1. JFM072902 Surgical management of GI and GU endometriosis Javier Magrina, MD Mayo Clinic in Arizona JFM100402

2. Visual vs histologic diagnosis of endometriosis Mayo Clinic Arizona Diagnosis % Visual  / histology  51 Visual  / histology  2 Am J Obstet Gynecol 184:1407, 2001 Am J Obstet Gynecol 184:1407, 2001 Diagnosis % Visual  / histology  51 Visual  / histology  2 Am J Obstet Gynecol 184:1407, 2001 Am J Obstet Gynecol 184:1407, 2001 N = 480

3. Pelvic Endometriosis Histological vs visual staging –35% reduced score –43% downstaging Am J Obstet Gynecol 184:1407, 2001 Am J Obstet Gynecol 184:1407, 2001 Histological vs visual staging –35% reduced score –43% downstaging Am J Obstet Gynecol 184:1407, 2001 Am J Obstet Gynecol 184:1407, 2001

4. Endometriosis involvement % Intestinal 3-37Intestinal 3-37 Urinary 2-16Urinary 2-16 Vascular <1Vascular <1 % Intestinal 3-37Intestinal 3-37 Urinary 2-16Urinary 2-16 Vascular <1Vascular <1

5. Intestinal and Urinary Tract Involvement by Endometriosis Definition Definition Extrinsic (non invasive)Extrinsic (non invasive) Bladder peritoneum,Ureteral adventitia Bladder peritoneum,Ureteral adventitia Intestinal serosa Intestinal serosa Intrinsic (invasive)Intrinsic (invasive) Detrusor muscle, Ureteral muscularis Detrusor muscle, Ureteral muscularis Intestinal muscularis Intestinal muscularis Definition Definition Extrinsic (non invasive)Extrinsic (non invasive) Bladder peritoneum,Ureteral adventitia Bladder peritoneum,Ureteral adventitia Intestinal serosa Intestinal serosa Intrinsic (invasive)Intrinsic (invasive) Detrusor muscle, Ureteral muscularis Detrusor muscle, Ureteral muscularis Intestinal muscularis Intestinal muscularis

6. Urinary Tract Involvement by Endometriosis Mayo Clinic Experience N=249 Incidence, % All AFS stages 1 Stage III and IV 16 Mayo Clinic Experience N=249 Incidence, % All AFS stages 1 Stage III and IV 16

7. Urinary Tract Involvement by Endometriosis Mayo Clinic Experience % Ureter(s) 83 Bladder 10 Both 7 Mayo Clinic Experience % Ureter(s) 83 Bladder 10 Both 7

8. Urinary Tract Involvement by Endometriosis Mayo Clinic Experience % InvolvementBladderUreter Extrinsic ---- 86 Intrinsic 100 14 Mucosal 100 5 Mayo Clinic Experience % InvolvementBladderUreter Extrinsic ---- 86 Intrinsic 100 14 Mucosal 100 5

9. Ureteral Obstruction Diagnosis % Preop 55 Intraop 27 Diagnosis % Preop 55 Intraop 27

10. Urinary Tract Involvement by Endometriosis Presentation as Patients with Advanced Endometriosis* % Pelvic pain 63 Pelvic mass 78 *Preop Dx of endometriosis 60%. Presentation as Patients with Advanced Endometriosis* % Pelvic pain 63 Pelvic mass 78 *Preop Dx of endometriosis 60%.

11. Intrinsic Bladder Involvement Presentation as Any Other Patient with Advanced Endometriosis % Urinary symptoms50 M/O hematuria25 Cyclic pain with hematuria 0 Presentation as Any Other Patient with Advanced Endometriosis % Urinary symptoms50 M/O hematuria25 Cyclic pain with hematuria 0

12. Intrinsic Ureteral Involvement Presentation as Any Other Patient with Advanced Endometriosis % Flank pain 5 Lower back pain 5 M/O hematuria 10 No symptoms 4 Presentation as Any Other Patient with Advanced Endometriosis % Flank pain 5 Lower back pain 5 M/O hematuria 10 No symptoms 4

13. Ureteral Obstruction: Ureterolysis vs Resection % negative IVP postop % negative IVP postop Ureterolysis 88 Resection 65 % negative IVP postop % negative IVP postop Ureterolysis 88 Resection 65

14. Invasive endometriosis stage IV Definitive vs Conservative Surgery Results, % Results, % Conservative Definitive n=6 n=34 n=6 n=34 Recurrence 0 3 Reoperation for 17* 3** other reasons *serous cystadenoma **bowel obstruction Results, % Results, % Conservative Definitive n=6 n=34 n=6 n=34 Recurrence 0 3 Reoperation for 17* 3** other reasons *serous cystadenoma **bowel obstruction

15. ConclusionConclusion Invasion of urinary tract increases with AFS stagingInvasion of urinary tract increases with AFS staging Clinical symptoms are not specificClinical symptoms are not specific Mucosal involvement is common in bladder not in uretersMucosal involvement is common in bladder not in ureters Ureteral obstruction is diagnosed intraop in 1/4 ptsUreteral obstruction is diagnosed intraop in 1/4 pts Invasion of urinary tract increases with AFS stagingInvasion of urinary tract increases with AFS staging Clinical symptoms are not specificClinical symptoms are not specific Mucosal involvement is common in bladder not in uretersMucosal involvement is common in bladder not in ureters Ureteral obstruction is diagnosed intraop in 1/4 ptsUreteral obstruction is diagnosed intraop in 1/4 pts

16. ConclusionConclusion 2/3 of pts require extensive additional surgery2/3 of pts require extensive additional surgery Conservative surgery is appropriate if all disease is removedConservative surgery is appropriate if all disease is removed Ureterolysis is preferable to resection if feasibleUreterolysis is preferable to resection if feasible 2/3 of pts require extensive additional surgery2/3 of pts require extensive additional surgery Conservative surgery is appropriate if all disease is removedConservative surgery is appropriate if all disease is removed Ureterolysis is preferable to resection if feasibleUreterolysis is preferable to resection if feasible

17. ConclusionConclusion Invasion of urinary tract increases with stageInvasion of urinary tract increases with stage Clinical symptoms are no differentClinical symptoms are no different Mucosal involvement is common in bladder not in ureter/sMucosal involvement is common in bladder not in ureter/s Ureteral obstruction is diagnosed intraop in 25% of ptsUreteral obstruction is diagnosed intraop in 25% of pts Invasion of urinary tract increases with stageInvasion of urinary tract increases with stage Clinical symptoms are no differentClinical symptoms are no different Mucosal involvement is common in bladder not in ureter/sMucosal involvement is common in bladder not in ureter/s Ureteral obstruction is diagnosed intraop in 25% of ptsUreteral obstruction is diagnosed intraop in 25% of pts

18. Invasive pelvic endometriosis (AFS stage IV) Mayo Clinic 1966-92 Mayo Clinic 1966-92 N=249 N=249 40 pts (16%) required radical pelvic surgery surgery JPS 1996 2:176 JPS 1996 2:176 Mayo Clinic 1966-92 Mayo Clinic 1966-92 N=249 N=249 40 pts (16%) required radical pelvic surgery surgery JPS 1996 2:176 JPS 1996 2:176

19. Radical surgery for endometriosis Additional surgeries to Hysterectomy Additional surgeries to Hysterectomy Partial resection % ureter 38 ureter 38 rectosigmoid 15 rectosigmoid 15 bladder 10 bladder 10 upper vagina 3 upper vagina 3 Ureterolysis 53 Appendectomy 33 JPS 1996 2:176 Additional surgeries to Hysterectomy Additional surgeries to Hysterectomy Partial resection % ureter 38 ureter 38 rectosigmoid 15 rectosigmoid 15 bladder 10 bladder 10 upper vagina 3 upper vagina 3 Ureterolysis 53 Appendectomy 33 JPS 1996 2:176

20. Radical surgery for endometriosis Results Results % Cure 97.3 Cure 97.3 Recurrence 2.7 Recurrence 2.7 Pain free 72 Pain free 72 f/u 76.1 mos (14-240) f/u 76.1 mos (14-240) Results Results % Cure 97.3 Cure 97.3 Recurrence 2.7 Recurrence 2.7 Pain free 72 Pain free 72 f/u 76.1 mos (14-240) f/u 76.1 mos (14-240)

21. Laparoscopic Excision of Rectosigmoid endometriosis % complications n=51* n=31** Fistula 10 10 Fistula 10 10 Abscess 2 3 PO. Bleeding 2 -- Urinoma 2 -- Urin dysfunction -- 17 Conversion 13 11 QOL Improved Improved * Human Rep 2006 21:1243 * Human Rep 2006 21:1243 **AJOG 2005 192: 394 **AJOG 2005 192: 394 % complications n=51* n=31** Fistula 10 10 Fistula 10 10 Abscess 2 3 PO. Bleeding 2 -- Urinoma 2 -- Urin dysfunction -- 17 Conversion 13 11 QOL Improved Improved * Human Rep 2006 21:1243 * Human Rep 2006 21:1243 **AJOG 2005 192: 394 **AJOG 2005 192: 394

22. Laparoscopic Excision of Rectosigmoid endometriosis Fertility results Fertility results Pregnancy rate 45% Pregnancy rate 45% IVF assisted 30% IVF assisted 30% Live births 82% Live births 82% FS 2005 84:945 FS 2005 84:945 Fertility results Fertility results Pregnancy rate 45% Pregnancy rate 45% IVF assisted 30% IVF assisted 30% Live births 82% Live births 82% FS 2005 84:945 FS 2005 84:945

23. Vascular complications due to endometriosis N Location N Location Ranney, 70 6 Implants, endom. Ranney, 70 6 Implants, endom. Carmichael, 72 1 Ulcer broad lig Carmichael, 72 1 Ulcer broad lig Kumar, 96 1 Implants Kumar, 96 1 Implants Mizumoto, 96 1 Uterine surface Mizumoto, 96 1 Uterine surface Harmanli, 98 1 R tube rupture Harmanli, 98 1 R tube rupture Janicki, 02 1 Endometrioma Janicki, 02 1 Endometrioma FS 2002 78:879 FS 2002 78:879 N Location N Location Ranney, 70 6 Implants, endom. Ranney, 70 6 Implants, endom. Carmichael, 72 1 Ulcer broad lig Carmichael, 72 1 Ulcer broad lig Kumar, 96 1 Implants Kumar, 96 1 Implants Mizumoto, 96 1 Uterine surface Mizumoto, 96 1 Uterine surface Harmanli, 98 1 R tube rupture Harmanli, 98 1 R tube rupture Janicki, 02 1 Endometrioma Janicki, 02 1 Endometrioma FS 2002 78:879 FS 2002 78:879

24. EndometriosisEndometriosis % Malignant transformation 1 Malignant transformation 1 ovarian 79 ovarian 79 other 21 other 21 Am Surg 71:696,2005 Am Surg 71:696,2005 % Malignant transformation 1 Malignant transformation 1 ovarian 79 ovarian 79 other 21 other 21 Am Surg 71:696,2005 Am Surg 71:696,2005

25. EndometriosisEndometriosis 500 patients with endometriosis500 patients with endometriosis 100 with cul-de-sac involvement100 with cul-de-sac involvement 34 required rectosigmoid resection34 required rectosigmoid resection Koh, Janick 07 Koh, Janick 07 500 patients with endometriosis500 patients with endometriosis 100 with cul-de-sac involvement100 with cul-de-sac involvement 34 required rectosigmoid resection34 required rectosigmoid resection Koh, Janick 07 Koh, Janick 07

26. Frozen pelvis Goals Goals Restore anatomy to normal Avoid injury to external, common iliac art. external, common iliac art. ureters ureters obturator nerve obturator nerve Goals Goals Restore anatomy to normal Avoid injury to external, common iliac art. external, common iliac art. ureters ureters obturator nerve obturator nerve

27. Frozen pelvis Identify intraperitoneal anatomyIdentify intraperitoneal anatomy bladder: inflated, 3 way catheter bladder: inflated, 3 way catheter vaginal probe vaginal probe rectal probe rectal probe Identify retroperitoneal anatomy as early as possible Identify intraperitoneal anatomyIdentify intraperitoneal anatomy bladder: inflated, 3 way catheter bladder: inflated, 3 way catheter vaginal probe vaginal probe rectal probe rectal probe Identify retroperitoneal anatomy as early as possible