Endometriosis

Endometriosis is the presence of functioning endometrial tissue outside of the endometrium and myometrium. The clinical syndrome involves cyclic pelvic pain that begins just before menses and lasts throughout the days of menstrual flow, noncyclic chronic pelvic pain, and dyspareunia. It is associated with inflammation, immune system abnormalities (28), and neoangiogenesis often causing infertility, scarring of the fallopian tubes, dysmenorrhea, dyschezia, and dyspareunia. The prevalence of pelvic endometriosis is estimated to be around 10% (29) of reproductive age women and prevalent in 2% of postmenopausal women (30). Sources of estrogen in the postmenopausal patient primarily arise from the cytochrome p450 enzyme aromatase. Aromatase is primarily expressed in ovarian granulosa cells, placental syncytiotro-phoblast, adipose tissue, skin fibroblasts, and the brain (31). Cases of endometriosis have been reported in the gastrointestinal tract, urinary tract, pulmonary, muscu-loskeletal, peripheral, and central nervous system.

In advanced cases of endometriosis, the pelvic exam reveals irregular and tender nodularity in the posterior fomix of the vagina in the area of the insertion of the uterosacral ligaments on the poster-apical portion of the vagina. An adnexal mass may also be palpated. Pelvic ultrasound may reveal echogenic cystic structures present in the adnexa containing debris consistent with blood present within the cyst walls.

Endometriotic implants vary in size and appearance. They range from the classically described "powder burn" appearance to reddish-blue nodules and ovarian cysts. The repetitive process of hemolysis and encapsulation of debris causes extensive scarring of the affected surface. These surfaces usually include the ovary and posterior cul-de-sac with involvement of the distal uterosacral ligaments. Extensive involvement will include the rectum, tubes and ovaries, and the bladder. The overall positive predictive value for laparoscopic visualization of endometriosis is 43% to 45% (32,33). This is similar to appropriate history taking and physical exam. It is preferable to have a pathologic diagnosis if one suspects an implant may be endometriosis.

First line therapy of endometriosis usually involves hormonal management. Medications include Danazol, an isoxazol derivative of 17 a-ethinyl testosterone, and progestational agents such as medroxyprogesterone acetate, norethindrone, or norgestrel. Gonadotropin releasing hormone agonists are also used. These agents down-regulate the pituitary gland causing a decline in gonadotropin levels, resulting in a castrating effect. Medical therapy seems to be useful in treatment of mild to moderate disease.

Surgical resection is a commonly used treatment for moderate to severe cases of endometriosis or those cases of failed medical management. It is recommended for cases of cyst formation, invasion or obstruction to the bowel, ureters, or bladder. Most patients with endometriosis will not have involvement of the lower urinary tract. However, in cases of extensive endometriosis, the ureters are frequently involved. The scarring results in fibrosis of the surrounding periureteral tissue, often leading to obstruction. It is often necessary to enter the retroperitoneal space releasing the ureter laterally, away from the affected implants along the pelvic peritoneum. The goal is to remove all diseased tissue and restore pelvic anatomy (34). However, in advanced cases of endometriosis, intentional and nonintentional ureterotomy are relatively common.

Data regarding surgical treatment for endometriosis causing recurrent pelvic pain are mixed. In 1994, Sutton et al. reported on a randomized, double-blind study of endometriosis ablation plus uterosacral nerve ablation versus sham surgery (35). Three months after laparoscopy, 56% of the surgically treated women continued to experience pain relief, whereas 48% of the sham operation women also experienced pain relief. Thus, for at least three months there is a persistent placebo effect of surgery. After six months, 22% of the sham operation women experienced pain relief, whereas 62.5% of the surgically treated women experienced pain relief (35). This study illustrates that even in the best of hands and when studied in a controlled and prospective manner, laparoscopic surgery in which lesions are ablated results in a nearly 40% failure rate six months after surgery.

Ureter repair in patients with endometriosis is difficult because of the extensive fibrosis. To access the endometriosis around the ureter, extensive dissection is performed with potential compromise of the blood supply. Repair of the ureter in these situations could lead to stenosis at the repair site. Experimental studies in the porcine model have shown that repair of the ureter after extensive dissection that is typical of endometriosis surgery has a higher rate of stenosis.

The most common form of vesicovaginal fistula in North America is injury to the bladder during hysterectomy.

Laparoscopic hysterectomy is the most common surgery associated with lower urinary tract injury.

Ureter repair in patients with endometriosis is difficult because of the extensive fibrosis. To access the endometriosis around the ureter, extensive dissection is performed with potential compromise of the blood supply. Repair of the ureter in these situations could lead to stenosis at the repair site. Experimental studies in the porcine model have shown that repair of the ureter after extensive dissection that is typical of endometriosis surgery has a higher rate of stenosis (36).

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