Problems in the treatment of deep infiltrating endometriosis

Endometriosis: Deeper it gets harder to manage, or not?

Key Points

Highlights:

• Deep infiltrating endometriosis (DIE) is a benign lesion, however it acts like an aggressive tumor and invades the Douglas space, many surrounding organs including bladder, ureter, uterine artery, colon, and even anterior rectal wall.
• Surgical and medical treatments for DIE are described, but each treatment has its advantages and disadvantages.

What's done here:

• The authors from University of Cagliari, Italy, evaluated the pros and cons of the medical and surgical treatments for the DIE by reviewing the literature.
• Medical treatment of DIE aims to improve symptoms, stopping enlargement of the lesions, and promote the success of surgical treatment.
• Surgical management of DIE is preferred for patients who do not have any benefits from medical treatment and have significant symptoms due to invasion of endometriosis.
• The main purposes of surgery were complete removal of DIE, eliminate pain, decrease the recurrence rate, and maintain the functional anatomy of invasive organs.

Key Results:

• Progestogens and combined oral contraceptives:
  • Mainly affect DIE-associated symptoms with long-term safety.
  • Early return of pain after stopping treatment, abnormal uterine bleeding, deep vein thrombosis, mood changes, disturbances in fluid-electrolyte balance are possible disadvantages.
• Gonadotropin-releasing hormone (GnRH) analogs
  • have two main advantages: pain relief and decreased digestive system symptoms.
  • Negative effects include menopausal symptoms, loss of bone mineral density, and hypoestrogenism.
• Danazol, a testosterone derivative, mainly administred through the vaginal route:
  • is well tolerated and improves DIE symptoms with the risk of hyperandrogenism.
• Aromatase inhibitors:
  • Decrease the estrogen synthesis and pain associated with DIE.  However, its administration has not been approved yet.
• In the surgical treatment for rectovaginal and bowel endometriosis:
  • Inferior hypogastric nerve spearing surgeries are associated with better urinary, sexual, and bowel functions.
  • The shaving technique in the rectal wall has the advantages of less complication rate without requiring opening the rectal wall.
  • Also, transanal stapler application could be accepted as a closed technique, cut the endometriosis infiltrative rectal wall, then suture wound edges.
  • Laparoscopic colorectal segmental resection can be done in patients with multiple and large intestinal lesions, and patients with intestinal obstruction.
• In the treatment of ureteral endometriosis:
  • Ureterolysis, ureteroureterostomy, ureteroneocystostomy, and nephrectomy are options depending on the involvement of the disease and the surgeon's choice.
  • Preoperative stenting of the ureter could decrease the rate of ureteral injuries.
  • Lesion site in the bladder and its association with the ureter wall are the most important factors in managing bladder endometriosis.
  • Partial cystectomy and transurethral resection of lesions are two main treatment choices.

Limitations:

• The treatments for endometriosis and studies examining these treatments were evaluated but a meta-analysis is not perfermoed, study selection criteria is not described.
• Additionally, the authors did not examine and compare the costs of the treatments.

Lay Summary

The Deep Infiltrating Endometriosis (DIE) is very aggressive in nature with infiltrating the whole pelvic, colon, rectum, bladder, ureter, and pelvic wall.

D’Alterio and colleagues analyzed the advantages and disadvantages of both medical and surgical therapies for DIE.

The authors concluded that medical therapies have potential benefits in the relief of pain and DIE related symptoms, but each therapy has side effects such as abnormal uterine hemorrhage, breast pain, psychological lability and risk of deep vein thrombosis for progestogens and combined oral contraceptives; menopausal symptoms, loss of bone mineral density, and hypoestrogenism for GnRH analogs; and hyperandrogenism symptoms for Danazol.

On the surgical side, shaving technique, transanal stapler application, and laparoscopic segmental resection of the endometrial lesions are analyzed and suggested in the treatment of rectovaginal and bowel endometriosis. Also, the authors highlighted that protection of inferior hypogastric nerve spearing surgeries are associated with better urinary, sexual, and bowel functions. For ureteral endometriosis, ureterolysis, ureteroureterostomy, ureteroneocystostomy, and nephrectomy are advised to be performed according to the depth and width of the endometriosis and surgeon preference.

Also, stenting of the ureter has been suggested for having a protective effect against ureteral injury. For bladder endometriosis, partial cystectomy or transurethral resection of the lesion is supported to be done in regards to lesion location and relation between the lesion and the ureter. 

"To clarify the optimal treatment modality for DIE, prospective randomized studies should be performed for comparing medical and surgical treatment alternatives", the authors added.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33687160/