DEEP INFILTRATING ENDOMETRIOSIS
Abstract
Background: Endometriosis is not considered a unified disease, but a disease encompassing three differ- ent forms differentiated by aetiology and pathogenesis: peritoneal endometriosis, ovarian endometriosis and deep infiltrating endometriosis (DIE). The disease is classified as DIE when the lesions penetrate 5 mm or more into the retroperitoneal space. The estimated incidence of endometriosis in women of reproductive age ranges from 10–15 % and that of DIE from 3–10 %, the highest being in infertile women and in those with chronic pelvic pain. The leading symptoms of DIE are chronic pelvic pain which increases with age and correlates with the depth of infiltration and infertility. The most important diagnostic procedures are patient’s history and proper gynecological examination. The diagnosis is confirmed with laparoscopy.
DIE can affect, beside reproductive organs, also bowel, bladder and ureters, therefore adi- tional diagnostic procedures must be performed preopertively to confirm or to exclude the involvement of the mentioned organs. Endometriosis is hormon dependent disease, there- fore several hormonal treatment regims are used to supress estrogen production but the symptoms recurr soon after caesation of the treatment. At the moment, surgical treatment with excision of all lesions, including those of bowel, bladder and ureters, is the method of choice but requires frequently interdisciplinary approach. Surgical treatment significantly reduces pain and improves fertility in inferile patients.
Conclusions: DIE is not a rare form of endometriosis characterized by chronic pelvic pain and infertility. Medical treatment is not efficient. The method of choice is surgical treatment with excision of all lesions. It significantly reduces pelvic pain and enables high spontaneus and IVF preg- nacy rates.Therefore such patients should be treated at centres with experience in treatment of DIE and with possibility of interdisciplinary approach.
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Serdar E, Bukun MD, Khaled M, Zeitoum MD, and Kilic G. Expres- sion of dioxin-related transactivating factors and target genes in human eutopic endometriasl and endometriotic tissues. Am J Obstet Gynecol 2000; 182: 767–75.
BirnbaumMD.Incidenceofendometriosis,www.Google.com, junij 2009, dosegljivo na http://www.infertilityphysician.com/ endometriosis/incidence.html
Goldstein DP, DeCholnocky C, Emans SJ. Adolescent endo- metriosis. J Adolesc Health Care 1980; 1: 37–41
LauferMR,GoiteinL,BushM,CramerDW,EmansSJ.Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy. J Pediatr Adolesc Gynecol 1997; 19: 199–202
European Union grants funding for endometriosis work in Europe. Endometriosis news May 2007. Dosegljivo na: www. endometriosis.org
Hadfield RM, Mardon H, Barlow D, Kennedy S. Delay in diagnosis of endometriosis: a survey of women from USA and UK. Hum Reprod 1996; 11: 878–80.
Husby GK, Haugen RS, Moen MH. Diagnostic delay in women with pain and endometriosis. Acta Obstet Gynecol Scand 2003; 82: 649–53.
BianconiL,HummelshojL,CocciaME,ViganoP,VittoriG,Veit J, et al. Recognizing endometriosis as a social disease: European Union-encouraged Italian Senate approach. Fertil Steril 2007; 85: 1285–4.
Seminar in the European parliament brings stake holders to- gether to tackle endometriosis. Endometriosis news March 2007. Dosegljivo na www.endometriosis.org
Cornillie FJ, Oosterlynck D, Lauweryns JM, Ko ninckx P. Deeply infiltrating pelvic endometriosis: histology and clinical signifi- cance. Fertil Steril 1990; 53: 978–83.
Chapron C, Fauconnier A, VieiraM, Barakat H, Dousset B, Pansini V, et al. Anatomical distribution of deeply infiltrating endometrio- sis: surgical implications and proposition for a classification. Hum Reprod 2003; 18: 157–61.
Fedele L, Bianci S, Zanconato G, Raffaelli R, Berlanda N. Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 2004; 191: 1539–42.
Canis M, Matsuzaki S, Botchorishvili R, Rabishong B, Pouly JL, Mage G. Pathophysiology of deep infiltrating disease. Deep infiltrating endometriosis: The laparoscopic challenge – 2nd International meeting 2008 Dec 13–14, Athens, Greece: Athens centre of endoscopic training.
Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endo- metriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril 1997; 68: 585 96.
Koninckx P, Kennedy SH, Barlow DH. Endometriotic disease: the role of peritoneal fluid. Hum Reprod Update 1998; 4: 741–51.
Matsuzaki S, Canis M, Pouly JL, Raboschong B, Bothorishvili R, Mage G. Relationship between delay of surgical diagnosis and severity of disease in patients with symptomatic deep infiltrating endometriosis. Fertil Steril 2006; 86: 1314–6.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion Number 310, April 2005. Endometriosis in adolescents. Obstet Gynecol 2005; 105: 921–7.
VercelliniP,FrontinoG,PietrpaoloG,GatteiU,DaguatiR,Cro- signani PG. Deep endometriosis: definition, pathogenesis, and clinical management. J Am Assoc Laparosc 2004; 11: 153–61.
Koninckx P, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991; 55: 759–65.
Anaf V, Simon Ph, El Nakadi I, Fayt I, Buxant F, Simonart T, et al. Relationship between endometriotic foci and nerves in rectovagi- nal endometriotic nodules. Hum Reprod 2000; 15: 1744–50.
Anaf V, Simon Ph, Fayt I, Noel JC. Smooth muscles are frequent components of endometriotic lesions. Hum Reprod 2000; 15: 767–77.
KoninckxP.Epidemiologyofendometriosis.In:TulandiT,Red- wine B, eds. Endometriosis: advances and contraversis. London: Informa Healthcare; 2003. p.1–18.
ChapronC,ChopinN,BorgheseB,FoulotH,DoussetB,Vacher- Lavenu MC, et al. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod 2006; 21: 1839–45.
TuttliesF,KecksteinJ,UlrichU,PossoverM,SchweppeKW,Wus- tlich M, et al. ENZIAN-score, a classification of deep infiltrating endometriosis. Zentralbl Gynakol 2005; 127: 275–81.
Mahmood TA, Templeton A. Prevalence and genesis of endo- metriosis. Hum Reprod 1991; 6: 544–9.
Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Breat G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril 2002; 78: 719–26.
Yantiss R, Clement PB, Young RH. Endometriosis of the intestinal tract. Am J Surg Pathol 2001; 25: 445–54.
Carmignani L, Vercellini P, Spinelli M, Fontana E, Frontino G, Fedele L. Pelvic endometriosis and hydroureternephrosis. Fertil Steril. V tisku 2009.
Canis M. Deep infiltrating endometriosis: a plea for listening to patients and for vaginal manual examination. Gynecol Obstet Fertil 2003; 31: 893–4.
Banerjee SK, Karen D, Ballard D, Wright JT. Endometriomas as a marker of disease severity. J Minimal Invasive Gynecol 2008; 15: 538–40.
Redwinw DB. Ovarian endometriosis: a marker for more exten- sive pelvic and intestinal disease. Fertil Steril 1999; 310–15.
LandiS,MereuL,PontrelliG,StepniewskaA,RomanoL,TateoS,
et al. The influence of adenomyosis in patients laparoscopically treated for deep endometriosis. J Minimal Invasive Gynecol 2008; 15: 566–70.
HudelistG,OberwinklerKH,SingerCF,TuttliesF,RautarG,Ritter O, et al. Combination of transvaginal sonography and clinical examination for preoperative diagnostis of pelvic endometriosis. Hum Reprod 2009; 24: 1018–24.
HudelistG,TuttliesF,RauterG,PucherS,KecksteinJ.Cantrans- vaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum? Hum Reprod 2009; 24: 1012–7.
KennedyS,BerquistA,ChapronC,D’HoogheT,DunselmanG, Greb R, et al. ESHRE guideline for diagnosis and treatment of endometriosis. Hum Reprod 2005; 20: 2698–704.
Ribič-Pucelj M, Kobal B, Jelenc F, Šinkovec J. Deep infiltrat- ing endometriosis. Poslijediplomski tečaj trajnog medicinskog usavršavanja iz obnove znanja: Nove spoznanje o patofiziologiji, dijagnozi i terapiji endometrioze i adenomioze. Zagreb, 19–20 studenog 2004.
Kinkel K, Chapron C, Balleyquir C, Fritel X, Dubuisson JB, Moreau Jf. Magnetic resonance imaging characteristic of deep endometriosis. Hum Reprod 1999; 14: 1080–6.
Barbieri F. Diagnostic strategies prior to laparoscopy. Deep infiltrating endometriosis: The laparoscopic challenge – 2nd International meeting 2008 Dec 13–14, Athens, Greece: Athens centre of endoscopic training.
Landi S, Barbieri F, Fiaccavento A. Preoperative double-contrast barium enema in patients with suspected intestinal endometrio- sis. J Am Assoc Gynecol Laparosc 2004; 11: 223–8.
Chapron C, Vieira M, Chopin N. Accuracy of rectal endoscopic ultrasonography an magnetic resonanc imaging in the diagno- sis of rectal involvement for patients presenting with deeply infiltrating endometriosis. Ultrasound Obstet Gynecol 2004; 24: 175–9.
Comiter CV. Endometriosis of the urinary tract. Urol Clin North Am 2002; 29: 625–35.
WallerK,ShawRW.Gonadotropin-releasinghormoneanalogues for the treatment of endometriosis: long-term follow-up. Fertil Steril 1993; 59: 511–5.
Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotropin-releasing hormone agonist versus a low dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril 1993; 60: 75–9.
Yap C, Furness S, Farquhar C. Pre and postoperative medical tretment for endometriosis surgery. Cochrane Database Syst Rev 2004; CD003678.
Vercellini P, Somigliana E, Daguati R, Vigano P, Meroni F, Cro- signani PG. Postoperative oral contraceptive exposure and risk of endometrioma recurrence. Am J Obstet Gynecol 2008; 198: 504.e1–e5.
Anaf V, El Nakadi I, Simon P, Englert Y, Peny MO, Fayt I, et al. Sigmoid endometriosis and ovarian stimulation. Hum Reprod 2000; 15: 790–4.
Rosa-e-Silva JC, Carvalho BR, Barbosa HF, Poli-Neto OB, Rosa-e- Silva AC, Candido-dos-Reis FJ, et al. Endometriosis in postmeno- pausal women without previous hormonal therapy: report of three cases. Climacteric 2008; 11: 525–8.
Matorras R, Elorriaga M, Pijoan JI, Ramon O, Rodriguez-Escudero F. Recurrence of endometriosis in women with bilateral adn- exectomy (with or without total hysterectomy) who received hormone replacement therapy. Fertil Steril 2002; 77: 303–8.
Jones KD, Owen E, Berresford A, Sutton C. Endometrial adeno- carcinoma arising from endometriosis of the rectosigmoid colon. Gynecol Oncol 2002; 86: 220–2.
Chapron C, Chopin N, Borghese B, Malartic C, Decuypere F, Fou- lot H. Surgical management of deeply infiltratinf endometriosis: un update. Ann NY Acad Sci 2004; 1034: 326–37.
Jelenc F, Ribič-Pucelj M, Kobal B, Juvan R, Šinkovec J, Norčič G, et al. Laparoskopsko asistirane resekcije debelega črevesa in danke zaradi endometrioze. Endoscopic Rev 2009; 14: 67.
Ribič-Pucelj M. Plodna sposobnost žensk po kirurškem zdrav- ljenju endometrioze. In: Takač I, ed. Mednarodni znanstveni simpozij 50 let načrtovanja družine v Mariboru.15.6. 2007; Mari- bor. Maribor: Univerzitetni klinični center; 2007. p. 241–50.
Angioni S, Peiretti M, Zirone M, Palomba M, Mais V, Gomel V, et al. Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up. Hum Reprod 2006; 21: 1629–34.
Remergida V, Ragni R, Ferrero S, Anserini P, Torelli P, Fulcheri E. How complete is full thickness disc resection of bowel en- dometriosi? A prospective surgical and histological study. Hum Reprod 2005; 20: 2317–20.
Darai E, Ackerman G, Bazot M, Rouzier R, Dubernard G. Lap- aroscopic segmental resection for endometriosis. Limits and complications. Surg Endosc 2007; 21: 1572–7.
Keckstein J. Laparoscopic treatment of endometriosis of the urinary tract. In: Ribič-Pucelj M, ed. Endoscopic surgery in gynecology. Radovljica: Didakta; 2007. p. 198–204.
Stepniewska A, Pomini P, Bruni F, Mereu L, Ruffo G, Ceccaroni M, et al. Laparoscopic treatment of bowel endometriosis in infertile women. Hum Reprod 2009; 24: 1619–25.
Bianchi PH, Pereira RM, Zanatta A, Alegretti JB, Motta EL, Serafini PC. Extensive excision of deep infiltrating endometriosis before in vitro fertilization significantly improves pregnancy rates. J Minim Invasive Gynecol 2009; 16: 174–80.
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