**6. Bowel endometriosis**

Endometriosis affects the gastrointestinal tract of 5-12% of women with this condition (Wills *et al.*, 2009). The rectum and the rectosigmoid junction are the most common sites of bowel endometriosis (70-93% of all bowel lesions). The rectovaginal septum, appendix, caecum and distal ileum may also be affected, with a lower incidences (12%, 3-18%, 2-5% and 2-20%, respectively). (Chapron *et al.*, 2003; De Cicco *et al.*, 2011). In most cases, intestinal endometriosis is associated to genital endometriosis. Rectal involvement is associated with DIE and adnexal endometriosis in 70% and 80% of the patients, respectively (Chapron *et al.*, 2003).

Bowel endometriosis is considered an infiltration or invasion phenomenom, found that there is a histological continuity between the superficial and underlying deep lesions originating from the serosa progressively invade the muscularis propria (Anaf *et al.*, 2004). Endometriosis infiltrating the muscularis propria may lead to localized fibrosis, strictures, and small or large bowel obstruction (Yantiss et al, 2001).

Bowel endometriosis is difficult to diagnose because of the lack of characteristic symptoms. The patients present with relapsing bouts of abdominal pain, abdominal distention, tenesmus, constipation, diarrhoea, rectal bleeding and pain during defecation (Brouwer & Woods, 2007). Colicky abdominal pain is the most common symptom. Rectal bleeding may be caused by mucosal injury during the passage of stools through a stenosed colon with the intramural endometriotic tissue increased at the time of menses if it occurs. Bowel endometriosis can mimic other abdominal pathologies such as malignancy, inflammatory bowel disease, ischaemic colitis, infectious diseases and irritable bowel syndrome (Bianchi *et al.*, 2007). Hematochezia is an uncommon symptom due to low incidence of mucosal involvement. Endometriosis of the small bowel should be suspected in young, nulliparous patients with abdominal pain, in conjunction with signs of obstruction (Del Rey-Moreno *et al.*, 2008).

Clinical examination has been shown to have a low sensitivity and moderate specificity for uterosacral, high rectovaginal and rectal involvement. The presence of a large, palpable rectovaginal nodule identifies the patient at risk of rectal involvement. The low percentage of rectal endometriosis extending to the mucosa means colonoscopy has too low a sensitivity to be a reliable test for rectal involvement. Preoperative colonoscopy should be performed on an individualised basis to exclude other pathology and suspicious mucosal lesions should be biopsied to exclude malignancy (Wills *et al.*, 2009). Endorectal ultrasound has shown a sensitivity of more than 90% for rectovaginal septum endometriosis and a lower specifity for rectal wall invasion. Transvaginal ultrasound may be as effective as endorectal ultrasound (Chapron *et al.*, 2004). Magnetic resonance imaging of cul-de-sac obliteration, deep pelvic nodules and rectal involvement have an accuracy of 72-90% in predicting disease when measured against findings at surgery (Kataoka *et al.*, 2005). Currently, MRI is the best imaging modality for enteric endometriosis with a sensitivity of between 77-93% (Bianchi *et al.*, 2007). When endoscopic and radiologic examinations (computed tomography, endorectal ultrasound, magnetic resonance imaging) are performed, an extrinsic process is revealed and nearly all patients undergo a diagnostic laparoscopy as part of their investigations their symptoms (De Cicco *et al.*, 2011). This is often the first test that identifies rectal involvement. Brouwer & Woods (2007) have proposed a preoperative approach that minimizes the use of endorectal ultrasound and

Endometriosis affects the gastrointestinal tract of 5-12% of women with this condition (Wills *et al.*, 2009). The rectum and the rectosigmoid junction are the most common sites of bowel endometriosis (70-93% of all bowel lesions). The rectovaginal septum, appendix, caecum and distal ileum may also be affected, with a lower incidences (12%, 3-18%, 2-5% and 2-20%, respectively). (Chapron *et al.*, 2003; De Cicco *et al.*, 2011). In most cases, intestinal endometriosis is associated to genital endometriosis. Rectal involvement is associated with DIE and adnexal endometriosis in 70% and 80% of the patients, respectively (Chapron *et al.*,

Bowel endometriosis is considered an infiltration or invasion phenomenom, found that there is a histological continuity between the superficial and underlying deep lesions originating from the serosa progressively invade the muscularis propria (Anaf *et al.*, 2004). Endometriosis infiltrating the muscularis propria may lead to localized fibrosis, strictures,

Bowel endometriosis is difficult to diagnose because of the lack of characteristic symptoms. The patients present with relapsing bouts of abdominal pain, abdominal distention, tenesmus, constipation, diarrhoea, rectal bleeding and pain during defecation (Brouwer & Woods, 2007). Colicky abdominal pain is the most common symptom. Rectal bleeding may be caused by mucosal injury during the passage of stools through a stenosed colon with the intramural endometriotic tissue increased at the time of menses if it occurs. Bowel endometriosis can mimic other abdominal pathologies such as malignancy, inflammatory bowel disease, ischaemic colitis, infectious diseases and irritable bowel syndrome (Bianchi *et al.*, 2007). Hematochezia is an uncommon symptom due to low incidence of mucosal involvement. Endometriosis of the small bowel should be suspected in young, nulliparous patients with abdominal pain, in conjunction with signs of obstruction (Del Rey-Moreno *et* 

Clinical examination has been shown to have a low sensitivity and moderate specificity for uterosacral, high rectovaginal and rectal involvement. The presence of a large, palpable rectovaginal nodule identifies the patient at risk of rectal involvement. The low percentage of rectal endometriosis extending to the mucosa means colonoscopy has too low a sensitivity to be a reliable test for rectal involvement. Preoperative colonoscopy should be performed on an individualised basis to exclude other pathology and suspicious mucosal lesions should be biopsied to exclude malignancy (Wills *et al.*, 2009). Endorectal ultrasound has shown a sensitivity of more than 90% for rectovaginal septum endometriosis and a lower specifity for rectal wall invasion. Transvaginal ultrasound may be as effective as endorectal ultrasound (Chapron *et al.*, 2004). Magnetic resonance imaging of cul-de-sac obliteration, deep pelvic nodules and rectal involvement have an accuracy of 72-90% in predicting disease when measured against findings at surgery (Kataoka *et al.*, 2005). Currently, MRI is the best imaging modality for enteric endometriosis with a sensitivity of between 77-93% (Bianchi *et al.*, 2007). When endoscopic and radiologic examinations (computed tomography, endorectal ultrasound, magnetic resonance imaging) are performed, an extrinsic process is revealed and nearly all patients undergo a diagnostic laparoscopy as part of their investigations their symptoms (De Cicco *et al.*, 2011). This is often the first test that identifies rectal involvement. Brouwer & Woods (2007) have proposed a preoperative approach that minimizes the use of endorectal ultrasound and

and small or large bowel obstruction (Yantiss et al, 2001).

**6. Bowel endometriosis** 

2003).

*al.*, 2008).

magnectic resonance imaging and focuses on assessing the possibility of rectal involvement on laparoscopy and clinical examination under anaesthetic. A significant number of patients have more than one laparoscopy and the number of laparoscopies has been shown to correlate to extent of rectal involvement.

Treatment consists of surgical excision, or segmental resection. Excision should be complete in order to achieve maximal pain relief and minimal recurrences (De Cicco *et al.*, 2011). When the rectum is involved there are several approaches to be considered. The choice of technique depends on the size, location, degree and depth of involvement of the endometriotic implant. As a general rule, less is better when it comes to removal of rectal endometriosis as long as the implant can be completely excised. The nodule can be shaved off the rectal wall leaving it intact if superficial serosal deposits are present, alternatively if there is a solitary penetrating nodule there may be the opportunity to perform a fullthickness disc resection of the rectal wall, or it may be necessary to consider a segmental resection of the rectum and/or sigmoid colon (Brouwer & Woods, 2007; Wills *et al.*, 2009). All these procedures can be carried out by either a laparoscopic, combined or open approach (Brouwer & Woods, 2007; Dousset *et al.*, 2010; Wills *et al.*, 2009). Robotic assistance may allow more bowel resections to be carried out by laparoscopy (Veeraswamy *et al.*, 2010). An initial laparoscopy is carried out unless the preoperative assessment mandate a laparotomy. It appears that most authors decide to perform a bowel resection before surgery, based on preoperative examinations. This approach seems to result in a very high incidence of bowel resection. The indication reported is based on dimensions of the nodule >2 cm or 3 cm, and/or on muscularis involvement and/or occupation of more than onethird of the rectal circumference (Brouwer & Woods, 2007). The other approach is to decide during surgery based on findings such as the size, localisation and extension of the disease. Laparoscopic conversion rates is from 0% to 13%, due to extent of disease, dense adhesions, bowel perforation, difficulty stapling a bowel anastomosis, bleeding and poor visualisation (Wills *et al.*, 2009).

Surgery is only indicated in enteric endometriosis in acute or subacute small bowel obstruction that fails to resolve, in endometriotic tumours or when it is impossible to exclude malignancy. In an emergency setting, the main aim of surgery should be to relieve the obstruction, and if the disease is suspected intra-operatively, then as many ectopic deposits as possible should be excised (Bianchi *et al.*, 2007; Del Rey-Moreno *et al.*, 2008). It can be difficult to exclude a malignancy intra-operatively, in such case is appropriate to carry out an oncological resection.

Appendiceal endometriosis may present as an incidental finding with or without pelvic disease. Acute symptoms are similar to those of appendicitis. The appendix should be inspected in all patients undergoing surgery for endometriosis and appendectomy is recommended if it seems abnormal (Veeraswamy *et al.*, 2010).

The overall complication rate after surgery is 22.2%. Major complications occur in 7%-12.6% of women: colorectal anastomotic leakage (3.7%-11%), recto-vaginal fistula (4%-8.5%), severe obstruction (2.7%), haemorrhage (2.5%), pelvic abscess (1-4.2%), delayed ureteral ischemic necrosis (2%). Minor complications occur in 14.7% of women: temporary bowel dysfunction (4%), bladder dysfunction (8%-17%) (De Cicco *et al.*, 2011; Dousset *et al.*, 2010). The combination of systematic diverting ileostomy, interposition of omentoplasty and

Abdominopelvic Complications of Endometriosis 73

It should always be considered when a mass appears in or near a caesarean section scar or other gynaecologic operative procedure sites, in the umbilicus or in the inguinal region, more so when pain accompanying the patient's menstrual cycle. The diagnosis may become difficult if cyclical pain is not present (43%). Also be diagnosed in patients without previous surgery. Moreover, abdominal wall endometriosis patients are often referred to the general surgeons and were diagnosed after surgical techniques such as appendectomy, inguinal hernia repair, or laparoscopic procedures. Accurate preoperative diagnosis varies between

Additional studies such as ultrasound, CT scan, MRI, or fine-needle aspiration may be obtained if the lesion is very large, there is concern for fascial involvement, or if the diagnosis is in doubt. This information may assist with surgical planning especially when an abdominal wall reconstruction is anticipated (Veeraswamy *et al.*, 2010). Ultrasonography is the most commonly used investigational procedure for abdominal masses; the mass may appear hypoechoic and heterogeneous with scattered internal echoes, solid, or with cystic changes. The findings on computed tomography scan depend on the phase of the menstrual cycle, the proportions of stromal and glandular elements, the amount of bleeding, and the degree of surrounding and fibrotic response, without pathognomonic findings. Owing to the relatively vascular nature of these lesions, enhancement often occurs when intravenous contrast material is used. Magnetic resonance imaging enables very small lesions to be detected and can distinguish the hemorrhagic signal of endometriotic lesions. Fine needle aspiration cytology can confirm the diagnosis and eliminate the possibility of malignancy. This is justified only in cases of large masses, doubtful diagnosis and atypical clinical manifestations. However, its use is still controversial of the risk of causing new implants at

The treatment of choice is surgical excision with at least 1 cm margin, even for recurrent cases and, if necessary, placement of mesh for fascia defects. A combination of surgical reexcision with hormonal therapy is also recommended (Bektas *et al.*, 2010; Horton *et al.*, 2008). During violation of endometrial cavity, inoculum of endometrial tissue spill and implant on the abdominal wound. Thus, it is strongly recommended that the abdominal wound be cleaned at the conclusion of the cesarean section. Other recommendations are delivering the uterus outside the abdomen to repair, not using the same suture material to close the abdomen as used for uterine closure, not swabbing out the uterine cavity following the delivery of the placenta or discarding the swab used to clean the endometrial cavity after delivery of placenta, or using wound edge protector to separate the edges of the incision from contact with the patient's abdominal contents, instruments, and gloves during the

Endometriosis expanding and invading the urinary tract is a rare occurrence found in 0.3%- 5% of all endometriotic patients (Chapron *et al.*, 2003; Mereu *et al.*, 2010). The bladder is the most frequently involved organ, followed by the ureters and the kidneys with a proportion of 40:5:1. The endometriosis that comprises the urinary tract cannot be considered to be

20% and 50% (Bektas *et al.*, 2010; Horton *et al.*, 2008).

the puncture site (Bektas *et al.*, 2010; Horton *et al.*, 2008).

procedure (Bektas *et al.*, 2010; Horton *et al.*, 2008).

primary lesions from these organs (Abrao *et al*., 2009).

**8. Urinary tract endometriosis** 

nonjuxtaposed vaginal and colorectal sutures are major factors in preventing and facilitating the conservative treatment of anastomotic leaks, and the increased use of preoperative endoscopic ureteral double pig-tail stenting may help to prevent delayed ureteral ischemic necrosis related to extensive ureterolysis. The most frequent specific complication of compete surgery for low rectal endometriosis is transient peripheral neurogenic bladder. The inferior hypogastric nerves are recognized and preserved during surgery but may require resection in cases with lateral pelvic wall invasion (Dousset *et al.*, 2010).

The recurrence of symptoms for follow-up periods of 2-5 years varies between 4% and 54%. The recurrence of pain requiring surgery is 0% to 34%. Proven bowel endometriosis recurrence is 0-25% (De Cicco *et al.*, 2011; Dousset *et al.*, 2010), and is higher for dissection off the rectal wall (22.2%) that anterior rectal wall excision (5.2%) and segmental rectal resection (0-4.7%) (Brouwer & Woods, 2007; Dousset *et al.*, 2010). Recurrence of endometriosis can be explained by the significant proportion of rectal lesions that extend into the submucosa (36%) (Brouwer & Woods, 2007). The overall improvement in pain-related symptoms is of 87%-94% and in quality of life assessment of 90% (Dousset *et al.*, 2010). Dousset y cols (2010) believe that the very low recurrence in rectal endometriosis is related to a "carcinologic" surgical approach: (i) all additional extrarectal sites of endometriosis were removed, (ii) total mesorectal excision and en-bloc resection of the rectal nodule together with posterior vaginal fornix and uterosacral to ensure free anterior and circumferential resection margins, (iii) rectal section at least 2-cm below the endometriotic nodule, and (iv) all additional intestinal and urologic endometriotic deposits were resected with 2-cm-free surgical margins.

The results of several series show that with a multidisciplinary approach (gynaecologic, gastrointestinal and urologist surgeons, radiologist) to the management of endometriosis involving the rectum and radical surgery to excise the disease as completely as possible at one operation, excellent results can be achieved with low morbidity and recurrence (Brouwer & Woods, 2007; De Cicco *et al.*, 2011; Dousset *et al.*, 2010).
