Not all cases of endometriosis are the same. You’ve probably heard that endometriosis can affect the ovaries, causing chocolate cysts (also known as endometriomas). However, deep endometriosis can be found in many different locations, both inside and outside the female pelvis. Each of these locations (although most are, fortunately, less common) requires a different surgical approach and, often, collaboration with other specialties. In all cases, the minimally invasive approach (laparoscopic or robotic) is feasible and superior, when compared to the open. Let’s just examine some of these locations individually:
Bowel Endometriosis: This is a relatively common location of the disease. Invasive endometriosis can affect various parts of the colon, from the rectum and sigmoid colon to the final part of the small intestine (terminal ileum). Often the intestinal symptoms are severe and surgical treatment is required. Depending on the location, surgical treatment may include shaving, disc excision, or even segmental resection of the infiltrated part of the intestine, with anastomosis. Significant experience of the surgeon as well as collaboration with a colorectal surgeon is necessary.
Urinary Tract Endometriosis: 2 main anatomical locations are of interest: the bladder and the ureter. In case of bladder endometriosis, the disease is usually located in the bladder dome. In such cases, the combined approach is of value, with simultaneous cystoscopy (a camera inserted in the bladder by a urologist) and laparoscopy (by the endometriosis surgeon), in order to remove the entire lesion without damaging the ureters.
On the other hand, the ureters can be affected by endometriosis in 2 ways: in endometriosis nodules that originate from the parametrium, the ureter is compressed externally and, in advanced cases, this can lead to hydronephrosis (dilatation of the ureters) and loss of kidney function (‘’silent kidney loss’’). In rare cases, endometriosis is intrinsic (in the wall, that is, of the ureter) and, to be adequately treated, removal of the infiltrated section and anastomosis over healthy borders may be necessary. If this is not possible, the surgeon should consider psoas hitch and Boari flap.
Parametrial Endometriosis: These are the anatomical spaces to the right and left of the uterus. One of the most challenging localisations of the disease. It can obstruct the ureter, while infiltrating the lower hypogastric nerve plexus, resulting in patients often being unable to completely empty their bladder. In the event that endometriosis has infiltrated both parameters, surgical treatment becomes particularly demanding, in terms of preserving the nerves and avoiding postoperative complications.
Sacral plexus Endometriosis: These are endometriosis nodules that start from the parametrium and infiltrate posteriorly and laterally, compressing on the sacral nerve plexus. Pain and numbness in the lower extremities are common symptoms. Here too, laparoscopic or robotic approaches are feasible, but require great experience and expertise.
Sciatic nerve Endometriosis: These are endometriosis nodules that infiltrate the sciatic nerve, the largest nerve in the body. Although fortunately rare, they can be found in isolation, without other visible foci of endometriosis. They often cause severe symptoms and require laparoscopic or robotic removal by appropriately-trained endometriosis surgeons.
Diaphragmatic endometriosis: This disease location is not that rare and may be accompanied by symptoms such as pain in the right shoulder blade or even cases of pneumothorax, especially during menstruation. To achieve complete excision of the lesions and suturing, a robotic approach is recommended.
Of course, these locations are not the only ones where endometriosis can be found! In a future article, we will refer to other, rare locations of the disease.
If you suffer from endometriosis, please do not hesitate to contact us. Led by endometriosis surgeon Dr. Georgios Grigoriadis, we have a highly- trained team of healthcare professionals, ready to manage any endometriosis case, from the simplest to the most challenging!
Endometriosis is common… get informed!