COLORECTAL SURGEON
IS NEEDED
Digital assessment
epubbed.com

27. PREDICTING RECTAL INVOLVEMENT
Digital assessment
Rectal involvement low sensitivity
moderate specificity
J Am Assoc Gynecol Laparosc 2002; 9: 115-9

28. PREDICTING RECTAL INVOLVEMENT
Laparoscopy
radiographics.rsna.org/content

29. PREDICTING RECTAL INVOLVEMENT
Laparoscopy
danmartinmd.com/_images/RV_Endometriosis

30. PREDICTING RECTAL INVOLVEMENT
Laparoscopy
danmartinmd.com/_images/RV_Endometriosis

31. PREDICTING RECTAL INVOLVEMENT
Laparoscopy
Redwine series
100 consecutive obliteration POD
27% did not have rectal or vaginal endometriosis
Fertil Steril 2001; 76: 358-65

32. PREDICTING RECTAL INVOLVEMENT
Colonoscopy
Endoanal ultrasound
Transvaginal ultrasound
MRI
Barium enema

33. PREDICTING RECTAL INVOLVEMENT
Colonoscopy
Poor
Human Reproduction 2003: 18; 1323-1327
A NZ J Surg 2007; 77: 562-71

34. PREDICTING RECTAL INVOLVEMENT
Transrectal ultrasound
90% sensitivity for rectovaginal nodules
Endoscopy 2005; 7: 357-61
Hum Reprod 2003; 18: 1686-92

35. PREDICTING RECTAL INVOLVEMENT
Transvaginal ultrasound
Similar effectiveness to TRUSS
Human Reprod 2005; 18: 1686-92

36. PREDICTING RECTAL INVOLVEMENT
MRI
radiographics.rsna.org

37. PREDICTING RECTAL INVOLVEMENT
MRI
72-90% positive predictive value for surgical findings
Radiology 2004; 232: 379-89
Fertil Steril 2005; 83: 442-7

38. Digital exam vs. TV USS vs. TRUSS vs. MRI
Bazot et al, Hôpital Tenon, Paris
N = 92 suspected pelvic endometriosis
Digital exam TV USS TRUSS MRI
Sensitivity 46% 94% 89% 87%
LR (+) 1.69 - 12.89 12.66
LR (-) 0.75 0.06 0.12 0.14
LR (+) = likelihood ratio of positive test being positive
LR (+) = likelihood ratio of positive test being positive
Fertil Steril. 2009 Dec;92(6):1825-33

39. PREDICTING RECTAL INVOLVEMENT
Barium enema
Road map
J Am Assoc Gynecol Laparosc 2002; 9: 115-9

40. DCBE
Landi et al, Verona
108 pts suspected LB endometriosis
55 – DCBE 28/28 adhesions, no endometriosis
53 + DCBE 38/39 endometriosis, 1 adhesions
DCBE
Sensitivity 85% Kappa 0.97
Specificity 50% X2 p<0.00001
PPV 96%
NPV 20%
J Am Assoc Gynecol Laparosc 2004; 11: 223-28

41. MRI vs. DCBE
Faccioli et al, University of Verona
83 pts suspected to have large bowel endometriosis
65 had surgery
50 confirmed endometriosis
MRI DCBE
Sensitivity 71% 85%
Specificity 83% 94%
PPV 93% 63%
NPV 75% 87%
Abdominal Imaging 2009 EPub

42. HOW OFTEN DO YOU NEED A COLORECTAL
SURGEON?

43. HOW OFTEN DO YOU NEED A COLORECTAL
SURGEON?
Redwine series
11 years
1149 patients presenting with endometriosis
100 patients with complete obliteration
of rectovaginal septum
84 had excisional surgery
Fertil Steril 2001; 76: 358-65

44. HOW OFTEN DO YOU NEED A COLORECTAL
SURGEON?
Melbourne series
11 years
213 operations rectal endometriosis
A NZ J Surg 2007; 77: 562-71

45. HOW OFTEN DO YOU NEED A COLORECTAL
SURGEON?
Melbourne series
11 years
213 operations Rectal endometriosis
91 operations Separation/protection of rectum
from gynae organs
A NZ J Surg 2007; 77: 562-71

46. HOW OFTEN DO YOU NEED A COLORECTAL
SURGEON?
Melbourne series (Rodney Woods)
11 years
213 operations Rectal endometriosis
91 operations Separation/protection of rectum
from gynae organs
252 operations “others”
A NZ J Surg 2007; 77: 562-71

47. AN EXTENDED ROLE FOR THE
COLORECTAL SURGEON?
Mr R Woods
Melbourne
A NZ J Surg 2007; 77: 562-71

48. AN EXTENDED ROLE FOR THE
COLORECTAL SURGEON?
Mr R Woods
St. Vincent’s Hospital, Melbourne
11 years
213 operations rectal endometriosis
18 shave
58 disc excision
137 segmental resection
A NZ J Surg 2007; 77: 562-71

49. AN EXTENDED ROLE FOR THE COLORECTAL
SURGEON?
Evolution over last 10 years
Rectal shave
Wedge excision
Segmental resection
A NZ J Surg 2007; 77: 562-71

50. AN EXTENDED ROLE FOR THE COLORECTAL
SURGEON?
What are they doing in Melbourne?
En bloc excision
A NZ J Surg 2007; 77: 562-71
Human Reproduction 2003: 18; 1323-1327

51. HISTOLOGICAL STUDIES
Remorgida et al, Genoa
16 pts undergoing surgery for LB endometriosis
Nodulectomy then resection
Histological evaluation
Human Reprod 2005; 20: 2317-20

52. HISTOLOGICAL STUDIES
Remorgida et al, Genoa
16 pts undergoing surgery for LB endometriosis
Endometriosis outside the nodule in 7 cases (44%)
Human Reprod 2005; 20: 2317-20

53. AN EXTENDED ROLE FOR THE COLORECTAL
SURGEON?
Evolution over last 10 years
Rectal shave
Wedge excision
Segmental resection
A NZ J Surg 2007; 77: 562-71
Human Reproduction 2003: 18; 1323-1327

54. AN EXTENDED ROLE FOR THE COLORECTAL
SURGEON?
Evolution over last 10 years
Rectal shave
Wedge excision
Segmental resection
Is this overtreatment? A NZ J Surg 2007; 77: 562-71
Human Reproduction 2003: 18; 1323-1327

55. ARE WE OVER TREATING?
Mr R Woods
St. Vincent’s Hospital, Melbourne
11 years
213 operations rectal endometriosis
18 shave
58 disc excision
137 segmental resection
5% stoma rate
A NZ J Surg 2007; 77: 562-71
Human Reproduction 2003: 18; 1323-1327

56. ARE WE OVER TREATING?
Melbourne
series
A NZ J Surg 2007; 77: 562-71

57. DIFFERENTIAL OUTCOMES?
Roman et al, Rouen University Hospital
41 pts had surgery for LB endometriosis
12-53 month follow-up
Nodulectomy Resection
Number 16 25
Human Reprod 2010; Jan: dep407ul

58. DIFFERENTIAL OUTCOMES?
Roman et al, Rouen University Hospital
41 pts had surgery for LB endometriosis
12-53 month follow-up
Nodulectomy Resection
Number 16 25
% dysmenorrhea 35% 20%
% non-cyclical pain 31% 19%
% dyspareunia 38% 57%
BO>3x/day 19% 52%
Human Reprod 2010; Jan: dep407ul

59. CONCLUSION

60. CONCLUSION
Evidence base supports
excisional surgery
for rectovaginal
endometriosis with
laparoscopic technique
Uncertain whether
nodulectomy or anterior
resection preferable

61. CONCLUSION
“stage 4 endometriosis
involving the bowel,
retroperitoneal fibrosis and
the rectovaginal septum are
among some of the most
challenging conditions facing
the pelvic surgeon”
Surgery of the Anus, Rectum & Colon.
2nd ed, W B Saunders. 1999

62. Questions?