hydronefrosis, unnecessary bowel resections and a rectovaginal nodule
hydronefrosis, unnecessary bowel resections and a rectovaginal nodule
AAGL-ENDO-EXCHANGE Digest – 28 Dec 2010 to 29 Dec 2010 (#2010-156)Date: Wed, 29 Dec 2010 20:00:34 -0500
From: Philippe R Koninckx
Subject: 31 y.o. with firm rectovaginal mass and intermittent hydronephrosis
To the ongoing discussion we would like to add some remarks, backed up with direct links to the articles referred to.
1. We fully agree with David Redwine that this lady needs surgical excision of all deep endometriosis. It is unclear whether LHRH agonists may be usefull. We do not recommend this since we have the impreesion that planes of cleavage become more difficult.
2. We do consider it a mistake to do IVF in a woman with a rectovaginal nodule as presented at the ESGE meeting in Amsterdam 2008.
3. In addition if the hydronefroses would not regress during an eventual pregnancy, it will become a painful decision what to do.(as I saw once)
4. We stronly oppose the concept of at team is required to treat the ureter. First for the lower ureter as written in Fertil steril last year ( http://www.gynsurgery.org/ols/pdf/2009_decicco_ureter.pdf ) any lesion can be treated conservatively and ureter reimplantation has no place anymore as a first line of treatment. Since in Europe mainly gynaecologists have the required skills and expertise for an eventual ureter reanastomosis, we recommended that the lower ureter should be considered part of gynaecology. Anyway the patient should be informed about the available skills otherwise informed consent cannot be obtained. ( http://www.gynsurgery.org/hysterectomy-myomectomy/surgical-mistakes-and-surgical-quality/ )
5. In over 2000 deep endometriosis excisions of the rectum or rectosigmoid, a low rectum resection was only needed a few times. This opens the discussion why we always try to avoid low bowel resections. Indeed as reported in up to 14% of women no endometriosis was found in the resected specimen ( http://www.gynsurgery.org/ols/pdf/2010_the-elephant.pdf ), while the long term problems (sexual-bowel bladder) of low bowel resections well. Unfortunately most of bowel resections seem to be decided before surgery.( http://www.gynsurgery.org/ols/pdf/2010_deCicco_bowelresection.pdf ) Again the patient should be informed about the available skills otherwise informed consent cannot be obtained, and a bowel resection can hardly be considerd an alternative to lack of expertise. ( http://www.gynsurgery.org/top-navigation/surgery/informed-consent/ )
6. As debated at the ESGE meeting in Barcelona this year, I do not see any advantage in using a robot for this type of surgery. Moreover we did not find any published data that would demonstrate superiority of the robot. ( http://www.gynsurgery.org/hysterectomy-myomectomy/robotic-surgery-is-not-superior-and-potentially-dangerous/ )
Philippe R. Koninckx , Carlo De Cicco, Anastasia Ussia
University of Leuven Belgium and Gruppo Italo Belga, Rome Italy
pkoninckx@gmail.com www.gynsurgery.org mondoginecologico.it
no conflicts of interest
PS : please notic the comment of Dr Charles Koh below confirming the concepts on team effort, the blind leading the blind. “A ‘team’ effort here is illusory if the gyn. is
relying on the surgeon or urologist to do the dissection for him/her.”
Tags: bowel resection, deep endometriosis, Endometriosis, hydronefrosis
January 4th, 2011 at 3:38 pm
Date: Mon, 3 Jan 2011 17:55:47 -0500
From: Elliot Greenberg
Subject: 31 y.o. with firm rectovaginal mass and intermittent hydronephrosis
Thanks to all who have responded to my request. I have been a member of
this discussion group almost from it’s inception (when Dr Frishman and I still
had some hair). It still never ceases to amaze me that I can sit at my desk
and get second opinions from such a broad and international group of
interested and expert surgeons such as Dr. Redwine and Dr. Koninckx. Both of
whom I have read and have a great deal of respect for.
I have two comments. I would agree that ultimately it is in this patient’s best
interest to have this mass excised by an individual or team who has extensive
experience in complicated minimally invasive excision of endometriosis. I have
read enough of Dr Redwine’s data and the Italian data to believe that total
excision of endometriosis with whatever means necessary to free up the bowel
and ureter is the best choice. I also understand that most bowel endometriosis
doesn’t require low anterior resection, but can be accomplished with superficial
dissection or disc resection and primary closure. In addition, I appreciated that
the Gyn literature suggests that ureteral reanastamosis is effective and
superior to ureteral reimplantation. With all that said, I would guess that I am
echoing many well meaning gynecologists in our country (USA) when I say
that it can be very challenging to put together a team that includes a
competent MIS colorectal surgeon, Urologist and Gynecologist. In our
institution we have a skilled MIS colorectal surgeon and I’m confident in my
MIS skill but I am not trained in ureteral reanastamosis/reimplantation. I don’t
think it’s is particularly difficult to learn but I have been involved in enough
malpractice cases due solely to the fact that I was willing to operate on
patients that others wouldn’t (and have helped) that I’m not about to go down
that road without the blessing of our local Urologist. So the responsible thing
to do would be to refer the pt to the closest “Uber Surgeon”. From what I’ve
read here there are only two in the country. As much as I respect Dr
Redwine’s talents, and I have mentioned his name to several of my patients,
most of our patients can’t afford to see a doctor out of their insurance plan,
much less across the country. This particular patient has the good fortune to
have an insurance that will allow her to see a specialist in Boston and I plan on
referring her there for a second opinion, primarily due to the concern about her
ureter.
This leads me to my second comment. We have all be trained that our first
responsibility is to “Do no harm.”. With that in mind I would suggest that the
best option for a patient is the one that is the most effective and least
harmful, given the resources available. In this patient that may be to allow her
to try and get pregnant prior to any definitive procedure. She is young enough
that if she is able to get pregnant and have a child that will minimize any
concerns of trauma/adhesions that could potentially occur to her tubes during
surgery. If she is unable to conceive, she has only lost 6 months or so and we
can move toward definitive surgery in the least invasive way possible. As I’ve
stated, if Dr Redwine et al were in my region, I would enthusiastically suggest
surgery first.
Thanks again for all the input. It has been most helpful and enlightening.
Elliot Greenberg MD
Springfield, MA
January 4th, 2011 at 3:41 pm
Date: Sun, 2 Jan 2011 07:46:30 -0500
From: Charles Koh
Subject: 31 y.o. with firm rectovaginal mass and intermittent hydronephrosis
The most effective treatment today for endometriotic hydroureter/nephrosis
which is often associated with cardinal lig. Endometriosis and also confluent
rectovaginal endometriosis is accurate laparoscopic surgical resection. The
magnification and access to as low in the rectovaginal space allows precise
surgery, which will involve everything philippe koninckx and david redwine
describes. The need for segmental bowel resection or disc resection should be
individualized. We are not talking about ubersurgeon here, but the ability to
dissect and resect the ureter, bowel disc resection etc is NOT a skill of
urologists or colorectal surgeons currently, and has to be the ability of the
gynecologist specialized in advanced endometriosis surgery, who acts as
leader and directs the operation. A ‘team’ effort here is illusory if the gyn. is
relying on the surgeon or urologist to do the dissection for him/her.
Finally in fairness to the patient, the group/center/team doing this kind of
surgery must have a track record of successfully doing this routinely every
year, (whether uber or team) rather than the ‘potential’ ability to do this by
assembling other specialists.
Charles Koh
Milwaukee
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