postgraduate tutorial describing the clinical, pathological and treatment aspects of endometriosis involving extragenital organs

1. EXTRAGENITAL
ENDOMETRIOSIS
Dr. Bulent Urman
Koc University School of Medicine
Department of Obstetrics and Gynecology
American Hospital of Istanbul

2. Extragenital endometriosis
Endometriosis involving other organs
Rectovaginal septum or retrocervical
Intestinal
Bladder
Abdominal wall
Diaphragm
Thoracic
Diagnosis is difficult
Cyclic symptoms may give a clue

5. Bowel endometriosis
• Bowel 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 endometriosis
• Endometriosis of the small bowel is rare

6. Symptoms
• Chronic abdominal pelvic pain
• Dyschezia (pain during defecation during menstrual
period)
• Dysmenorrhoea
• Dyspareunia
• Tenesmus,
• Constipation or diarrhea
• Rectal bleeding

7. Innervation of DIE
From Wang et al. HR 2010

8. From Bazot et al. F&S 2009

9. From Bazot et al. F&S 2009

10. Evaluation of DIE with bowel involvement
From Saccardi et al. Ultrasound Obstet Gynecol 2012

11. Treatment
• Aysmptomatic patient-Watchful waiting
• Symptomatic patient-Surgery
• Shaving of superficial lesions
• Discoid resection/anterior rectal wall excision
• Segmental colorectal resection-anastomosis

13. Surgical treatment of DIE with colorectal involvement
Bowel surgery N (%) Previous
surgeries
Indication Histological
confirmation
Mixed
Procedures
17 studies
1791
patients
Resection/
anastomosis
737 (39.9%) 58.8% Pain (62.9%) 83.2%
Full thickness
disc excision
375 (20.3%)
Shaving/
superficiaal
excision
679 (36.8%)
Only resection
and
anastomosis
32 studies
2039
patients
59% Pain 75.2%
Pain and
infertility
24.8%
99.2%
From Meuleman HR Update 2011

14. A-Complete segmental resection
B-Residual disease
C-No bowel endo From Stepnievska et al. F&S 2010
Long term follow-up of patients who underwent LS
surgery for colorectalendometriosis

15. Recurrence
From de Cicco et al. BJOG 2010

16. Laparoscopic procedures performed for deep
infiltrating endometriosis (n=101)
Procedure Number
Dissection of the culdesac+resection or shaving of the
uterosacral ligaments
26
Dissection of the culdesac+deep endometriosis nodule
excision
37
Dissection of the culdesac+shaving of rectal and sigmoid
endometriosis lesions
8
Dissection of the culdesac and+rectal resection 11
Dissection of the culdesac+nodule excision and rectal
resection
10
Dissection of the culdesac+sigmoid colon resection 7
Dissection of the culdesac+nodule excision+rectal
resection+partial cyctectomy
2
American Hospital Data (unpublished)

17. Complications (Bowel endometriosis-mixed surgery
n=38)
Complication Number
Fistula formation 0
Temporary voiding problems 2
Infection 0
Follow-up 1-38 mo
Recurrence of bowel lesions 2/38
Recurrence of pain 21 (20.8%)

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

19. From Horton et al. Am J Surg 2008

20. Diagnosis
• Palpation
• US
• MRI-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;
32:2031–2043)
• Fine needle aspiration biopsy (Journal of Cytology / January
2015 / Volume 32 / Issue 1)

25. Differential diagnosis

26. Treatment
• Medical treatment is not successful (Hensen et al. AJR
2006)
• Wide surgical excision is necessary

28. Other sites of extragenital endometriosis
• Bowel
• Bladder
• Skin
• Diaphgram
• Lung
• Kidney
• Liver
• CNS and the spine
• Pericardium
• Leg
• Eyes, nose, ears

29. Liver

30. Brain

31. Lung and diaphgram

32. Eyes

33. Conclusions
• Extragenital endometriosis is relatively common
• Almost all organs are affected
• A high index of suspicion is necessary to make the
diagnosis
• Surgical resection is often necessary and curative