Our Summary

Endometriosis is a painful condition where tissue similar to the lining of the uterus grows outside the uterus. This paper discusses a surgical procedure to remove deep endometriosis that has spread to the area between the uterus and rectum (also known as the Douglas space). The procedure, called a laparoscopic modified radical hysterectomy, has to be thorough to prevent the disease from coming back, but can also lead to more complications.

This surgery follows nine key steps and is designed based on the body’s anatomy. Some of the critical steps involve carefully separating the uterus from surrounding tissues and nerves, and dealing with the ureter (the tube that carries urine from the kidneys to the bladder) if needed. Depending on how deep the disease has penetrated the rectum, the surgeon may also need to perform additional procedures on the rectum.

This standardized procedure aims to provide a comprehensive surgical solution for patients with severe endometriosis.

FAQs

  1. What is a laparoscopic modified radical hysterectomy and how is it performed?
  2. How does the depth of rectal infiltration and number of nodules affect the rectal step during a radical hysterectomy?
  3. Why is a more complex hysterectomy required for patients with obliterated Douglas space who wish for definitive treatment for their endometriosis-related pain?

Doctor’s Tip

A doctor might tell a patient undergoing a radical hysterectomy for endometriosis to ensure they follow post-operative care instructions carefully, including taking prescribed pain medication, avoiding heavy lifting or strenuous activity, and attending follow-up appointments for monitoring and support. It is important for patients to communicate any concerns or unusual symptoms to their healthcare provider promptly.

Suitable For

Patients with deep infiltrating endometriosis who have a desire for definitive treatment of their symptoms, particularly those with obliterated Douglas space, are typically recommended radical hysterectomy. This procedure aims to remove all lesions and prevent symptomatic recurrences. Surgeons may consider performing a laparoscopic modified radical hysterectomy, which involves a standardized dissection process that includes extrafascial dissection of the uterine pedicle, nerve sparing, ureterolysis if necessary, and potentially a rectal step depending on the depth of rectal infiltration. This complex surgery can help provide relief for patients with endometriosis and obliterated Douglas space.

Timeline

Before radical hysterectomy:

  1. Patient presents with symptoms of deep infiltrating endometriosis, such as pelvic pain, painful periods, and painful intercourse.
  2. Patient undergoes thorough evaluation and imaging studies to confirm the diagnosis and extent of the disease.
  3. Patient discusses treatment options with their healthcare provider, including the possibility of a radical hysterectomy for complete removal of the lesions.
  4. Patient undergoes pre-operative preparation, which may include additional imaging studies, blood work, and consultations with other specialists.

After radical hysterectomy:

  1. Patient undergoes laparoscopic modified radical hysterectomy, which involves 9 steps including extrafascial dissection of the uterine pedicle, nerve sparing, and ureterolysis if needed.
  2. Surgeon performs retrograde dissection of the rectovaginal space and assesses the need for a rectal step based on the depth of rectal infiltration.
  3. The rectal step may involve rectal shaving, disc excision, or rectal resection to remove all endometriotic nodules.
  4. Patient is monitored closely post-operatively for any complications and is provided with pain management and supportive care as needed.
  5. Patient undergoes follow-up appointments to monitor their recovery and assess for any recurrence of symptoms.
  6. Patient may experience improvements in their symptoms and quality of life following the radical hysterectomy.

What to Ask Your Doctor

  1. What is the reason for recommending a radical hysterectomy for my condition?
  2. What are the potential risks and complications associated with a radical hysterectomy?
  3. How will this surgery impact my fertility and future reproductive options?
  4. What is the expected recovery time and post-operative care for a radical hysterectomy?
  5. Are there alternative treatment options available for my condition?
  6. Will I need further treatment or follow-up care after the surgery?
  7. How experienced are you in performing radical hysterectomies for endometriosis and obliterated Douglas space?
  8. What is the success rate of this surgery in terms of relieving symptoms and preventing recurrences?
  9. Are there any long-term effects or considerations I should be aware of after undergoing a radical hysterectomy?
  10. Can you provide me with any additional resources or information to help me prepare for the surgery and recovery process?

Reference

Authors: Darlet G, Fauconnier A, Bloomfield J, Margueritte F. Journal: J Gynecol Obstet Hum Reprod. 2023 May;52(5):102571. doi: 10.1016/j.jogoh.2023.102571. Epub 2023 Mar 11. PMID: 36907512