Surgery for deep endometriosis: a pathogenesis-oriented approach

Background: Deep endometriosis is usually associated with severe symptoms and constitutes a complex treatment challenge.

Methods: The available evidence has been revisited with the aim of defining an effective diagnostic workup and a safe surgical strategy based on pathogenetic findings.

Results: Vaginal, rectal, and bladder detrusor endometriosis appear to be caused by intraperitoneal seeding of regurgitated endometrial cells which implant in the posterior and anterior cul-de-sac and trigger an inflammatory process leading to adhesion of contiguous organs. Excision of posterior deep lesions implies removal of a fibrotic cast of the Douglas's pouch which may involve the posterior vaginal fornix and the rectal muscular layer, with a not negligible risk of major complications. Removal of full-thickness bladder detrusor endometriosis entails excision of the bladder dome or posterior wall, generally well above the trigone. Transurethral resection is contraindicated. A radical approach to obstructive uropathy is suggested, with resection of the stenotic ureteral tract and reimplantation with antireflux vesicoureteral plasty.

Conclusion: Infiltrating endometriotic lesions appear to originate intraperitoneally sharing common pathogenetic mechanisms. Involvement of the intestinal and urologic apparatuses should be identified before surgery, in order to schedule intraoperative consultation and to inform the woman about the type of intervention required and its potential sequelae.