New Paradigms in Endometriosis Surgery of the Distal Ureter

It is estimated that 2% of endometriosis cases involve the urinary tract and that the ureter is involved in up to 30% of these cases, or 0.6% of all endometriosis cases. Increasingly, the standardization and systematization of surgical treatment of endometriosis require the surgeon to have knowledge of the surgical spaces and the ureteral and surrounding pelvic anatomy in order to carry out a cytoreductive surgery that is as possible. A thorough workup is essential for the differentiation of intrinsic or extrinsic endometriosis of the ureter. The use of the resonance imaging preoperatively and ureteroscopy intraoperatively is now considered indispensable. The decision and choice of the best technique will be guided by the diagnosis (intrinsic or extrinsic), the location of the lesions, the length of the involved segment (greater or less than 3 cm), vitality of the ureter stumps, and anastomosis without tension. The main alternatives are ureterolysis and dilatation with balloon catheter which is performed for extrinsic endometriosis more than 85% of the time and ureterectomy for intrinsic endometriosis. To perform the reconstruction, the techniques with end-to-end anastomosis with the distal ureter stump or uretero-vesical reimplantation are used. Increasingly, with better knowledge of the distal ureter anatomy, easier access through laparoscopy and in contradiction to the current recommendations, we are verifying that the end-to-end anastomosis has become the preferred option or procedure of choice for ureteral reconstruction, with ureterovesical reimplantation the second option

Endometriosis Surgery during the First Wave of the COVID-19 Pandemic: A Brazilian Single Institution Experience

Introduction. Early in the 2020 Coronavirus pandemic stay-at-home guidelines, there were public health orders that elective surgeries be deferred to prioritize hospital beds for critically ill COVID-19 patients. Besides, several reasons led to the postponement of consultations, diagnostic tests, and elective therapeutic procedures. As a result, some women with endometriosis faced chronification of their pain and decreased prospects for pregnancy. The aim of this study was to describe individual responses to minimally invasive complete excision of endometriosis through 40 days of follow-up of women whose endometriosis was considered severe enough to proceed with surgery during the fourth, fifth, and sixth months of constraints imposed by the pandemic. Preventive strategies and safety measures employed to protect patients and staff from acquiring or transmitting Coronavirus infection are presented. Case Presentation. This case series report enrolled 11 consecutive Brazilian women (ages 22 to 47 y) who underwent minimally invasive surgical treatment of endometriosis between June 26 and August 17, 2020. Cases of endometriosis requiring more urgent surgery were promptly identified and considered individually. The strict safety measures were well accepted by patients. No women developed any flu-like or COVID-19-related symptoms (cough, dyspnea, fever, or anosmia) in the 40 days of postoperative follow-up. One of the most praised measures reported by patients was the routine testing of the patient, the person who would accompany her in the hospital, and all medical staff and employees. Discussion. It is feasible to safely perform elective endometriosis surgery in selected cases during a pandemic.</jats:p

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

Study objectiveTo assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance.MethodsThis preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail.ResultsPreoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P &lt; .001) by 3 points or more in 75.8% (95%CI: 64.7–86.2) and disappeared totally in 59.7% of cases (95%CI:47.8–71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0–10.7) and the probability of a woman with no DDyspareunia developing “de novo” moderate or severe DDyspareunia was 7.7% (95%CI: 1.8–15.8) and 5.8% (95%CI: 0.0–13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region.ConclusionEndometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.</jats:sec

Endometriosis Surgery during the First Wave of the COVID-19 Pandemic: A Brazilian Single Institution Experience

Introduction. Early in the 2020 Coronavirus pandemic stay-at-home guidelines, there were public health orders that elective surgeries be deferred to prioritize hospital beds for critically ill COVID-19 patients. Besides, several reasons led to the postponement of consultations, diagnostic tests, and elective therapeutic procedures. As a result, some women with endometriosis faced chronification of their pain and decreased prospects for pregnancy. The aim of this study was to describe individual responses to minimally invasive complete excision of endometriosis through 40 days of follow-up of women whose endometriosis was considered severe enough to proceed with surgery during the fourth, fifth, and sixth months of constraints imposed by the pandemic. Preventive strategies and safety measures employed to protect patients and staff from acquiring or transmitting Coronavirus infection are presented. Case Presentation. This case series report enrolled 11 consecutive Brazilian women (ages 22 to 47 y) who underwent minimally invasive surgical treatment of endometriosis between June 26 and August 17, 2020. Cases of endometriosis requiring more urgent surgery were promptly identified and considered individually. The strict safety measures were well accepted by patients. No women developed any flu-like or COVID-19-related symptoms (cough, dyspnea, fever, or anosmia) in the 40 days of postoperative follow-up. One of the most praised measures reported by patients was the routine testing of the patient, the person who would accompany her in the hospital, and all medical staff and employees. Discussion. It is feasible to safely perform elective endometriosis surgery in selected cases during a pandemic