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 ( ) 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. ( )
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 ( ), while the long term problems (sexual-bowel bladder) of low bowel resections well. Unfortunately most of bowel resections seem to be decided before surgery.( ) 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. ( )
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. ( )

Philippe R. Koninckx , Carlo De Cicco, Anastasia Ussia
University of Leuven Belgium and Gruppo Italo Belga, Rome Italy

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.”

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