A Multidisciplinary Approach to the Patient with Deep Infilt
41-year-old G4P0040 with a 15-year history of chronic pelvic pain with symptoms of dysmenorrhea, dyschezia, constipation, dysuria, and abnormal uterine bleeding failed previous management with hormonal suppression. Her history was significant for irritable bowel syndrome, depression, alcoholism, and a prior laparoscopic excision of endometriosis and appendectomy. Given her bladder and bowel symptoms, pre-operatively the patient was seen by both urology and general surgery. Colonoscopy noted a 3-centimeter non-obstructing lesion protruding into but not all the way through mucosa with negative mucosal biopsies. Pre-operative cystoscopy was negative.

On exam in the office, she was noted to have a 10-week sized uterus with mobility limited by posterior cul-de-sac lesion with a 2-centimeter posterior fornix lesion tethered to a rectal lesion. The MRI, which this time was performed with intravenous, oral, rectal, and vaginal contrast, reported deep pelvic endometriosis with mass like T2-hypointense process in the rectovaginal septum, with gross invasion into the anterior rectal wall. The endometrial mass appeared to invade the full thickness of the rectal wall, extending into the rectal lumen. MRI also demonstrated adenomyosis and thickening of the right fallopian tube and right proximal round ligament. Pre-operatively, both general surgery and gynecology surgeons had extensive discussions with the patient regarding etiology, treatment options and surgical options. She did not desire childbearing but desired ovarian conservation to avoid premature menopause. She then underwent a robotically-assisted total laparoscopic hysterectomy, bilateral salpingectomy, cystoscopy, bilateral ureterolysis, lysis of adhesions, segmental rectosigmoidectomy and anastomosis, partial vaginectomy, and flexible sigmoidoscopy. EBL for the case was 500 cc. Findings at the time of surgery were notable for a 2-centimeter mid-upper vaginal posterior fornix nodule with blue-brown hue consistent with transmural vaginal endometriosis nodule, 12-week sized globular uterus consistent with adenomyosis, normal adnexa bilaterally, DIE endometriosis lesions limited to rectosigmoid (5 × 3 centimeters), upper vagina (3 × 3 centimeters), bilateral uterosacral ligaments, 10 centimeters in aggregate, not noted in other areas. Dense adhesions and obliterated posterior cul-de-sac were noted in the pelvis. At the conclusion of the procedure, all grossly visible endometriosis had been completely resected. Pathology was consistent with endometriosis in all specimens observed during surgery and the uterus was consistent with adenomyosis and leiomyomata.

The post-operative course was complicated by postoperative urinary retention, presumably secondary to disruption of the parasympathetic plexus during the deep endometriosis resection for which she required intermittent catheterization with timed voids.