Surgery for Bladder Endometriosis: Long-term Results and Concomitant Management of Associated Posterior Deep Lesions

Charles Chapron; Antoine Bourret; Nicolas Chopin; Bertrand Dousset; Mahaut Leconte; Delphine Amsellem-Ouazana; Dominique de Ziegler; Bruno Borghese

Disclosures

Hum Reprod. 2010;25(4):884-889. 

In This Article

Abstract and Introduction

Abstract

Background: Deep infiltrating endometriosis (DIE) is presented as a disease with high recurrence risk. Bladder DIE is the most frequent location in cases of urinary endometriosis. Surgical removal has been recommended for bladder DIE but long-term outcomes remains unevaluated. The objectives of this study are to evaluate the rate of recurrence after partial cystectomy for patients presenting with bladder DIE and to outline the surgical modalities for handling associated posterior DIE nodules.
Methods: Seventy-five consecutive patients with histologically proved bladder DIE were enrolled at a single tertiary academic center between June 1992 and December 2007. A partial cystectomy was performed for each patient. Complete surgical exeresis of all associated symptomatic DIE lesions was carried out during the same surgical procedure. Bladder DIE patients were classified into three groups: patients with isolated bladder DIE (Group A); patients with associated symptomatic posterior DIE (Group B); patients with associated asymptomatic posterior DIE (Group C). Bladder DIE recurrence was defined as a clinical reappearance of the disease or radiological evidence that mandated a new surgical procedure. We assessed pelvic pain symptoms pre- and post-operatively using a 10-cm visual analogue scale.
Results: In a series of 627 patients with DIE, we observed 75 patients (12%) with bladder DIE. With a 50.9 ± 44.6 months mean follow-up after partial cystectomy no patient presented evidence of bladder DIE recurrence. Post-operatively, we observed a significant improvement with respect to pain symptoms, with only two patients (2.7%) developing major complications during follow-up. Among patients with non-operated associated asymptomatic posterior DIE lesions (n = 15), a second surgical procedure indicated for pain symptoms was necessary in only one patient (6.7%).
Conclusions: For patients presenting with bladder DIE, no patients required further surgery for bladder recurrence after radical surgery consisting in partial cystectomy. Exeresis of associated posterior DIE nodules is indicated only when they are symptomatic.

Introduction

Endometriosis, defined as the presence of endometrial-like tissue outside the uterus, affects up to 15% of women of reproductive age (Hemmings et al., 2004), and causes a considerable economic burden for society (Gao et al., 2006). Aside from endometriosis extension scored with the revised American Fertility Society (rAFS) (1985), three types of endometriosis are recognized: superficial endometriosis (peritoneum and/or ovary), ovarian endometriomas (OMA) and deeply infiltrating endometriosis (DIE). The latter is mainly located in the uterosacral ligaments (USL), the upper third of the posterior vaginal wall, the intestine and in the urinary tract (bladder and/or ureter; Chapron et al., 2006). Endometriosis expanding and invading the urinary tract is a rare occurrence found in ~1–2% of all endometriotic patients (Schneider et al., 2006). In cases of urinary endometriosis, the bladder is the most frequent location (Denes et al., 1980). Amongst women suffering from DIE, 11% present DIE lesions that affect the bladder (Chapron et al., 2006).

Bladder DIE may present with infertility and/or variable painful symptoms (including suprapubic pain, dysuria, hematuria, repeated urinary infection; Abrao et al., 2009). Several physiopathological mechanisms might explain the relation between endometriosis and pelvic pain: (i) recurrent cyclic micro-bleeding in the endometriotic lesions responsible for hyperpressure; (ii) production of inflammatory mediators by endometriotic lesions, which can stimulate the nerves; (iii) adhesions responsible for fixed position of pelvic structures; (iv) compression and/or infiltration of the sub-peritoneal nerve fibres by deep implants (Fauconnier and Chapron, 2005).

Although medical treatment may be effective in some DIE patients (Fedele et al., 2001; Vercellini et al., 2005), the treatment of choice is surgical excision (Garry, 1997). The multifocal nature of DIE lesions—a major characteristic of this form of endometriosis—must be taken into account when defining the surgical strategy (Chapron et al., 2003). Preliminary data on small patient series support the feasibility of laparoscopic partial cystectomy for patients presenting with bladder DIE (Donnez et al., 2000; Nezhat et al., 2002; Antonelli et al., 2006). However, as endometriosis is a disease with a high recurrence risk (Redwine and Wright, 2001; Fedele et al., 2004a, b), long-term outcome of such surgery needs to be evaluated.

We therefore conceived the present study with two primary objectives in mind: (i) to assess surgical results and the risk of recurrence after partial cystectomy for bladder DIE and (ii) to review the surgical modalities that are best adapted for treating the associated DIE nodules found in the posterior pelvic area.

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