Surgical treatment of rectovaginal endometriosis with extensive vaginal infiltration: results of a systematic three-step vagino-laparoscopic approach

Objective: Recto-vaginal endometriosis remains a surgical challenge. We propose a systematic surgical approach combining vaginal and laparoscopic steps for patients affected by deep endometriosis infiltrating the vaginal wall. Study design: This is a prospective observational study, performed at Campus Bio-Medico of Rome, University Teaching Hospital. All consecutive patients, from 2008 to 2011, affected by symptomatic deep recto-vaginal endometriosis with full thickness vaginal wall involvement, underwent a systematic surgical approach, based on three consecutive surgical steps: vaginal route, laparoscopic approach and final vaginal excision. All patients included in the study were scheduled for two years' follow-up with pelvic examination, transvaginal ultrasound and visual analog scale (VAS) evaluation of symptoms (dysmenorrhea, dyspareunia and chronic pelvic pain) at 3, 6, 12 and 24 months. Results: Thirty-four patients were enrolled. No major complications were registered. Complications included superficial vascular lesions in two cases (5.9%), ureteral stenosis two weeks after surgery in one patient (2.9%), and bowel obstruction for paralytic ileus in one patient (2.9%). A de novo endometrioma was found at 12 months after surgery and a recurrent endometrioma was evident at 24 months. For all symptoms evaluated, there was a significant improvement within 3 months after surgery (p < 0.05) and no statistically significant difference during follow-up (at 3, 6, 12 and 24 months). Conclusion: The proposed systematic surgical approach consisting of three consecutive steps could simplify the approach to deep endometriosis while at the same time increasing the quality of endometriosis surgery, with important benefit for the women affected. (C) 2013 Elsevier Ireland Ltd. All rights reserved.