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Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series

      Objective

      To report postoperative outcomes after rectal shaving for deep endometriosis infiltrating the rectum.

      Design

      Retrospective study using data prospectively recorded in the CIRENDO database.

      Setting

      University tertiary referral center.

      Patient(s)

      One hundred and twenty-two consecutive patients whose follow-up observation ranged from 1 to 6 years.

      Intervention(s)

      Rectal shaving performed using ultrasound scalpel or scissors and plasma energy in 68 and 54 women, respectively.

      Main Outcome Measure(s)

      Postoperative digestive function assessed using standardized gastrointestinal questionnaires: the Gastrointestinal Quality of Life Index (GIQLI) and the Knowles-Eccersley-Scott-Symptom Questionnaire (KESS).

      Result(s)

      Nodules were between 1 and 3 cm, <1 cm, and >3 cm in diameter, in 73.7%, 11.5%, and 14.8% of cases, respectively. They were located on the middle (49.2%) and upper rectum (50.8%). Clavien-Dindo 3a, 3b, 4a, and 4b complications occurred in 0.8%, 5.7%, 1.6%, and 0.8% of cases, respectively. Excepting two rectal fistulas (1.6%), the majority of complications were not related to rectal shaving itself. Gastrointestinal scores revealed statistically significant improvement in digestive function and pelvic pain at 1 and 3 years after rectal shaving, but not constipation. Rectal recurrences occurred in 4% of patients, 2.4% of whom had segmental resection, 0.8% shaving, and 0.8% disc excision. Three years postoperatively, the pregnancy rate was 65.4% among patients with pregnancy intention, 59% of whom conceived spontaneously.

      Conclusion(s)

      Our data suggest that rectal shaving is a valuable treatment for deep endometriosis infiltrating the rectum, providing a low rate of postoperative complications, good improvement in digestive function, and satisfactory fertility outcomes.

      Key Words

      Rectal shaving is among the first techniques used to treat deep endometriosis infiltrating the rectum (
      • Reich H.
      • McGlynn F.
      • Salvat J.
      Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis.
      ,
      • Donnez J.
      Excision of deep endometriotic nodules by laparoscopy.
      ,
      • Nezhat C.
      • Nezhat F.
      • Ambroze W.
      • Pennington E.
      Laparoscopic repair of small bowel and colon: a report of 26 cases.
      ). In the literature, the terms shaving or partial full thickness excision correspond to removal of endometriosis nodules from the rectal wall without opening the lumen (
      • Darai E.
      • Cohen J.
      • Ballester M.
      Colorectal endometriosis and fertility.
      ). For this reason, the technique of shaving does not mandatorily require suturing of the rectal wall, except in cases where the shaved rectal wall is excessively thin. In this latter case, the muscular layer may be considerably or completely removed, with a consecutive and increasing risk of necrosis and fistula of rectal wall.
      Postoperative outcomes of rectal shaving have been evaluated in the literature through retrospective case series, most of them noncomparative. The investigators emphasized low rates of postoperative complications, which were presumed inferior to those after colorectal segmental resection (
      • Mohr C.
      • Nezhat F.R.
      • Nezhat C.H.
      • Seidman D.S.
      • Nezhat C.R.
      Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis.
      ,
      • Kondo W.
      • Bourdel N.
      • Tamburro S.
      • Cavoli D.
      • Jardon K.
      • Rabischong B.
      • et al.
      Complications after surgery for deeply infiltrating pelvic endometriosis.
      ). In addition, postoperative digestive function related to conservation of mesorectum and overall rectal capacity could be better after rectal shaving than after colorectal resection (
      • Roman H.
      • Vassilieff M.
      • Tuech J.J.
      • Huet E.
      • Savoye G.
      • Marpeau L.
      • et al.
      Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum.
      ). Conversely, the rate of postoperative recurrences could be higher, particularly in women seeking to conceive and having stopped contraceptive pill intake (
      • Donnez J.
      • Squifflet J.
      Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.
      ).
      Our case series assessed postoperative rectal function, pelvic pain, fertility outcomes, and risk of recurrence in a series of consecutive patients managed by rectal shaving for deep endometriosis infiltrating the rectum.

      Materials and methods

       Patients

      We included consecutive patients managed by rectal shaving for deep endometriosis infiltrating the rectum in the Department of Gynecology and Obstetrics of Rouen University Hospital (France) from June 2009 to September 2014, respecting a minimal follow-up of 12 months. Inclusion criteria were deep endometriosis revealed by clinical examination, confirmed by magnetic resonance imaging and/or endorectal ultrasound and intraoperatively; infiltration of the rectal muscular, submucosal, or mucosal layer; rectal involvement up to 15 cm above the anus; and a postoperative follow-up evaluation of more than 12 months. Patients presented with at least one rectal nodule, in some cases associated with nodules located on the upper digestive tract, so segmental resection of the sigmoid colon could be associated with rectal shaving. Patients presenting with deep rectovaginal endometriosis involving only rectal serosa and requiring superficial rectal shaving were excluded.
      Patients were prospectively enrolled in the CIRENDO database (the North-West Inter Regional Female Cohort for Patients with Endometriosis), a prospective cohort financed by the G4 Group (the University Hospitals of Rouen, Lille, Amiens, and Caen, France), and coordinated by the corresponding author of the present study (H.R.). Information was obtained from surgical and histologic records and from self-questionnaires completed before surgery. Data recording, patient contact, and follow-up evaluations were performed by a clinical research technician. Postoperative follow-up evaluation was based on data from the aforementioned questionnaires completed at 1 and 3 years. Prospective data recording and analysis were approved by the French authorities CNIL (Commission Nationale de l'Informatique et des Libertés, the French data protection commission) and CCTIRS (Comité Consultatif pour le Traitement de l'Information en matière de Recherche dans le domaine de la Santé, the advisory committee on information technology in healthcare research).
      The protocol for management of patients with rectal endometriosis in our department has been described previously elsewhere (
      • Roman H.
      • Vassilieff M.
      • Tuech J.J.
      • Huet E.
      • Savoye G.
      • Marpeau L.
      • et al.
      Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum.
      ). Patients underwent preoperative assessment of deep endometriosis that included clinical examination, magnetic resonance imaging, endorectal ultrasound, and later computed tomography-based virtual colonoscopy, performed exclusively by experienced operators (Fig. 1). One senior gynecologic surgeon with experience in surgery of deep endometriosis selected the type of surgery to perform then performed the rectal shaving without being assisted by general surgeons. For the women who were not intending to conceive, postoperative treatment by continuous contraceptive pill intake was systematically recommended.
      Figure 1
      Figure 1Preoperative assessment of deep endometriosis infiltrating the rectum in patients managed via rectal shaving (magnetic resonance imaging and computed tomography-based virtual colonoscopy).

       Rectal Shaving

      We reserved rectal shaving for patients presumed to be at lower risk of postoperative recurrence. We routinely considered rectal shaving in cases with infiltration of the rectal wall that did not exceed the muscular layer and in women who, at the time of the surgery, did not intend to conceive in the future and accepted the need for long-term postoperative medical treatment. Shaving was also preferred for patients in whom spontaneous conception appeared to be impossible and systematic assisted reproduction technology (ART) was presumed to be mandatory, as no interruption of long-term medical treatment was required. Rectal shaving was also preferred in women with digestive symptoms that had been completely relieved preoperatively by therapeutic amenorrhea, even though the infiltration of the rectal wall could exceed the muscular layer. When shaving was performed deep within the mucosa, we preferred to repair the rectal wall by disc excision using transanal staplers rather than placing stitches on the rectal muscularis. We also performed rectal shaving in stenosis with a minimal diameter of bowel lumen superior to 10 mm, due to nodules infiltrating the bowel over an area of <4 cm in length. In this latter case, rectal shaving was performed using an intrarectal probe, which allowed us to estimate the progressive reduction of the stenosis (
      • Roman H.
      Deep rectal shaving using plasma energy for endometriosis causing rectal stenosis—a video vignette.
      ,
      • Roman H.
      Rectal shaving using plasma energy in deep endometriosis of the rectum.
      ).
      Our surgical procedure of rectal shaving is similar to that performed by other surgical teams and was previously described by Donnez and Squifflet (
      • Donnez J.
      • Squifflet J.
      Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.
      ). The deep subperitoneal space located between the uterosacral ligaments and the rectum is longitudinally opened to avoid injury of the hypogastric and splanchnic nerves (
      • Roman H.
      Rectal shaving using plasma energy in deep endometriosis of the rectum.
      ). Dissection is performed in close contact with the lateral face of the rectum and is directed toward the healthy rectovaginal space located below the endometriosis nodule. Once the lateral faces of the rectum are freed, by use of a high-magnification endoscopic view the rectal shaving is performed as deeply as possible into the thickness of the rectal wall to remove abnormal fibrous lesions involving rectal layers. Thus, the nodule is dissected away from the rectal wall, which then can be progressively mobilized upward. The deep endometriotic nodule is then treated by resection of the vaginal fornix adjacent to the uterine torus and the anterior root of the uterosacral ligaments, when infiltrated.
      Up to December 2012, the procedure was performed using the Harmonic scalpel device (Ethicon Endo-Surgery) and scissors. In December 2012, we introduced an original procedure using the PlasmaJet device (Plasma Surgical), which may increase the efficiency of rectal shaving due to the precise ablative property of plasma (
      • Roman H.
      Rectal shaving using plasma energy in deep endometriosis of the rectum.
      ). When the shaved rectal area appeared thickened and fibrous, we are able to perform in situ ablation by painting the area with a plasma beam (
      • Roman H.
      Deep rectal shaving using plasma energy for endometriosis causing rectal stenosis—a video vignette.
      ,
      • Roman H.
      Rectal shaving using plasma energy in deep endometriosis of the rectum.
      ) (Supplemental Fig. 1, available online).
      We analyzed the follow-up data recorded in the CIRENDO database, including two gastrointestinal standardized questionnaires. The usefulness of standardized gastrointestinal questionnaires has been discussed previously elsewhere (
      • Roman H.
      • Vassilieff M.
      • Tuech J.J.
      • Huet E.
      • Savoye G.
      • Marpeau L.
      • et al.
      Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum.
      ,
      • Knowles C.H.
      • Eccersley A.J.
      • Scott S.M.
      • Walker S.M.
      • Reeves B.
      • Lunniss P.J.
      Linear discriminant analysis of symptoms in patients with chronic constipation: validation of a new scoring system (KESS).
      ,
      • Nieveen van Dijkum E.J.M.
      • Terwee C.B.
      • Oosterveld P.
      • van der Meulen J.H.P.
      • Gouma D.J.
      • de Haes J.C.J.M.
      Validation of the gastrointestinal quality of life index for patients with potentially operable periampullary carcinoma.
      ).

       Diagnosis of Constipation

      For diagnosis of constipation we used the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) (
      • Knowles C.H.
      • Eccersley A.J.
      • Scott S.M.
      • Walker S.M.
      • Reeves B.
      • Lunniss P.J.
      Linear discriminant analysis of symptoms in patients with chronic constipation: validation of a new scoring system (KESS).
      ), composed of 11 individual items with a maximum of 39 points. Lower scores represent symptom-free states whereas higher scores represent increased symptom severity. The KESS score differentiates patients with constipation (for whom the overall values are superior to 10) from the healthy controls, for whom the median value averages 2 (range: 0–6).
      The Gastrointestinal Quality of Life Index (GIQLI) (
      • Nieveen van Dijkum E.J.M.
      • Terwee C.B.
      • Oosterveld P.
      • van der Meulen J.H.P.
      • Gouma D.J.
      • de Haes J.C.J.M.
      Validation of the gastrointestinal quality of life index for patients with potentially operable periampullary carcinoma.
      ) is a self-administered questionnaire including 36 questions concerning digestive symptoms, physical status, emotions, social dysfunction, and effects of medical treatment. The 36 items of the GIQLI are scored from 0 to 4, with the total score ranging from 0 (worst quality of life) to 144 (best quality of life). Total score median values vary around 126 for healthy controls.
      Complications were recorded using the Clavien-Dindo classification (
      • Dindo D.
      • Demartines N.
      • Clavien P.A.
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ). When recurrence of endometriosis was suspected on the basis of recurrent pelvic or digestive complaints and/or clinical examination, patients underwent magnetic resonance imaging assessment. The patients with symptomatic evidence of deep endometriosis and inefficacy of medical therapy then were offered a second surgery. Thus, the definition of recurrence used in our study was that of the fifth category in the classification proposed by Meuleman et al. (
      • Meuleman C.
      • Tomassetti C.
      • Wolthuis A.
      • Van Cleynenbreugel B.
      • Laenen A.
      • Penninckx F.
      • et al.
      Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study.
      ): “Recurrence of histologically proven endometriosis: during laparoscopy, endometriosis is visually observed and confirmed histologically.”

       Statistical Analysis

      Statistical analysis was performed by the use of Stata 9.0 software (Stat Corporation). The characteristics of the patients were compared using either the Kruskal-Wallis test (continuous variables) or the Fischer exact test (qualitative variables), according to nodule size and vagina opening. P<.05 was considered statistically significant. The present case-series study was approved by the Institutional Ethics Committee for Non Interventional Research.

      Results

      We enrolled 122 patients to be managed by rectal shaving from June 2009 to September 2014. They represented 36.7% of the whole series of 332 patients managed for deep colorectal endometriosis infiltrating the rectum during the study period. Disc excision was performed in 50 cases (15.1%) and segmental resection in 160 patients (48.2%). Rectal shaving was performed using ultrasound scalpel and plasma energy in 68 (55.7%) and 54 (44.3%) women, respectively. Four (4%) patients did not answer the follow-up questionnaires, but no recurrence was observed during their postoperative visit in our department.
      Table 1 presents patients' clinical history and main pelvic and digestive complaints. Most patients were nullipara and previously had been surgically managed elsewhere. Their previous surgeries were not confined to deep endometriosis but rather could include ovarian and superficial endometriosis. The patients presented with various digestive complaints, and their overall values for KESS and GIQLI scores revealed high rates with constipation and impaired gastrointestinal quality of life.
      Table 1Patients' clinical history and complaints.
      Patient characteristicsN = 122 (%)

      Mean ± SD
      Age (y)36 ± 6.9
      Antecedents of gynecologic surgery77 (63.1)
       Open surgeries26 (21.3)
      Patients with documented preoperative infertility40 (32.8)
      Obstetric antecedents
       Nulligesta52 (42.6)
       Nullipara65 (53.3)
      Dysmenorrhea118 (96.7)
       Biberoglou and Behrman dysmenorrhea score1.85 ± 0.7
       Intensity of dysmenorrhea (VAS >4)113 (92.6)
      Cyclic symptoms associated with dysmenorrhea
       Defecation pain87 (71.3)
       Rectorrhagia12 (9.8)
       Constipation54 (44.3)
       Diarrhea55 (45.1)
       Bloating73 (59.8)
       Urinary pain36 (29.5)
      Women having had sexual intercourse during previous 12 mo100 (90)
       Deep dyspareunia56 (45.9)
      Biberoglou & Behrman deep dyspareunia score1.82 ± 1.1
      Intensity of dyspareunia (VAS >4)68 (55.7)
      Assessment of digestive function
       KESS constipation score (total value)12.1 ± 6.6
       GIQLI score (total value)86.7 ± 22.7
      Note: GIQLI = Gastrointestinal Quality of Life Index; KESS = Knowles-Eccersley-Scott-Symptom Questionnaire; SD = standard deviation; VAS = visual analogue scale.
      Table 2 presents the intraoperative findings and surgical procedures as well as immediate postoperative complications, which were stratified by nodule size. Deep nodules infiltrated either the middle or upper rectum, and their diameter varied mostly between 1 and 3 cm. There were multiple associated pelvic and abdominal localizations of stage 3 and 4 endometriosis, which required various procedures of excision or ablation. In two patients with multiple colorectal nodules, rectal shaving was associated with sigmoid colon resection, with the aim of avoiding long and low colorectal resections. Vaginal infiltration was statistically significantly more frequent when the nodule size was >3 cm in diameter. The operative time was longer for large nodules, even though the revised American Fertility Society scores were rigorously similar between the three groups. Hysterectomy was performed in one woman out of three, and was justified by associated adenomyosis in women who had no further pregnancy intentions.
      Table 2Intraoperative findings and immediate postoperative complications.
      FindingsWhole sample

      N = 122 (%)
      Nodule sizeP value
      <1 cm

      n = 14 (11.5%)
      1–3 cm

      n = 90 (73.7%)
      >3 cm

      n = 18 (14.8%)
      Height of rectal nodule
       <5 cm (low)0000
       5–10 cm (middle)60 (49.2)8 (57.1)44 (48.9)8 (44.4).80
       >10 cm (upper)62 (50.8)6 (42.9)46 (51.1)10 (55.6).80
      Operative time (min)162 ± 7286.4 ± 32.5165.7 ± 66.5204.7 ± 78.1<.001
      Operative route.64
       Open surgery1 (0.8)01 (1.1)0
       Laparoscopy109 (89.3)12 (85.7)80 (88.9)16 (88.9)
       Robotic assistance6 (4.9)2 (14.3)8 (8.9)1 (5.6)
       Laparoscopy followed by open route2 (1.6)01 (1.11)1 (5.6)
      AFSr score76.7 ± 4776.9 ± 45.475.9 ± 49.580.7 ± 35.6.93
      Douglas pouch complete obliteration70 (57.4)8 (61.5)50 (58.8)12 (80).61
      Associated endometriosis localizations
       Diaphragm22 (18)3 (21.4)13 (14.4)6 (33.3).13
       Small bowel5 (4.1)04 (4.4)1 (5.6)1
       Appendix3 (2.5)04 (4.4)01
       Cecum1 (0.8)01 (1.1)01
       Sigmoid colon33 (27)1 (7.1)26 (28.9)6 (33.3).18
       Bladder5 (4.1)05 (5.6)0.78
       Vagina58 (47.5)6 (42.9)38 (42.2)14 (77.8).02
      Management of ovarian endometriomas
       Right70 (57.4)7 (50)53 (58.9)10 (55.6).80
       Left72 (59)8 (57.1)55 (61.1)9 (50).66
      Hysterectomy42 (34.4)3 (21.4)32 (35.6)7 (38.9).38
      Surgical procedures on digestive tract
       Sigmoid colon resection2 (1.6)02 (2.2)01
       Cecum resection1 (0.8)01 (1.1)01
       Appendectomy4 (3.3)04 (4.4)01
       Resection of small bowel2 (1.6)02 (2.2)01
       Transitory stoma1 (0.8)001 (5.6).26
      Surgical procedures on urinary tract
       Resection of the bladder5 (4.1)05 (5.6)0.78
       Ureterolysis for ureter stenosis4 (3.3)04 (4.4)01
       Ureterocystostomy2 (1.6)02 (2.2)01
      Postoperative complications
       Rectovaginal fistulae1 (0.8)01 (1.1)01
       Rectal fistulae1 (0.8)001 (5.6)1
       Bladder atony requiring daily catheterization after discharge from hospital8 (6.6)1 (7.1)6 (6.7)1 (5.6)1
       Ureteral anastomosis fistulae1 (0.8)01 (1.1)01
       Pelvic hematoma/abscess7 (5.7)1 (7.1)4 (4.4)2 (11.1).33
      Clavien-Dindo classification of complications
       110 (8.2)1 (7.1)7 (7.8)2 (11.1).86
       216 (13.1)3 (21.4)12 (13.3)1 (5.6).49
       3a1 (0.8)01 (1.1)01
       3b7 (5.7)06 (6.7)1 (5.6)1
       4a2 (1.6)01 (1.1)1 (5.6).46
       4b1 (0.8)001 (5.6).26
      Note: AFSr = revised American Fertility Society.
      Severe postoperative complications were rare; however, they required a second surgical procedure under general anesthesia in 4.9% of cases. Nodule size was not statistically significantly associated with postoperative complications (Table 2). Conversely, pelvic abscess and hematoma were statistically significantly more frequent in women who underwent hysterectomy (Supplemental Table 1, available online). Eight patients had bladder postvoiding volume >100 mL on the day of discharge from the hospital, and they were offered systematic bladder daily self-catheterizations for 6 ± 4 weeks postoperatively.
      There were five rectal recurrences originating from the site of previous shaving (4%) after a period of 1 to 5 years. Nodule size varied from 1 to 3 cm in four patients, and >3 cm in one woman (P=1). These recurrences were managed by shaving (1 case, 0.8%), disc excision using the Rouen technique (disc excision of the low rectum using a transanal semicircular stapler, 1 case, 0.8%) (
      • Roman H.
      • Abo C.
      • Huet E.
      • Bridoux V.
      • Auber M.
      • Oden S.
      • et al.
      Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort.
      ), and segmental resection (3 cases, 2.4%). Two patients were managed in a facility located in another region, which provided complete surgical reports related to recurrence management.
      Two fistulas were recorded in our series (1.6%). The first patient was managed in 2009 for a deep nodule infiltrating 6 cm of the rectum and sigmoid colon. Shaving was performed using ultrasound scalpel, and peritonitis occurred on day 6 due to delayed necrosis of the rectal wall. The patient was managed by colostoma for 3 months. The second patient had Steinert's disease and previously had undergone surgery for pelvic endometriosis. She was managed for recurrent pelvic pain related to extensive pelvic adhesions and a 2-cm nodule of the upper rectum. We performed adhesiolysis and partial rectal shaving with favorable outcomes, and she then was referred to the emergency department for rectovaginal fistula on day 21. She was managed by colostoma but required a second colorectal resection 12 months later due to absence of healing.
      Table 3 presents the postoperative assessment of digestive function at 1 and 3 years after surgery. Patients reported statistically significant improvement in overall gastrointestinal quality of life, abdominal pain, and bowel frequency. Conversely, both the KESS and GIQLI scores failed to show statistically significant improvement in constipation.
      Table 3Postoperative assessment of digestive function.
      ParameterBaseline (n = 122)1 y (n = 117)P value3 y (n = 61)P value
      KESS score (n.v. <7)12.1 ± 6.69.9 ± 6.6.0110.9 ± 6.4.24
      GIQLI (n.v. >100)86.7 ± 22.7104.8 ± 22.1.001106.9 ± 19<.001
      Abdominal pain (GIQLI item 1)1.72 ± 0.962.65 ± 1.10<.0012.55 ± 1.02<.001
      Embarrassed by bowel frequency (GIQLI item 7)2.7 ± 1.153.04 ± 1.12.023.24 ± 0.94.002
      Diarrhea (GIQLI item 31)2.9 ± 1.163.35 ± 0.95.0013.45 ± 0.8.001
      Note: GIQLI = Gastrointestinal Quality of Life Index; KESS = Knowles-Eccersley-Scott Symptom Questionnaire; n.v. = normal values.
      Of the 117 patients observed over 1 year, 29 attempted to conceive during the first year of follow-up evaluation, resulting in 14 pregnancies or a 1-year pregnancy rate of 48.3%. Of the 68 patients evaluated over 3 years, 26 attempted to conceive, resulting in 17 pregnancies or a 3-year pregnancy rate of 65.4%. Of these 17 pregnancies, 10 (59%), 5 (29%), 1 (6%), and 1 (6%) were obtained by spontaneous conception, in vitro fertilization (IVF), insemination, and ovarian stimulation, respectively.

      Discussion

      We report a series of patients managed by rectal shaving, who were prospectively enrolled in a cohort and benefited from close follow-up observation and detailed assessment of postoperative digestive outcomes. Our results suggest that rectal shaving is a valuable surgical procedure, leading to a low complication rate, good improvement in digestive function, and satisfactory fertility outcomes.
      Our series presents several strengths. Recording of data was prospective and was performed by a clinical researcher dedicated to managing follow-up data, which explains the low rate of patients without follow-up data. The assessment of baseline and postoperative digestive function was based on universally accepted and standardized gastrointestinal questionnaires (
      • Knowles C.H.
      • Eccersley A.J.
      • Scott S.M.
      • Walker S.M.
      • Reeves B.
      • Lunniss P.J.
      Linear discriminant analysis of symptoms in patients with chronic constipation: validation of a new scoring system (KESS).
      ,
      • Nieveen van Dijkum E.J.M.
      • Terwee C.B.
      • Oosterveld P.
      • van der Meulen J.H.P.
      • Gouma D.J.
      • de Haes J.C.J.M.
      Validation of the gastrointestinal quality of life index for patients with potentially operable periampullary carcinoma.
      ), which provide an accurate evaluation of the effect of rectal shaving on baseline digestive complaints.
      Our study also has several weaknesses. One of them concerns the lack of a comparative group. Although our database includes a large number of patients managed by disc excision or segmental resection, differences in their baseline characteristics and nodule features prevented direct comparison between surgical procedures. However, postoperative outcomes, complications, and recurrences after disc excision and segmental resection have been repeatedly reported by various surgical teams worldwide and were pooled in large systematic reviews (
      • De Cicco C.
      • Corona R.
      • Schonman R.
      • Mailova K.
      • Ussia A.
      • Koninckx P.R.
      Bowel resection for deep endometriosis: a systematic review.
      ,
      • Meuleman C.
      • Tomassetti C.
      • D'Hoore A.
      • Van Cleynenbreugel B.
      • Penninckx F.
      • Vergote I.
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ). In a review pooling 49 studies, Meuleman et al. (
      • Meuleman C.
      • Tomassetti C.
      • D'Hoore A.
      • Van Cleynenbreugel B.
      • Penninckx F.
      • Vergote I.
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ) reported that in women managed by colorectal resection, the rate of rectovaginal fistula varied around 2.7% and that of anastomosis leakage averaged 1.5%. However, in several retrospectives series reported by experienced surgeons who routinely perform bowel resection in endometriosis, the rate of rectovaginal fistula rose to 8.4% (
      • Daraï E.
      • Ackerman G.
      • Bazot M.
      • Rouzier R.
      • Dubernard G.
      Laparoscopic segmental colorectal resection for endometriosis: limits and complications.
      ) or 10.7% (
      • Bracale U.
      • Azioni G.
      • Rosati M.
      • Barone M.
      • Pignata G.
      Deep pelvic endometriosis (Adamyan IV stage): multidisciplinary laparoscopic treatments.
      ), while that of anastomotic leakage rose to 2.1% (
      • Ferrero S.
      • Anserini P.
      • Abbamonte L.H.
      • Ragni N.
      • Camerini G.
      • Remorgida V.
      Fertility after bowel resection for endometriosis.
      ), 4.7% (
      • Mereu L.
      • Ruffo G.
      • Landi S.
      • Barbieri F.
      • Zaccoletti R.
      • Fiaccavento A.
      • et al.
      Laparoscopic treatment of deep endometriosis with segmental colorectal resection: short-term morbidity.
      ), or 6% (
      • Possover M.
      • Diebolder H.
      • Plaul K.
      • Schneider A.
      Laparascopically assisted vaginal resection of rectovaginal endometriosis.
      ). As regards disc excision, the rate of rectovaginal fistula may average 4% (
      • Roman H.
      • Abo C.
      • Huet E.
      • Bridoux V.
      • Auber M.
      • Oden S.
      • et al.
      Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort.
      ). Concerning the recurrence rates after colorectal resection, overall risk of recurrence was estimated at 5.8%, while that of proven recurrence in women undergoing secondary surgery was 2.5% (
      • Meuleman C.
      • Tomassetti C.
      • D'Hoore A.
      • Van Cleynenbreugel B.
      • Penninckx F.
      • Vergote I.
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ). The fertility rate after colorectal resection was recently studied in a review of the literature and was estimated at 46.9%, whereas that of spontaneous conception averaged 28.6% (
      • Cohen J.
      • Thomin A.
      • Mathieu D'Argent E.
      • Laas E.
      • Canlorbe G.
      • Zilberman S.
      • et al.
      Fertility before and after surgery for deep infiltrating endometriosis with and without bowel involvement: a literature review.
      ). Thus, when compared with data in the literature, the postoperative outcomes in our series were satisfactory in terms of complications, recurrences, fertility, and digestive function.
      The larger the deep endometriosis nodule, the higher the risk of posterior vagina infiltration requiring surgical excision (
      • Matsuzaki S.
      • Houlle C.
      • Botchorishvili R.
      • Pouly J.L.
      • Mage G.
      • Canis M.
      Excision of the posterior vaginal fornix is necessary to ensure complete resection of rectovaginal endometriotic nodules of more than 2 cm in size.
      ). However, our patients managed by vagina excision and hysterectomy had a tendency toward more frequent bladder dysfunction, respectively, 12.8% and 4.8% versus 2.6%. This tendency is logical as retroperitoneal dissection is more extended during hysterectomy or resection of deep rectovaginal endometriosis. However, performing hysterectomy in patients with adenomyosis and no further pregnancy intention can improve postoperative pelvic pain (dysmenorrhea, deep dyspareunia, and chronic pelvic pain) (
      • Ferrero S.
      • Camerini G.
      • Menada M.V.
      • Biscaldi E.
      • Ragni N.
      • Remorgida V.
      Uterine adenomyosis in persistence of dysmenorrhea after surgical excision of pelvic endometriosis and colorectal resection.
      ) and avoid spontaneous metrorrhagia or spotting under continuous medical treatment.
      The aim of complete removal of endometriotic foci is probably not accomplished with the technique of rectal shaving. We are aware that endometriotic foci may be left behind after rectal shaving (
      • Roman H.
      • Opris I.
      • Resch B.
      • Tuech J.J.
      • Sabourin J.C.
      • Marpeau L.
      Histopathologic features of endometriotic rectal nodules and the implications for management by rectal nodule excision.
      ). The question is whether these foci can further develop and be responsible for postoperative recurrence (
      • Donnez O.
      • Orellana R.
      • Van Kerk O.
      • Dehoux J.P.
      • Donnez J.
      • Dolmans M.M.
      Invasion process of induced deep nodular endometriosis in an experimental baboon model: similarities with collective cell migration?.
      ). The answer is probably affirmative, as demonstrated in our cohort by the five rectal recurrences originating from the site of rectal shaving. However, a risk of recurrence also exists in patients managed by colorectal resection (
      • Meuleman C.
      • Tomassetti C.
      • D'Hoore A.
      • Van Cleynenbreugel B.
      • Penninckx F.
      • Vergote I.
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ,
      • Roman H.
      • Hennetier C.
      • Darwish B.
      • Badescu A.
      • Csanyi M.
      • Aziz M.
      • et al.
      Bowel occult microscopic endometriosis in resection margins in deep colorectal endometriosis specimens has no impact on short-term postoperative outcomes.
      ) and disc excision. The persistence of endometriosis implants after disc excision (
      • Roman H.
      • Abo C.
      • Huet E.
      • Bridoux V.
      • Auber M.
      • Oden S.
      • et al.
      Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort.
      ,
      • Remorgida V.
      • Ragni N.
      • Ferrero S.
      • Anserini P.
      • Torelli P.
      • Fulcheri E.
      How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study.
      ) and segmental resection (
      • Roman H.
      • Hennetier C.
      • Darwish B.
      • Badescu A.
      • Csanyi M.
      • Aziz M.
      • et al.
      Bowel occult microscopic endometriosis in resection margins in deep colorectal endometriosis specimens has no impact on short-term postoperative outcomes.
      ,
      • Badescu A.
      • Roman H.
      • Aziz M.
      • Puscasiu L.
      • Molnar C.
      • Huet E.
      • et al.
      Mapping of endometriosis microimplants surrounding deep endometriosis nodules infiltrating the bowel.
      ,
      • Anaf V.
      • El Nakadi I.
      • Simon P.
      • Van de Stadt J.
      • Fayt I.
      • Simonart T.
      • et al.
      Preferential infiltration of large bowel endometriosis along the nerves of the colon.
      ,
      • Nirgianakis K.
      • McKinnon B.
      • Imboden S.
      • Knabben L.
      • Gloor B.
      • Mueller M.D.
      Laparoscopic management of bowel endometriosis: resection margins as a predictor of recurrences.
      ) has been reported in the literature.
      Nevertheless, the risk of recurrence of deep endometriosis could probably be decreased by continuous postoperative amenorrhea, as already demonstrated in ovarian endometriomas (
      • Seracchioli R.
      • Mabrouk M.
      • Frasca C.
      • Manuzzi L.
      • Montanari G.
      • Keramyda A.
      • et al.
      Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence: a randomized controlled trial.
      ). On the basis of this presumption and with the aim of providing good functional results along with a low risk of postoperative complications, we use rectal shaving in our routine management of rectal endometriosis in women with no further pregnancy intention. This strategy has led to an overrepresentation of women older than 35 years in our series, a high rate of associated hysterectomy, and a low rate of women with postoperative intention to conceive.
      One year after surgery, assessment of digestive function revealed a statistically significant improvement in overall gastrointestinal quality of life, bowel frequency, abdominal pain, and diarrhea. The improvement in symptoms remained unchanged during the following 2 years. Conversely, both the KESS and GIQLI scores failed to show an improvement in constipation. This result may have several explanations. In women with stenosis of the digestive tract, rectal shaving does not completely remedy rectal narrowness (
      • Roman H.
      Deep rectal shaving using plasma energy for endometriosis causing rectal stenosis—a video vignette.
      ), which may still be responsible for various degrees of constipation. In addition, the improvement in anal sphincter tonus in most patients with rectal endometriosis may potentially hinder stool evacuation (
      • Mabrouk M.
      • Ferrini G.
      • Montanari G.
      • Di Donato N.
      • Raimondo D.
      • Stanghellini V.
      • et al.
      Does colorectal endometriosis alter intestinal functions? A prospective manometric and questionnaire-based study.
      ). Postoperative residual constipation has already been observed in numerous patients managed by rectal shaving (
      • Seracchioli R.
      • Ferrini G.
      • Montanari G.
      • Raimondo D.
      • Spagnolo E.
      • Di Donato N.
      Does laparoscopic shaving for deep infiltrating endometriosis alter intestinal function? A prospective study.
      ) and also in those having undergone colorectal resection (
      • Roman H.
      • Vassilieff M.
      • Tuech J.J.
      • Huet E.
      • Savoye G.
      • Marpeau L.
      • et al.
      Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum.
      ).
      The rate of postoperative complications directly due to rectal shaving appears low. We recorded two rectal fistulas due to delayed necrosis of the shaved area, which were probably the consequence of thermal diffusion during the procedure of deep shaving. This severe event should be emphasized, as patients presenting with rectal fistula after shaving are not usually protected by transitory stoma, so the severity of the complication is alarming. Our rectal fistula rate is comparable with the 0.7% reported by Meuleman et al. (
      • Meuleman C.
      • Tomassetti C.
      • D'Hoore A.
      • Van Cleynenbreugel B.
      • Penninckx F.
      • Vergote I.
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ) in a review of the literature pooling data from 679 patients managed by shaving. In addition, it is at least twofold less than the rates reported in series of patients managed by colorectal resection (
      • Meuleman C.
      • Tomassetti C.
      • D'Hoore A.
      • Van Cleynenbreugel B.
      • Penninckx F.
      • Vergote I.
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ) or disc excision (
      • Roman H.
      • Abo C.
      • Huet E.
      • Bridoux V.
      • Auber M.
      • Oden S.
      • et al.
      Full-thickness disc excision in deep endometriotic nodules of the rectum: a prospective cohort.
      ). Other severe complications in our cohort were rather due to hysterectomy or large excision of vaginal endometriosis (pelvic abscess) or to resection of the ureter (fistula of uretero-ureteral anastomosis) than to rectal shaving itself.
      The rate of immediate bladder voiding dysfunction appears to be high, but it may be overestimated when compared with other series. As bladder postvoiding volume was systematically measured after bladder catheter removal, all patients with values >100 mL on the day of discharge were recorded as presenting “bladder dysfunction after discharge from hospital.”

      Conclusion

      Our results support the hypothesis that rectal shaving is a valuable procedure allowing management of deep endometriosis of the rectum and offering low postoperative risk. Although most of our patients presented with rectal nodules of 1 to 3 cm in diameter, rectal shaving is not limited to small nodules and can be used successfully in large nodules responsible for stenosis. However, in this latter indication, patients should be aware that the relief of baseline constipation might be incomplete. Taking into account the low rate of postoperative complications and recurrences, along with good improvement in digestive function and satisfactory fertility outcomes, patients' informed choice may favor rectal shaving over radical surgical management of deep endometriosis infiltrating the rectum.

      Acknowledgments

      The authors thank Amelie Breant for her valuable management of the CIRENDO database; and Nikki Sabourin-Gibbs, Rouen University Hospital, for her help in editing the manuscript.

      Appendix

      Supplemental Figure 1
      Supplemental Figure 1Laparoscopic view of rectal shaved area when shaving was performed by use of (A) scissors, (B) ultrasound scalpel, or (C) plasma energy.
      Supplemental Table 1Postoperative complications according to vagina opening or hysterectomy.
      Postoperative complicationsWhole sample

      n = 122 (%)
      No vagina opening

      n = 39 (32%)
      Vaginal excision

      n = 41 (33.6%)
      Hysterectomy

      n = 42 (34.4%)
      P value
      Rectovaginal fistulae1 (0.8)1 (2.6)00.32
      Rectal fistulae1 (0.8)1 (2.6)00.32
      Bladder atony requiring daily catheterization after leaving the hospital8 (6.6)1 (2.6)5 (12.2)2 (4.8).26
      Ureteral anastomosis fistulae1 (0.8)0011
      Pelvic hematoma/abscess7 (5.6)2 (5.1)05 (11.9).049

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