JFM072902 Surgical management of GI and GU endometriosis Javier Magrina, MD Mayo Clinic in Arizona JFM100402

JFM072902

Surgical management of GI and Surgical management of GI and GU endometriosisGU endometriosis

Javier Magrina, MDJavier Magrina, MDMayo Clinic in ArizonaMayo Clinic in Arizona

Surgical management of GI and Surgical management of GI and GU endometriosisGU endometriosis

Javier Magrina, MDJavier Magrina, MDMayo Clinic in ArizonaMayo Clinic in Arizona

JFM100402

Visual vs histologic diagnosis of Visual vs histologic diagnosis of endometriosis endometriosis

Mayo Clinic ArizonaMayo Clinic Arizona

Visual vs histologic diagnosis of Visual vs histologic diagnosis of endometriosis endometriosis

Mayo Clinic ArizonaMayo Clinic Arizona

Diagnosis Diagnosis %%

Visual Visual / histology / histology 51 51

VisualVisual / histology / histology 2 2

Am J Obstet Gynecol 184:1407, 2001Am J Obstet Gynecol 184:1407, 2001

Diagnosis Diagnosis %%

Visual Visual / histology / histology 51 51

VisualVisual / histology / histology 2 2


N = 480N = 480

Pelvic EndometriosisPelvic EndometriosisPelvic EndometriosisPelvic Endometriosis

Histological vs visual stagingHistological vs visual staging

– 35% reduced score35% reduced score

– 43% downstaging43% downstaging


Histological vs visual stagingHistological vs visual staging

– 35% reduced score35% reduced score

– 43% downstaging43% downstaging


Endometriosis involvement Endometriosis involvement Endometriosis involvement Endometriosis involvement

%%• Intestinal 3-37Intestinal 3-37

• Urinary 2-16Urinary 2-16

• Vascular <1Vascular <1

%%• Intestinal 3-37Intestinal 3-37

• Urinary 2-16Urinary 2-16

• Vascular <1Vascular <1

Intestinal and Urinary Tract Involvement by Intestinal and Urinary Tract Involvement by EndometriosisEndometriosis

Intestinal and Urinary Tract Involvement by Intestinal and Urinary Tract Involvement by EndometriosisEndometriosis

DefinitionDefinition• Extrinsic (non invasive)Extrinsic (non invasive) Bladder peritoneum,Ureteral adventitiaBladder peritoneum,Ureteral adventitia Intestinal serosaIntestinal serosa

• Intrinsic (invasive)Intrinsic (invasive) Detrusor muscle, Ureteral muscularisDetrusor muscle, Ureteral muscularis Intestinal muscularis Intestinal muscularis

DefinitionDefinition• Extrinsic (non invasive)Extrinsic (non invasive) Bladder peritoneum,Ureteral adventitiaBladder peritoneum,Ureteral adventitia Intestinal serosaIntestinal serosa

• Intrinsic (invasive)Intrinsic (invasive) Detrusor muscle, Ureteral muscularisDetrusor muscle, Ureteral muscularis Intestinal muscularis Intestinal muscularis

Urinary Tract Involvement by Urinary Tract Involvement by EndometriosisEndometriosis


Mayo Clinic ExperienceMayo Clinic Experience

N=249N=249

Incidence, Incidence, %%

All AFS stages 1All AFS stages 1

Stage III and IVStage III and IV 16 16


N=249N=249

Incidence, Incidence, %%

All AFS stages 1All AFS stages 1

Stage III and IVStage III and IV 16 16




%%

Ureter(s)Ureter(s) 83 83

BladderBladder 10 10

BothBoth 7 7


%%

Ureter(s)Ureter(s) 83 83

BladderBladder 10 10

BothBoth 7 7



Mayo Clinic ExperienceMayo Clinic Experience %%

InvolvementInvolvement BladderBladder UreterUreterExtrinsicExtrinsic ---- ---- 86 86IntrinsicIntrinsic 100 14 100 14 Mucosal 100 5 Mucosal 100 5

Mayo Clinic ExperienceMayo Clinic Experience %%

InvolvementInvolvement BladderBladder UreterUreterExtrinsicExtrinsic ---- ---- 86 86IntrinsicIntrinsic 100 14 100 14 Mucosal 100 5 Mucosal 100 5

Ureteral ObstructionUreteral ObstructionUreteral ObstructionUreteral Obstruction

Diagnosis %Diagnosis %

Preop 55Preop 55

Intraop 27Intraop 27

Diagnosis %Diagnosis %

Preop 55Preop 55

Intraop 27Intraop 27



Presentation as Patients with Presentation as Patients with Advanced Endometriosis*Advanced Endometriosis*

%%Pelvic pain Pelvic pain 6363Pelvic mass Pelvic mass 7878

*Preop Dx of endometriosis 60%.*Preop Dx of endometriosis 60%.

Presentation as Patients with Presentation as Patients with Advanced Endometriosis*Advanced Endometriosis*

%%Pelvic pain Pelvic pain 6363Pelvic mass Pelvic mass 7878

*Preop Dx of endometriosis 60%.*Preop Dx of endometriosis 60%.

Intrinsic Bladder InvolvementIntrinsic Bladder InvolvementIntrinsic Bladder InvolvementIntrinsic Bladder Involvement

Presentation as Any Other Patient with Presentation as Any Other Patient with Advanced EndometriosisAdvanced Endometriosis

%%

Urinary symptomsUrinary symptoms 5050

M/O hematuriaM/O hematuria 25 25

Cyclic pain with hematuriaCyclic pain with hematuria 0 0


%%

Urinary symptomsUrinary symptoms 5050

M/O hematuriaM/O hematuria 25 25

Cyclic pain with hematuriaCyclic pain with hematuria 0 0

Intrinsic Ureteral InvolvementIntrinsic Ureteral InvolvementIntrinsic Ureteral InvolvementIntrinsic Ureteral Involvement


%%

Flank pain Flank pain 5 5

Lower back pain Lower back pain 5 5

M/O hematuria M/O hematuria 1010

No symptoms No symptoms 4 4


%%

Flank pain Flank pain 5 5

Lower back pain Lower back pain 5 5

M/O hematuria M/O hematuria 1010

No symptoms No symptoms 4 4

Ureteral Obstruction:Ureteral Obstruction: Ureterolysis vs Resection Ureterolysis vs Resection

Ureteral Obstruction:Ureteral Obstruction: Ureterolysis vs Resection Ureterolysis vs Resection

% negative IVP postop % negative IVP postop

Ureterolysis Ureterolysis 88 88

Resection 65 Resection 65

% negative IVP postop % negative IVP postop

Ureterolysis Ureterolysis 88 88

Resection 65 Resection 65

Invasive endometriosis stage IVInvasive endometriosis stage IVDefinitive vs Conservative SurgeryDefinitive vs Conservative Surgery

Invasive endometriosis stage IVInvasive endometriosis stage IVDefinitive vs Conservative SurgeryDefinitive vs Conservative Surgery

Results, %Results, %

Conservative Conservative DefinitiveDefinitive

n=6 n=34n=6 n=34

RecurrenceRecurrence 0 0 3 3

Reoperation for 17* 3** Reoperation for 17* 3** other reasonsother reasons

*serous cystadenoma*serous cystadenoma

**bowel obstruction**bowel obstruction

Results, %Results, %

Conservative Conservative DefinitiveDefinitive

n=6 n=34n=6 n=34

RecurrenceRecurrence 0 0 3 3

Reoperation for 17* 3** Reoperation for 17* 3** other reasonsother reasons

*serous cystadenoma*serous cystadenoma

**bowel obstruction**bowel obstruction

ConclusionConclusionConclusionConclusion

• Invasion of urinary tract increases Invasion of urinary tract increases with AFS staging with AFS staging

• Clinical symptoms are not specificClinical symptoms are not specific

• Mucosal involvement is common in Mucosal involvement is common in bladder not in uretersbladder not in ureters

• Ureteral obstruction is diagnosed Ureteral obstruction is diagnosed intraop in 1/4 ptsintraop in 1/4 pts

• Invasion of urinary tract increases Invasion of urinary tract increases with AFS staging with AFS staging

• Clinical symptoms are not specificClinical symptoms are not specific

• Mucosal involvement is common in Mucosal involvement is common in bladder not in uretersbladder not in ureters

• Ureteral obstruction is diagnosed Ureteral obstruction is diagnosed intraop in 1/4 ptsintraop in 1/4 pts


• 2/3 of pts require extensive 2/3 of pts require extensive additional surgeryadditional surgery

• Conservative surgery is appropriate Conservative surgery is appropriate if all disease is removedif all disease is removed

• Ureterolysis is preferable to Ureterolysis is preferable to resection if feasible resection if feasible

• 2/3 of pts require extensive 2/3 of pts require extensive additional surgeryadditional surgery

• Conservative surgery is appropriate Conservative surgery is appropriate if all disease is removedif all disease is removed

• Ureterolysis is preferable to Ureterolysis is preferable to resection if feasible resection if feasible


• Invasion of urinary tract increases Invasion of urinary tract increases with stage with stage

• Clinical symptoms are no differentClinical symptoms are no different

• Mucosal involvement is common in Mucosal involvement is common in bladder not in ureter/sbladder not in ureter/s

• Ureteral obstruction is diagnosed Ureteral obstruction is diagnosed intraop in 25% of ptsintraop in 25% of pts

• Invasion of urinary tract increases Invasion of urinary tract increases with stage with stage

• Clinical symptoms are no differentClinical symptoms are no different

• Mucosal involvement is common in Mucosal involvement is common in bladder not in ureter/sbladder not in ureter/s

• Ureteral obstruction is diagnosed Ureteral obstruction is diagnosed intraop in 25% of ptsintraop in 25% of pts

Invasive pelvic endometriosis Invasive pelvic endometriosis (AFS stage IV)(AFS stage IV)

Invasive pelvic endometriosis Invasive pelvic endometriosis (AFS stage IV)(AFS stage IV)

Mayo Clinic 1966-92Mayo Clinic 1966-92 N=249N=249 40 pts (16%) required radical pelvic 40 pts (16%) required radical pelvic surgerysurgery JPS 1996 2:176JPS 1996 2:176

Mayo Clinic 1966-92Mayo Clinic 1966-92 N=249N=249 40 pts (16%) required radical pelvic 40 pts (16%) required radical pelvic surgerysurgery JPS 1996 2:176JPS 1996 2:176

Radical surgery for endometriosisRadical surgery for endometriosisRadical surgery for endometriosisRadical surgery for endometriosis

Additional surgeries to HysterectomyAdditional surgeries to HysterectomyPartial resection Partial resection %% ureter 38 ureter 38 rectosigmoid 15 rectosigmoid 15 bladder 10bladder 10 upper vagina 3upper vagina 3Ureterolysis 53Ureterolysis 53Appendectomy 33 Appendectomy 33 JPS 1996 2:176JPS 1996 2:176

Additional surgeries to HysterectomyAdditional surgeries to HysterectomyPartial resection Partial resection %% ureter 38 ureter 38 rectosigmoid 15 rectosigmoid 15 bladder 10bladder 10 upper vagina 3upper vagina 3Ureterolysis 53Ureterolysis 53Appendectomy 33 Appendectomy 33 JPS 1996 2:176JPS 1996 2:176

Radical surgery for endometriosisRadical surgery for endometriosisRadical surgery for endometriosisRadical surgery for endometriosis

ResultsResults

%%

Cure 97.3Cure 97.3

Recurrence 2.7Recurrence 2.7

Pain free 72Pain free 72

f/u 76.1 mos (14-240)f/u 76.1 mos (14-240)

ResultsResults

%%

Cure 97.3Cure 97.3

Recurrence 2.7Recurrence 2.7

Pain free 72Pain free 72

f/u 76.1 mos (14-240)f/u 76.1 mos (14-240)

Laparoscopic ExcisionLaparoscopic Excisionofof Rectosigmoid endometriosisRectosigmoid endometriosis


% complications n=51* n=31**% complications n=51* n=31**

Fistula 10 10 Fistula 10 10 Abscess 2 3Abscess 2 3PO. Bleeding 2 --PO. Bleeding 2 --Urinoma 2 --Urinoma 2 --Urin dysfunction -- 17Urin dysfunction -- 17Conversion 13 11Conversion 13 11QOL Improved ImprovedQOL Improved Improved **Human Rep 2006 21:1243Human Rep 2006 21:1243 **AJOG 2005 192: 394**AJOG 2005 192: 394

% complications n=51* n=31**% complications n=51* n=31**

Fistula 10 10 Fistula 10 10 Abscess 2 3Abscess 2 3PO. Bleeding 2 --PO. Bleeding 2 --Urinoma 2 --Urinoma 2 --Urin dysfunction -- 17Urin dysfunction -- 17Conversion 13 11Conversion 13 11QOL Improved ImprovedQOL Improved Improved **Human Rep 2006 21:1243Human Rep 2006 21:1243 **AJOG 2005 192: 394**AJOG 2005 192: 394



Fertility resultsFertility results

Pregnancy rate 45%Pregnancy rate 45%

IVF assisted 30%IVF assisted 30%

Live births 82%Live births 82%

FS 2005 84:945FS 2005 84:945

Fertility resultsFertility results

Pregnancy rate 45%Pregnancy rate 45%

IVF assisted 30%IVF assisted 30%

Live births 82%Live births 82%

FS 2005 84:945FS 2005 84:945

Vascular complications due to Vascular complications due to endometriosisendometriosis

Vascular complications due to Vascular complications due to endometriosisendometriosis

N LocationN Location Ranney, 70 6 Implants, endom.Ranney, 70 6 Implants, endom. Carmichael, 72 1 Ulcer broad ligCarmichael, 72 1 Ulcer broad lig Kumar, 96 1 ImplantsKumar, 96 1 Implants Mizumoto, 96 1 Uterine surfaceMizumoto, 96 1 Uterine surface Harmanli, 98 1 R tube ruptureHarmanli, 98 1 R tube rupture Janicki, 02 1 EndometriomaJanicki, 02 1 Endometrioma FS 2002 78:879FS 2002 78:879

N LocationN Location Ranney, 70 6 Implants, endom.Ranney, 70 6 Implants, endom. Carmichael, 72 1 Ulcer broad ligCarmichael, 72 1 Ulcer broad lig Kumar, 96 1 ImplantsKumar, 96 1 Implants Mizumoto, 96 1 Uterine surfaceMizumoto, 96 1 Uterine surface Harmanli, 98 1 R tube ruptureHarmanli, 98 1 R tube rupture Janicki, 02 1 EndometriomaJanicki, 02 1 Endometrioma FS 2002 78:879FS 2002 78:879

EndometriosisEndometriosisEndometriosisEndometriosis

%%

Malignant transformation Malignant transformation 11

ovarian 79ovarian 79

other 21other 21

Am Surg 71:696,2005Am Surg 71:696,2005

%%

Malignant transformation Malignant transformation 11

ovarian 79ovarian 79

other 21other 21

Am Surg 71:696,2005Am Surg 71:696,2005

EndometriosisEndometriosisEndometriosisEndometriosis

• 500 patients with endometriosis500 patients with endometriosis

• 100 with cul-de-sac involvement100 with cul-de-sac involvement

• 34 required rectosigmoid resection34 required rectosigmoid resection

Koh, Janick 07Koh, Janick 07

• 500 patients with endometriosis500 patients with endometriosis

• 100 with cul-de-sac involvement100 with cul-de-sac involvement

• 34 required rectosigmoid resection34 required rectosigmoid resection

Koh, Janick 07Koh, Janick 07

Frozen pelvisFrozen pelvisFrozen pelvisFrozen pelvis

GoalsGoalsRestore anatomy to normalRestore anatomy to normal

Avoid injury toAvoid injury to external, common iliac art.external, common iliac art. uretersureters obturator nerveobturator nerve

GoalsGoalsRestore anatomy to normalRestore anatomy to normal

Avoid injury toAvoid injury to external, common iliac art.external, common iliac art. uretersureters obturator nerveobturator nerve

Frozen pelvisFrozen pelvisFrozen pelvisFrozen pelvis

• Identify intraperitoneal anatomyIdentify intraperitoneal anatomy

bladder: inflated, 3 way catheterbladder: inflated, 3 way catheter

vaginal probevaginal probe

rectal proberectal probe

Identify retroperitoneal anatomy as early Identify retroperitoneal anatomy as early as possible as possible

• Identify intraperitoneal anatomyIdentify intraperitoneal anatomy

bladder: inflated, 3 way catheterbladder: inflated, 3 way catheter

vaginal probevaginal probe

rectal proberectal probe

Identify retroperitoneal anatomy as early Identify retroperitoneal anatomy as early as possible as possible

Documents

JFM072902 Surgical management of GI and GU endometriosis Javier Magrina, MD Mayo Clinic in Arizona JFM100402