Endometriosis
Endometriosis is defined as presence of functional endometrial tissues outside the uterus. It is a complex, yet common disorder of reproductive organ of female and is the leading causes for chronic pelvic pain. Most common in women between 25-35 years of age. Though endometriosis is a benign condition it has aggressive clinical behavior. Based on extent of tissue growth, ASRM classified endometriosis as minimal (Grade I), mild(Grade II ),moderate(grade III), severe(grade IV). It is also classified into superficial and deep endometriosis
Newer classification also included EFI [Endometriosis Fertility Index] to access the fertility outcome of women with endometriosis.
Symptoms included pelvic pain (40-50%), dysmenorrhea (60-80%) dyspareunia, dysuria, dysthymia, gastro intestinal discomfort. The main cause of pain is due to compression and infiltration of nerves by the lesion.
Infertility is also common finding in patients with endometriosis.
Laparoscopy is the gold standard in diagnosis of endometriosis, offers staging of the disease and curative surgery in one setting.
Medical management is reserved for patients with minimal and mild form of endometriosis.
Surgery is the treatment of choice for grade III and Grade IV disease, Deep Infiltrating Endometriosis, in cases with Endometrioma and infertility and for patients with chronic pelvic pain.
Laparoscopic removal of endometriotic tissues, ovarian cystectomy for endometrioma, adhesiolysis improves the fertility outcome in patients with infertility
Laparoscopic uterosacral nerve ablation (LUNA) presacral neurectomy [PSN], LION [Laparoscopic insertion of nerve prosthesis] procedures can be tried in patients with chronic pelvic pain.
Overall outcome of the treatment relies on the excision of the endometriotic tissue, release of adhesion and nerve entrapment that depends on the expertise of the surgeon. All these ultimately offers a better fertility outcome, an improved lifestyle and sexual activity for the patients.
Although endometriosis is usually confined to ovaries, uterosacral ligaments and cul-de-sac, it has been documented in almost every organ system in the body.
Bladder Endometriosis:
Bladder endometriosis is defined as presence of endometrial glands and stroma at detrusor muscle of bladder
It causes cyclical non specific urinary symptoms which include urinary frequency, urgency or urinary retention. Cyclic hematuria is characteristic.
The most common complaint is mild to severe pain in pelvic region which is more intense during monthly periods.
The gold standard for diagnosis of bladder endometriosis is biopsy, HPE of lesion during cystoscopy or laparoscopy.
Medical therapy is effective for pain relief, yet symptoms often recurs once treatment is stopped.
Surgery is the definitive treatment for bladder endometriosis.
Deep infiltrating bladder endometriosis requires fell thickness resection and repair of bladder wall which can be done laparoscopically.
Overall outcome of surgical treatment of bladder endometriosis has been good and complications and need for reoperations are low,
Ureteral endometriosis:
The ureter is involved in 15-20% of urinary tract endometriosis.
Ureteral endometriosis may be extrinsic or intrinsic. 80% of cases is extrinsic and most commonly involves distal ureter. Both intrinsic and extrinsic form may lead to ureteral stenosis.
Most patients with ureteral endometriosis do not have genitourinary symptoms and as a result it may lead to silent loss of renal function.
Often diagnosed as incidental finding during laparoscopy for evaluation of pelvic pain.
It can be suspected in cases of hydroureteronephrosis in a patient with known endometriosis.
Medical treatment is not effective in reliving ureteral obstruction and the treatment for ureteral endometriosis with HUN is mainly surgical
Laparoscopic ureterolysis is done to correct obstruction due to extrinsic disease.
In case of intrinsic disease in which the endometriotic tissue infiltrate the ureteral wall, distal ureterectomy with reimplantation (Ureteroneocystostomy) is the best choice of treatment.
If middle or upper third of ureter is involved, End ureteroureterostomy is done after resecting the lesions.
Rectal Endometriosis:
Endometriosis affects GI tract in 5-12% of women with this condition.
The rectum and rectosigmoid junction are the most common sites of involvement.
Rectal involvement is associated with deep infiltrating endometriosis in 70% of cases.
Endometriosis infiltrating the muscularis propria lead to fibrosis, stricture and bowel obstruction.
Colicky abdominal pain in the most common symptom Rectal bleeding during passage of stools through stenosed colon may occur which is increased during menses.
Laparoscopy is gold standard in diagnosing rectal involvement. Treatment consist of surgical excision or segmental resection.
Laparoscopy procedures included removal of endometriotic nodule by rectal wall shaving leaving intact rectal wall if superficial deposits are present.
Alternatively, if solitary penetrating nodule is present, a full thickness or segmental rectal wall resection in considered.
Neural endometriosis:
The most common site of neural endometriosis are the nerves in and near pelvis. Symptoms occur due to entrapment and compression of nerves by the fibrotic endometriotic tissues.
Sciatic nerve endometriosis presents with cyclic sciatica, muscle weakness, sensory deficit and pelvic pain.
Similarly, Obturator Nerve endometriosis causes pain and proximal nerve weakness.
Treatment is laparoscopy excision on endometriotic tissue and associated fibrosis surrounding the nerve.
Presacral neurectomy [PSN] and laparoscopic uterosacral nerve ablation (LUNA) can be tried to alleviate chronic pelvic pain.
LION procedure can also be tried as an alternative to improve the nerve function and chronic pelvic pain.
What to Expect from Laparoscopy for Endometriosis
A laparoscopy is a surgical procedure that may be used to diagnose and treat various conditions, including endometriosis.
During a laparoscopy, a long, thin viewing instrument, called a laparoscope, is inserted into the abdomen through a small, surgical incision. This allows your doctor to view tissue or take a tissue sample, called a biopsy. They may also remove cysts, implants, and scar tissue caused by endometriosis.
A laparoscopy for endometriosis is a low-risk and minimally invasive procedure. It’s typically performed under general anesthesia. Most people are released from the hospital on the same day. Overnight monitoring is sometimes required, though.
Who should have a laparoscopy?
Your doctor may recommend a laparoscopy if:
You regularly experience severe abdominal pain believed to be caused by endometriosis.
Endometriosis or related symptoms have continued or reappeared following hormone therapy.
Endometriosis is believed to be interfering with organs, such as the bladder or bowel.
Endometriosis is suspected to be causing infertility.
An abnormal mass has been detected on your ovary, called ovarian endometrioma.
Endometriosis that affects the bowel or bladder may require further surgery.
How to prepare for a laparoscopy
You may be instructed to not eat or drink for at least eight hours leading up to the procedure. Most laparoscopies are outpatient procedures. That means you don’t need to stay at the clinic or hospital overnight. However, if there are complications, you may need to stay longer. It’s a good idea to pack a few personal items just in case.
Arrange for a partner, family member, or friend to drive you home and stay with you after your procedure. General anesthesia can cause nausea and vomiting, too. Having a bag or bin ready for the car ride home is a good idea.
You might be instructed not to shower or take a bath for up to 48 hours following a laparoscopy to allow the incision to heal. Showering right before the procedure might make you feel more comfortable.
How the procedure is done
You’ll be given a general or a local anesthetic prior to the surgery to induce either general or local anesthesia. Under general anesthesia, you’ll fall asleep and not feel any pain. It’s usually administered through an intravenous (IV) line, but may also be given orally.
Under local anesthesia, the area where the incision is made will be numb. You’ll be awake during the surgery, but won’t feel any pain.
During the laparoscopy, your surgeon will make an incision in your abdomen, typically above your bellybutton. Next, a small tube called a cannula is inserted into the opening. The cannula is used to inflate the abdomen with gas, usually carbon dioxide. This helps your surgeon to see the inside of your abdomen more clearly.
Your surgeon inserts the laparoscope next. There’s a small camera on the top of the laparoscope that allows them to see your internal organs on a screen. Your surgeon may make additional incisions to get a better view. This can take up to 45 minutes.
When endometriosis or scar tissue is found, your surgeon will use one of several surgical techniques to treat it. These include: Excision. Your surgeon will remove the tissue. Endometrial ablation. This procedure uses freezing, heating, electricity, or laser beams to destroy the tissue.
Once the procedure is finished, your surgeon will close the incision with several stitches.
What’s recovery like?
Immediately after the surgery, you might experience:
side effects from the anesthetic, including grogginess, nausea, and vomiting
discomfort caused by excess gas
mild vaginal bleeding
mild pain at the site of the incision
soreness in the abdomen
mood swings
You should avoid certain activities immediately after your surgery. These include:
intense exercise
bending
stretching
lifting
sexual intercourse
It can take a week or more before you’re ready to return to your regular activities.
You should be able to resume having sex within two to four weeks following the procedure, but check with your doctor first. If you’re planning to get pregnant, you can start trying again once your body has recovered.
Your first period after the surgery may be longer, heavier, or more painful than usual. Try not to panic. Your body is still healing on the inside, even if you feel better. If pain is severe, contact your doctor or emergency medical care.
After your surgery, you can ease the recovery process by:
getting enough rest
eating a mild diet and drinking enough fluids
doing gentle movements to help eliminate excess gas
taking care of your incision by keeping it clean and out of direct sunlight
giving your body the time it needs to heal
contacting your doctor immediately if you experience complications
Your doctor may suggest a follow-up appointment between two and six weeks after surgery. If you have endometriosis, this is a good time to talk about a long-term monitoring and treatment plan and, if necessary, fertility options.
Is it effective?
Laparoscopic surgery is associated with decreased overall pain both at 6 and 12 months post-surgery. Pain caused by endometriosis may eventually reappear.
Infertility
The link between endometriosis and infertility remains unclear. However, endometriosis affects up to 50 percent of infertile women, according to the European Society of Human Reproduction and Embryology.
In one small study, 71 percent of women under the age of 25 who underwent laparoscopic surgery to treat endometriosis went on to get pregnant and give birth. Conceiving without the use of assisted reproductive technologies is more difficult if you’re over the age of 35.
For women seeking treatment for infertility who experience severe endometriosis, in vitro fertilization (IVF) may be suggested as an alternative to laparoscopic surgery.
Are there any complications of having this surgery?
Complications of laparoscopic surgery are rare. As with any surgery, there are certain risks. These include:
infections in the bladder, uterus, or surrounding tissues
uncontrolled bleeding
bowel, bladder, or ureter damage
scarring
Contact your doctor or emergency medical care if you experience any of the following after laparoscopic surgery:
severe pain
nausea or vomiting that doesn’t go away within one or two days
increased bleeding
increased pain at the site of the incision
abnormal vaginal discharge
unusual discharge at the site of the incision
The takeaway
Laparoscopy is a surgical procedure used to diagnose endometriosis and treat symptoms such as pain. In some cases, laparoscopy may improve your chances of getting pregnant. Complications are rare. Most women make a full recovery.