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Rectovaginal Septum Endometriosis Società Italiana di Chirurgia ColoRettale www.siccr.org 2012; 33: 270-274 Rectovaginal Septum Endometriosis Nicola Foti, MD General Surgery Department Hospital of Civita Castellana Viterbo Introduction Endometriosis is a condition where tissue stage I (minimal) similar to the endometrial stroma or glands is stage II (mild) found in locations outside the uterus. The stage III (moderate) disease generally affects women during their stage IV (severe) reproductive years (more commonly in their 40s or 50s) and involves 7-10% of the female (1) The staging is obviously only fully known after population . Among women who undergo a surgery and histological study. diagnostic laparoscopy for infertility the (2-3) prevalence of endometriosis is 20-50% . Treatment is based upon the dimension, When chronic pelvic pain is associated, the (4) localization and extension of the lesions, prevalence can increase up to 80% . severity of symptoms, age, the desire of the The ectopic endometrium can be found inside patient to become pregnant and associated the uterine wall (adenomyosis), or outside, infertility. either within the pelvic organs (internal pelvic It is aimed at improving symptoms and fertility. endometriosis or deep pelvic endometriosis) or Permanent resolution of the disease cannot be in organs and tissues outside the pelvic space guaranteed. The main therapeutic options (extrapelvic endometriosis). It is often divided include pharmacological suppression of the into peritoneal, ovarian and deep pelvic (5) ectopic tissue or surgical ablation. endometriosis . It is most frequently localized The pharmacological treatment aims at to the ovaries, utero-sacral ligaments and reducing the estrogen level to retard the peritoneum, then in the recto-vaginal septum, development of the disease. Systemic uterine tubes, rectosigmoid colon and bladder. estroprogestins, progesteron, danazol and Less frequent or rare localizations include the other gonadotropins are used. appendix, cervix, vagina, umbilicus, inguinal Surgical therapy attempts to remove the region, ureter, pleura, lung, limbs, and brain. lesions to achieve improvement of symptoms. In deep pelvic endometriosis (DPE) the lesions The approach is generally laparoscopic and are found more than 5 mm below the pelvic allows confirmation of the diagnosis, in peritoneal surface. The estimated incidence of particular in the case of superficial bowel endometriosis in DPE varies between localizations. Complete excision of the lesions 3% and 37% and in 90% of cases the involved can be obtained and the advantages of tract is the rectum or the rectosigmoid colon (6- 7) laparoscopy, in terms of mini-invasiveness, . Several locations can be affected by DPE cosmetics and reduction in convalescence, are including the retro-cervical region, utero-sacral offered to the patient. ligaments, rectum, rectovaginal septum, If laparoscopy is performed for fertility vagina, ureters and other extraperitoneal improvement a 44-72% pregnancy rate can be tissues. achieved (8). Robotic surgery can be used in selected cases The staging of the disease most commonly and is particularly useful for microsurgical utilized has been proposed by the American reconstruction of the tubes damaged by Fertility Society in 1979 (AFS 1979), and then endometriosis. revised in 1985 (rAFS 1985). There are four stages: www.siccr.org 270 Società Italiana di Chirurgia ColoRettale www.siccr.org 2012; 33: 270-274 The Recto-Vaginal Septum Does “rectovaginal septum” exist and if so what is it? The posterior wall of the vagina lies is related to the rectum along its entire length. It has a direct relationship with the rectal wall only in its inferior three quarters, while in the upper quarter, the rectovaginal pouch of Douglas separates the two organs. The posterior vaginal wall can, therefore, be divided into two parts, a peritoneal and a rectal segment. In the latter lying below the pouch of Douglas, the vagina is applied to the rectum from which is separated only by a layer of connective tissue and small vessels. A few authors maintain that the space contains a fibrous layer, the true “rectovaginal septum” corresponding to Denonvilliers’ fascia of the The thickness increases gradually and the male. The posterior attachments of the vagina rectum is separated from the vagina by a to the rectum are much looser than those to space that in sagittal section would be the bladder, anteriorly, so in vaginal prolapse triangular with the base at the perineal skin. the rectum is less commonly drawn down than This is sometimes called the rectovaginal the bladder. The space between the vagina triangle. The rectovaginal septum is actually a and the posterior rectal wall is very thin in the virtual space that can be occupied by an endopelvic part of the vagina, but in its lower, enterocele or by pathologic tissue such as (9) perineal part it is thicker, due to the posterior endometriosis nodules . angle of the anal canal. Rectovaginal Septum Endometriosis Definition Stage IV: The rectal wall, rectosigmoid Rectovaginal endometriosis is the most zone and recto-uterine important form of deep pelvic endometriosis peritoneum are completely (10). Endometriosis nodules may be found involved, and the recto-uterine below a plane drawn horizontally through the pouch is totally obliterated inferior margin of the cervix. Classification Adamyan devised a classification of retrocervical endometriosis according to the extent of the disease in the retrocervical area. This is also called the “rectovaginal pouch of Douglas” or the “posterior cul–de-sac”. Classification of adamyan (11) Stage I: Endometriosis lesions are Stage I Stage II confined to the rectovaginal tissue in the area of the vaginal vault Stage II: Endometriosis tissue invades the cervix and penetrates the vaginal wall, causing fibrosis and small cyst formation Stage III: Lesions spread into sacro-uterine ligaments and the rectal serosa Stage III Stage IV www.siccr.org 271 Società Italiana di Chirurgia ColoRettale www.siccr.org 2012; 33: 270-274 Symptoms diagnosis. It is extremely useful for the Chronic pelvic pain is one of the most common identification of involvement of the and relevant symptoms. It is generally felt retrocervical region and of the rectum and posteriorly and its intensity appears to be ovary (12). Ano-rectal ultrasound shows the related to the depth of infiltration of the nodules and can study their dimensions, the disease. It worsens during menstruation. degree of infiltration of the rectal wall and the Pelvic pain can be associated with deep distance from the anal verge, which is dyspareunia, tenesmus and rectal bleeding important when planning resection. related to the degree of involvement of the Magnetic resonance (MRI) is considered a rectal wall. second line examination, useful to define the involvement of peritoneal and extra-peritoneal Diagnosis lesions. It allows a complete evaluation of the The history is essential in raising the suspicion extent of the disease, essential for surgical of recto-vaginal endometriosis. Generally the planning. The literature reports also the use of patient experiences a sensation of being CT virtual colonoscopy, modified by seated on a thorn. Pain occurs during the insufflation of the rectum with CO2 and menstrual cycle and sexual intercourse. A placement of a tampon in the vagina (13). This combined vaginal and rectal examination is examination is not commonly used, however, diagnostic in more than 80% of cases (6). because the high predictive value of the Trans-vaginal ultrasound usually confirms the previously mentioned imaging techniques. Tabella 1 (14) Rectovaginal Rectovaginal Uterosacral Uterosacral septum septum Rectal wall Rectal wall ligaments ligaments endometriosis endometriosis infiltration infiltration involvement involvement nodule nodule sensitivity specificity sensitivity specificity sensitivity specificity MRI 73% 50% 53% 82% 84% 95% AREAS Anorectal 93% 100% 100% 71% endosonography Ultrasound is more sensitive than MRI for the detection of rectal wall infiltration and for the diagnosis of endpmetriosis of the rectovaginal septum. Therapy its circumference. When it is not possible to Drug treatment can certainly improve perform a nodule resection or in patients of symptoms but it is often not sufficient and can Adamyan stage IV, bowel resection is cause side effects (15-17). The literature indicated. Sixty to 100% of patients who have supports surgery not responding to medical bowel resection show symptom improvement. treatment for symptomatic disease to improve New surgical approaches to DPE include quality of life. Complete surgical ablation of the single access surgery and robotics. When endometriosis results in the long-term possible, the use of a single access reduction of symptoms and improves quality laparoscopic approach (SILS) can be very with a low recurrence rate in the DPE patients. beneficial, but there are no reports in the (18-22) literature proving its effectiveness. A large Laparoscopic pelvic surgery performed by an experience in advanced laparoscopic surgery, expert surgeon is the gold standard of surgery. (pelvic and colorectal) is mandatory for DPE. The extent of resection (whether nodule The technique has several potential excision or bowel resection) is determined in advantages for the treatment of DPE each individual case. Most authors agree with particularly of the recto-vaginal septum, but a superficial resection of the nodule or a full confirmation in the literature is required. disk resection of
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