Surgery for DIE

If there is clinical evidence of DIE, the possibility of ureteric, bladder and bowel involvement should be considered pre-operatively to determine the best management. Surgery needs to be performed as safely as possible and by the most appropriate surgeons because it may be necessary to resect part of the bladder or ureter, as well as bowel wall. Occasionally, more extensive bowel resection (e.g. the rectum and/or sigmoid) is needed. Such operations require a team of experienced surgeons rather than a single surgeon. Therefore, pre-operative assessment is important as it aims to predict as accurately as possible which specialities should be available to avoid leaving disease behind and unnecessary complications. The ideal work-up should comprise an intravenous pyelogram (IVP) to detect ureteric strictures and hydronephro-sis and a contrast enema to diagnose extensive narrowing at the level of the rectum or sigmoid (an indication for bowel resection). Pre-operative ureteric stenting is advisable if a patient with bladder symptoms is found to have a vesico-uterine nodule on ultrasound. Whether ultra-sound/CT/MR imaging should be routinely performed is unclear, although in less experienced centres the findings will influence the decision to refer to a tertiary centre. How radical surgery should be performed is also controversial. If a general principle of removing all endometriosis is adopted, then bowel resection with 2 cm safety margins should be considered as small endometriotic foci can be found up to 2 cm from a bowel lesion. A conservative discoid resection, however, is preferable for most patients as it

Study

Laparosoopic surgery n/N

Control n/N

Peto Odds Ratio 95% CI

Gruppo Italiano 1999 10/51 10/45

Marcoux 1997 50/172 29/169

Test for heterogeneity chi-square = 2.14 df = 1 p = 0.1431 Test for overall effect = 2.17 p = 0.03

100.0

Favours control Favours treatment

Fig. 44.4 Cochrane review showing ongoing pregnancy or live birth rates in controls and women undergoing laparoscopic surgery [25].

is associated with fewer complications. Moreover, a recurrence rate of only 1% casts doubt on the need to remove large segments of bowel.

Pregnancy And Childbirth

Pregnancy And Childbirth

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