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24 Composite Pelvic Resection forDeeply Inltrating Endometriosis
257
forming nerve-sparing techniques during endometriosis excision, with dissection of the
connective tissue and separation of the nerves
and surrounding fascia from the underlying peritoneum and endometriotic lesions [18, 19].
Approach toUrologic
Endometriosis
Urinary tract involvement by endometriosis is a
rare occurrence, affecting only 1–2% of women
with endometriosis [20]. This number may be
underreported. The symptomatology of urinary
tract endometriosis varies based on the location
of the endometriotic lesions, and diagnosis is
often challenging due to the complexity of symptoms and difculty in identifying lesions through
imaging studies. The distribution of bladder to
ureteral to urethral endometriosis follows a ratio
of 40:5:1 [21].
Bladder Endometriosis
Diagnosis
Bladder involvement by endometriosis typically
presents with urinary frequency, hematuria, and
dysuria (symptoms similar to urinary tract infection). A high level of suspicion is prudent. MRI
and ultrasound can be useful for visualizing
lesions above 3cm [22]. Cystoscopy and intravenous pyelogram (IVP) are good adjuvant
studies.
Treatment
The treatment of bladder endometriosis involves
both medical and surgical evaluation. In cases
where lesions are situated near the trigone, medical management is typically indicated to avoid
postoperative morbidity related to bladder neck
surgery [23]. If the detrusor muscle is affected,
the condition is more likely to be an endometrioma of the bladder [23] and resection is the preferred surgical treatment option.
Resection of bladder endometriosis can be
performed via a combination of laparoscopic and
cystoscopic techniques to excise deep bladder
endometriosis without removal of the normal
bladder tissue. The lesion can be visualized cystoscopically to better dene its margins. Via laparoscopy, the medial and lateral paravesical spaces
can be taken down and the vesicouterine space
should be dissected to allow for adequate bladder
visualization [24]. Dissection should then be carried out through the layers of the bladder [25].
Closure of the resection site can be achieved with
one or two layers of either barbed or monolament sutures [23]. The healing process is typically uncomplicated due to the vascularity of the
area. Complications include leakage, stula formation, and bleeding. Complications of bladder
resection are covered in detail in Chap. 12. Rates
of bladder recurrence are low: 2% at 12months
and 4% at 24months [24].
Ureteral Endometriosis (UE)
Diagnosis
Ureteral endometriosis (UE) often affects the distal portion of the ureter, more commonly the left
side [26]. It can be either extrinsic or intrinsic,
with a ratio of 1:4 [27]. Extrinsic disease is
caused by endometriosis that compresses the ureter, whether it is from peritoneal adhesions overlying the ureter or a large endometrioma. Intrinsic
endometriosis involves invasion of the ureteral
muscular or uroepithelial layer. Diagnosis of ureteral endometriosis is frequently delayed, and
most women do not present until they experience
silent renal failure [20]. Some patients have
cyclic hematuria or cyclic colicky ank pain [28].
Imaging studies can be useful in assisting to
visualize any obstruction or narrowing caused by
an endometriotic lesion. Ultrasound has difculty visualizing endometriosis in the ureter, but
it can identify hydronephrosis. Magnetic resonance imaging (MRI) and computed tomography
(CT) scans can also be helpful in identifying ureteral endometriosis. Retrograde pyelography or
intravenous pyelogram are useful to identify the
degree and level of ureteral involvement [23]. In
some cases, ureteroscopy may be necessary to
conrm the diagnosis and obtain a tissue sample
for histological analysis.
258
A. R. Ramanathan et al.
Treatment
Treatment is focused on relieving the obstruction, improving symptoms, and addressing any
renal dysfunction. Similar to endometriosis in
other locations, UE can be treated via hormonal
suppression or surgical resection. Hormonal
suppression is risky as endometriosis is a
progressive disease. If there are signs of obstruction, surgical treatment is the most appropriate
management.
The goal of surgery is to remove any ureteral
obstruction. Laparoscopy is the recommended
approach. Ureteral stents are not necessary prior
to starting the procedure and have not been shown
to improve outcomes [29]. Resection of extrinsic
endometriosis involves ureterolysis. Ureterolysis
alone is useful to treat approximately 90% of
cases of hydroureter [30]. There are multiple
techniques for ureterolysis, with the overlying
goal being to free the intact ureter from any
brotic tissue and restore normal anatomy.
Intrinsic ureteral disease can impact all layers of
the ureter, including the muscularis, lamina propria,
and ureteral lumen. Intrinsic disease is more likely
with deep inltrating endometriosis. Treatment
necessitates resecting the involved segment and,
then, depending on the location of the resection,
performing a primary ureteroureterostomy or ureteroneocystostomy with or without a psoas hitch
[21]. This often requires a multidisciplinary
approach.
While there is a risk of recurrence, a conservative ureter-sparing approach is preferred. Half of
patients who presented with hydronephrosis preoperatively showed improvement after ureterolysis
and ureteral preservation [30]. Untreated UE can
lead to ureteral compression, hydroureter, hydronephrosis, and, ultimately, loss of kidney function.
The overall complication rates are low, occurring in 1–5% of patients [30]. Major postoperative complications include ureteral stula or
stenosis, hemorrhage, anastomotic bowel leakage, bowel perforation, bowel atony, and vesicovaginal stula. Ureteral and bladder complications
are covered in detail in Chaps. 17 and 12.
Approximately 4% needed reoperation for endometriosis recurrence or persistence [30].
Ureteral Complications
Complications can occur from deep endometriosis
resection in the genitourinary (GU) system.
Endometriosis is a risk factor for ureteral injury.
DIE is a benign but inltrating pelvic disease. The
ureters are frequently densely adherent to the
affected endometriotic tissues and are occasionally encased or even inltrated themselves.
Surgical expiration of DIE therefore commonly
requires extensive ureterolysis and, occasionally,
purposeful ureteral resection. Expected ureteral
complications include leak, stulas, or strictures.
Other risk factors include prior surgery, history of
pelvic inammatory disease, history of pelvic
radiation, and ureteral duplication [35]. It is important to diagnose ureteral and bladder injuries intraoperatively as this leads to improved outcomes
[35]. Overall, intraoperative complications are rare
[30]. Complications include hemorrhage requiring
conversion, visceral injury, and ureteral injury.
Postoperative injuries occur in as many as 16% of
women treated for ureteral endometriosis, signicantly less in women treated for bladder endometriosis [20]. Injuries include ureteral injury, ureteral
strictures, ureteral stulas, and bladder dysfunction [20]. There is also the risk of endometriosis
recurrence: the need for reoperation is 3.9%.
In order to avoid complications, a multidisciplinary team is crucial in respect to management of
GU endometriosis. This includes a gynecologist, a
urologist, and a gastrointestinal surgeon when the
digestive tract is involved. Careful dissection must
be undertaken near the ureters and bladder to avoid
excessive denervation or thermal injury. Careful
technique with surgical exposure of the pelvic retroperitoneum is important toward preventing ureteral
injury [35]. Knowledge regarding the ureteral
course and measures such as adequate mobilization,
ureteral tracing, and avoidance of blind clamping
for hemostasis can assist in avoiding injury [36].
After resection, a cystoscopy can be performed to
evaluate the bladder and ureteral jets. If ureteral jets
are not visualized, an intraoperative intravenous
pyelogram or retrograde pyelogram with possible
ureteral stent placement is indicated next. A cystoscopy can detect most bladder injuries and up to
80–90% of ureteral injuries. It is important to recog-
• Cutaneous ur
y with
24 Composite Pelvic Resection forDeeply Inltrating Endometriosis
259
• Ureteroureterostomy
• Ureteroileal interpostion
• Transureteroureterostomy
• Nephrectomy
eteroenterostomy
• Cutaneous ureterocolostomy
• Partial bowel substitution
of ureter
Fig. 24.1 Ureteral injury
nize injury of the ureter intraoperatively. The surgeon must maintain a high level of vigilance during
any steps of an operation that are in close proximity
to the ureter, as injury can be most easily recognized
the moment it happens. Upon completion of the
case, inspection of the operative eld includes
examination for possible ureteral injury. This may
be facilitated by an intravenous injection of uorescein dye to look for a leak, an intravenous injection
of ICG to evaluate the integrity of the blood supply,
and cystoscopy. Ureteral injuries caused by a postoperative swelling of nonocclusive suture ligatures
and thermal injuries can be missed [34].
The surgeon operating on DIE must have thor-
ough knowledge of the normal course of the ureters
• Ureteroureterostomy
• Ureteroileal interpostion
• Transureteroureterostomy
• Ureterocolostomy
• Cutaneous ureterostomy
• Ureteroneocystostom
or without bladder tube flap
• Cutaneous ureterostomy
• Vesicopsoas hitch
• Boari flap
as well as the effect of DIE on the ureteral anatomy.
Resection of DIE must often begin with extensive
ureterolysis, which must be meticulous and gentle in
order to avoid direct injury, loss of adventitia, and
occult thermal damage. Ureteral stents have a controversial role and may even be detrimental as they
stiffen the ureter which may predispose to stripping
of adventitia. Use of indocyanine green (ICG) dye
with a near infrared camera is a good alternative.
When ureteral resection is necessary for the management of DIE, prevention of complications is
based on an appropriately selected and performed
ureteral reconstruction (see Chap. 17 ). For a ureteral
injury, repair depends on the location (Fig.24.1).
This can include ureteroureterostomy, primary clo-
260
A. R. Ramanathan et al.
sure, or ureteroneocystostomy. Generally, ureteral
injuries at the pelvic brim can be managed with an
end-to-end anastomosis around a ureteric stent. The
principle involves ureteral mobilization, resection of
the nonviable tissue, and then a tension-free anastomosis [38]. Depending on the length and integrity of
the distal segment, the injury can be repaired with
either an end-to-end anastomosis or a Boari ap for
ureteric reimplantation [36]. Management of ureteral injury is covered in detail in Chap. 17.
For bladder injury, repair depends on the grade
of the injury. Surgical management includes
repair with Polyglactin 910in one or two layers,
depending on the size of the defect [37], followed
by an indwelling catheter.
Endometriosis is a risk factor for ureteral and
bladder injury. Careful dissection is important to
help avoid injury. Intraoperative diagnosis of
injury leads to improved outcomes.
Approach toGastrointestinal
Endometriosis
Diagnosis
Endometriosis of the bowel affects 3.8–37% of
patients and can be a supercial disease on the
bowel serosa or a deeply inltrative disease
within the muscularis or mucosa. Common
symptoms include dysmenorrhea, deep dyspareunia, chronic pain, and/or dyschezia [31].
Physical exam can be helpful with typical ndings including palpable nodules or thickened
areas along the uterosacral ligaments on rectovaginal exam. If the exam is performed during
menstruation, lesions may be more inamed, tender, and palpable. A speculum exam may reveal a
blackish-blue lesion [32].
Several imaging modalities may be used to
visualize endometriosis of the bowel, including
transvaginal ultrasonography, rectal water contrast transvaginal ultrasonography, rectal endoscopic sonography, MRI, and double barium
contrast enema. In our practice, MRI is typically
used which has the benet of being easily accessible by patients and providing information about
lesions above the sigmoid colon. It can lack sensitivity in determining the depth of invasion of
lesions [23]. In our practice, such images are
often reviewed at a multidisciplinary conference
involving radiologists and minimally invasive
gynecologic surgeons to discuss lesion characteristics and the treatment plan.
Surgical Treatment
Surgical resection of these bowel lesions also
benets from a multidisciplinary approach.
Typically, a minimally invasive trained gynecologic surgeon and a colorectal surgeon experienced in endometriosis should be involved. We
recommend laparoscopic excision with or without robotic assistance for its superior outcomes
when compared with an open approach.
There are three surgical options with regard
to excision of bowel endometriosis (Fig.24.2):
supercial shaving, disc resection, and segmental resection of the rectosigmoid colon.
The choice of technique has been the subject of
extensive debate. Considerations should
include the location of the bowel lesion, depth
of inltration, number of nodules, and the presence or absence of strictures. Some would
argue that a more extensive excision with segmental resection translates to less residual disease and a lower risk of recurrence; however,
even with radical excision, occult endometriosis has been shown to be present in the resection margins in up to 15% of patients [33]. We
opt for a more conservative approach to minimize the risks of neurologic injury and longterm morbidity.
Shaving Excision
Shaving excision is the most conservative form
of surgical management. With shaving excision,
diseased tissue is removed layer by layer until
healthy underlying tissue is reached. The aim is
to remove the majority of endometriosis while
preserving bowel integrity. Complication rates
with this technique are low with good long-term
outcomes reported [23].
a
24 Composite Pelvic Resection forDeeply Inltrating Endometriosis
Resection line
Resection line
261
Muscularis
Mucosa
Muscularis
Mucosa
b
1
2
3
3
2
1
1 Discoid resection
2 Mucosal skinning 3 Shaving
Serosa
Muscularis
Mucosa
Submucosa
c
Fig. 24.2 Supercial shaving, disc resection, and segmental resection of the recto-sigmoid colon
Laparoscopic Disk Excision
Laparoscopic disk excision can be used to excise
full-thickness bowel lesions that are limited to
less than 50% of the circumference of the bowel.
The resultant defect is stapled or sutured.
Outcomes are good, and complication rates are
lower than those of segmental resection [23].
Segmental Resection
Segmental resection involves complete resection
of the segment of bowel containing endometriotic
disease. Primary or end-to-end anastomosis of the
bowel can be performed following excision. It is
generally avoided when possible due to higher
rates of serious complications, including anasto-
262
A. R. Ramanathan et al.
motic leak and anastomotic stricture [23].
Complications of bowel resection are covered in
multiple other chapters.
Bowel Complications
The estimated rate of bowel injury during surgery for endometriosis is 3–5/1000 cases [19].
When resection of DIE nodules is undertaken,
bowel complication rates range from 2 to 3%.
Laparoscopic excision of bowel endometriosis has been associated with multiple intestinal
complications, including bowel anastomotic
dehiscence, rectovaginal stula, anastomotic
bleeding, intra- abdominal and wound infection,
bowel stricture, intestinal obstruction, chronic
constipation, and diarrhea. These complications
may happen in the immediate postoperative
period or later. Early recognition is fundamental
to decreasing morbidity and mortality [39].
Contributing factors to bowel injury include
laparoscopic entry, electrosurgery, and injury
from grasping forceps or scissors. Approximately
40% of injuries are not recognized at the time of
surgery [40].
Preoperatively, nutritional deciencies should
be corrected as patients with low albumin and low
total protein are at a higher risk of anastomotic
leaks. The evidence for or against mechanical
bowel preparation is unclear. Prophylactic antibiotics prior to elective gastrointestinal surgery have
been shown to decrease the rate of wound infection. Most bowel injuries can be repaired primarily
in one or two layers. Intraoperatively, rectosigmoid integrity testing with air (“bubble” or “at
tire” test) in a uid- lled abdomen can help in the
early diagnosis of a leak [39].
Conclusions
Endometriosis is a complex disease that can be
difcult to diagnose and causes signicant morbidity. It can affect multiple organ systems, and
surgical excision requires careful planning with
consideration of a multidisciplinary approach.
With knowledge of the pelvic anatomy and the
distortions caused by DIE, as well as sound surgical judgment and technique, the likelihood of
major complications can be reduced.
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Inammatory Bowel Disease
ScottA.Strong
25
Introduction
Women aficted with inammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, often require resection of the rectum
when their disease is refractory to appropriate
medical therapy, or they develop a complication
that cannot be resolved with medications. These
procedures can be plagued by intraoperative and
postoperative complications that can be occasionally avoided but more commonly require
management based on patient-related factors,
disease-specic variables, and complicationassociated features.
Intraoperative Complications
Injuries to other pelvic structures can occur during surgery for IBD, especially if inammatory
or reoperative conditions distort the normal anatomy. Careful review of preoperative crosssectional imaging studies can help identify
individuals in whom lateral structures have been
drawn more medially or were previously mobilized to lie in an abnormal position.
S. A. Strong (*)
Department of Surgery, Feinberg School of Medicine,
Northwestern University, Chicago, IL, USA
e-mail: scott.strong@nm.org
Injury totheUreter andBladder
Injury to a ureter or the bladder uncommonly
occurs and is best managed by recognition at the
time of the index operation as opposed to discovery during the postoperative period. The prevention, recognition, and management of this type of
injury are discussed in Chap. 17.
Injury totheReproductive Organs
An injury to a fallopian tube or an ovary is rare
but occurs more often during pelvic surgery for
Crohn’s disease than for ulcerative colitis because
extensive inammation or stulas complicating
Crohn’s disease can cause the diseased bowel to
be densely adherent to the fallopian tubes and
ovaries. If a fallopian tube is injured, it might be
repaired to restore its function depending on the
type and extent of the injury and the woman’s
desire for future conception. The approach
largely depends on the location and severity of
the damage [1]. A salpingostomy or mbrioplasty is performed for distal tubal occlusions,
especially if the mbrial portion of the tube is
involved. A salpingo-salpingostomy is used for
more extensive injuries where a portion of the
fallopian tube has been damaged or resected, and
tubal implantation is recommended when the
proximal aspect of the tube has been injured and
the distal, healthy segment can be implanted
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_25
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directly into the uterus. An accidentally resected
ovary can be grafted to a pelvic site with a good
blood supply (e.g., a broad ligament, peritoneal
surface). Following such transplantation, the
ovarian tissue can begin to function, producing
hormones and potentially allowing for natural
conception. However, the duration of function
varies, with some grafts functioning for a few
months and others for several years. Successful
pregnancies have been reported following ovarian tissue transplantation, both through natural
conception and assisted reproductive technologies [2].
An injury to the vagina can occur when its
posterior aspect is being mobilized off the anterior wall of the rectum. These injuries are usually
readily identied and primarily suture repaired in
a transverse manner, but closure can be challenging if the injury occurs near the apex of the vagina
because the cervix must be accommodated. If the
repair is going to lie close to a bowel anastomosis, it is advisable to interpose a tissue such as the
omentum between the two suture lines to avoid
breakdown at either site, leading to the development of a stula. Alternatively, the mesentery of
the bowel used for an ileal pouch or a neo-rectum
can be oriented to lie anterior rather than posterior to separate the suture lines.
tion grafts, or ligation. Ligation is a last resort
option because ligating the internal iliac vein or
artery can have consequences depending on other
factors such as the level of injury, integrity of the
collateral vessels, and remaining pelvic structures. Consultation with a vascular surgeon is
sometimes warranted, especially if the responsible surgeon does not have sufcient experience
with vascular repairs.
Pelvic bleeding can also arise from the veins
of the vertebral venous system located both outside and inside the vertebral canal that communicate via the sacral basivertebral veins that
penetrate the boney surface of the anterior sacrum
within the foramina located in the bodies of S3–
S5 [3]. The adventitia of these sacral basivertebral veins is blended with the sacral periosteum
at the margin of the opening of the foramina.
When the presacral fascia tissue is lifted during
dissection, the basivertebral vein is potentially
lacerated near the opening of the foramen and the
transected end retracts into the foramen causing
massive hemorrhage (Fig.25.1). Massive presacral bleeding is best avoided by deliberate incision of the rectosacral fascia, and sharp dissection
Injury totheVessels
Major vascular injuries are rare but can be catastrophic and most commonly involve the internal
iliac vein, internal iliac artery, or branches of
these vessels. Proper management of a vascular
injury entails control of hemorrhage through
direct pressure, clamp application, or temporary
packing to halt or tamponade the bleeding and
stabilize the patient while appropriate blood
products are made available, the team is readied,
and repair is planned. The extent and type of
injury should be assessed, and the surrounding
structures must be examined to exclude concomitant damage. Small lacerations can be directly
sutured, but larger injuries or transections may
require more complex repair, such as end-to-end
anastomosis, placement of patches or interposi-
Fig. 25.1 Presacral bleeding from the basivertebral vein
secondary to blunt dissection of the posterior
mesorectum