Deep endometriosis: Definition, diagnosis and treatment

Deep endometriosis remains a subject of debate. A comprehensive overview of the definition, pathophysiology, prevalence, classification, diagnosis, and treatment was therefore attempted.

Philippe R. Koninckx, Ph.D., Anastasia Ussia, M.D., Leila Adamyan, Ph.D., Arnaud Wattiez, Ph.D., Jacques Donnez, Ph.D.

Volume 98, Issue 3, Pages 564-571, September 2012

Deep endometriosis, defined as adenomyosis externa, mostly presents as a single nodule, larger than 1 cm in diameter, in the vesicouterine fold or close to the lower 20 cm of the bowel. When diagnosed, most nodules are no longer progressive. In >95% of cases, deep endometriosis is associated with very severe pain (in >95%) and is probably a cofactor in infertility. Its prevalence is estimated to be 1% –2%. Deep endometriosis is suspected clinically and can be confirmed by ultrasonography or magnetic resonance imaging. Contrast enema is useful to evaluate the degree of sigmoid occlusion. Surgery requires expertise to identify smaller nodules in the bowel wall, and difficulty increases with the size of the nodules. Excision is feasible in over 90% of cases often requiring suture of the bowel muscularis or full-thickness defects. Segmental bowel resections are rarely needed except for sigmoid nodules. Deep endometriosis often involves the ureter causing hydronephrosis in some 5% of cases. The latter is associated with 18% ureteral lesions. Deep endometriosis surgery is associated with late complications such as late bowel and ureteral perforations, and recto-vaginal and uretero-vaginal fistulas. Although rare, these complications require expertise in follow-up and laparoscopic management. Pain relief after surgery is excellent and some 50% of women will conceive spontaneously, despite often severe adhesions after surgery. Recurrence of deep endometriosis is rare. In conclusion, defined as adenomyosis externa, deep endometriosis is a rarely a progressive and recurrent disease. The treatment of choice is surgical excision, while bowel resection should be avoided, except for the sigmoid.

  • Deep endometriosis surgery highlights the different approach to evidence based medecine. It took us 20 years to develop the technique which we use use today, and as judged from the recent meetings in Strassbourg and ESGE in Paris, this technique has over the years evolved through numerous discussions, meetings and live surgery. This thus is not an opinion of a few surgeons but something build progressively by many. The level of evidence should be graded pretty high. In addition as long as technique evolved, RCT’S were premature. Today it is time for thos who want to continue to do bowel resection to prove that no additional and unnecessary harm is inflicted. Unfortunately I fear that the number of these surgeons who are able to perform also conservative discoid excision is very low – at least too low for a trial.

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