Robotic-assisted conservative excision of retrocervical-rectal deep infiltrating endometriosis: a case series

Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Colorectal DIE accounts for 70% to 93% of all the intestinal endometriotic sites and frequently needs a surgical approach. However, the indications for the surgical management of this condition are still controversial. From March 2010 to June 2014, we scheduled 33 consecutive patients presenting with retrocervical-rectal DIE of any diameter not involving the mucosa nor producing rectal stenosis > 50% for laparoscopic robotic assisted nerve-sparing rectal nodulectomy (LRN). All patients were examined preoperatively, 3 and 6 months post-operatively and yearly thereafter. Dysmenorrhoea, dyschezia, dyspareunia and dysuria were evaluated with a 10-point visual analogue scale. 31 out of 33 (93.9%) enrolled patients fulfilled the selection criteria and were submitted to LRN. In 1 out of 31 (3.2%) available patients a segmental bowel resection was considered necessary for prudential purpose at the end of the nodulectomy procedure. No laparotomic conversion was performed in any case. A large variety of associated surgical procedures were performed in 25 out of 30 (83.3%) patients. No intraoperative complications were observed. We recorded one grade 3b and 2 grade 1 post-operative complications. The mean larger axis of the excised nodules measured on the formalin fixed specimen was 26.4 mm. We found a significant improvement of patient symptoms at 3 months follow-up which persisted over the time. We observed 2 (6.7%) recurrences of intestinal endometriosis and one (3.3%) recurrence of chronic pelvic pain without clinical and/or radiological evidence of endometriotic lesions. The mean follow up time was 27.6 months. We believe that LRN is feasible, safe and show promising results in terms of radicality, anatomical recurrence rate and pain recurrence rate for treating isolated retrocervical-rectal DIE not involving the mucosa, without limiting this procedure to nodule smaller than 3 cm.