Background: Surgical management of deep endometriosis infiltrating pelvic nerves may allow an overall improvement in pain and neurologic disorders. Objective: To assess 1-year postoperative outcomes of surgery for deep endometriosis involving sacral roots and the sciatic nerve. Study Design: Retrospective study including 52 women undergoing surgery for deep endometriosis involving sacral roots and the sciatic nerve. We assessed 1-year postoperative outcomes. Results: Deep endometriosis involved sacral roots in 49 women (94.2%) and the sciatic nerve in 3 cases (5.8%). Sciatic pain was recorded in 43 women (82.7%), pudendal neuralgia in 11 women (21.2%) and leg motor weakness in 14 cases (27%). Surgical procedures carried out on pelvic nerves included complete releasing and decompression (92.3%), excision of epineurium (5.8%) and intraneural excision (1.9%). Additional procedures involved the digestive tract in 82.7% of cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of cases. Self-catheterisation was required in 14 cases (27%) at 3 weeks after surgery, and in only 3 women (5.8%) 12 months later. One-year follow up showed significant improvement in quality of life using SF36 and standardised gastrointestinal scores. De novo hypoesthesia, hyperaesthesia or allodynia were recorded in 9 women (17.2%). The cumulative pregnancy rate was 77.2% following natural conception in 47%. Conclusions: Laparoscopic management of deep endometriosis involving sacral roots and the sciatic nerve improves patient symptoms and overall quality of life. Although pain reduction may be rapid following surgery, other sensory or motor complaints including bladder dysfunction may be recorded over months or years.

Background: Rectovaginal fistula is a major complication of surgery for deep endometriosis. Objective: To assess whether placement of a biological mesh (Permacol) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula, in patients with deep rectovaginal endometriosis. Study Design: Retrospective, comparative study enrolling patients with vaginal infiltration > 3cm diameter and rectal involvement in two centers. They benefited from complete excision of rectovaginal endometriotic nodules, with or without a biological mesh placed between the vaginal and rectal sutures. Rectovaginal fistula rate was compared between the two groups. Results: 209 patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). 92% of cases and 86.2% of controls had rectal infiltration greater than 3cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a lower distance between the rectal stapled line and the anal verge (4.4+/-1.4 cm vs. 6+/-2.9cm). Rectovaginal fistulae occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adj OR 0.61, 95%CI 0.2-2.3). A distance < 7cm between the rectal stapled line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistulae (adj OR 16.4, 95%CI 1.8-147). Conclusions: Placement of a biological mesh between the vagina and rectal sutures has no impact on the rate of postoperative rectovaginal fistula formation following excision of deep infiltrating rectovaginal endometriosis.

Background: Even though preventive stoma is unlikely to ensure primary healing in women with juxtaposed rectal and vaginal sutures, it may be considered, in selected patients at risk of rectovaginal fistula, to reduce fistula related complications. Objective: To assess whether a generalized use of preventive stoma reduces the rate of rectovaginal fistula in women with excision of deep endometriosis requiring concomitant vaginal and rectal sutures. Study Design: Retrospective comparative study including 363 patients with deep endometriosis infiltrating the rectum and the vagina. They were managed by either rectal disk excision or colorectal resection, concomitantly with vaginal excision, in two centers (Rouen and Bordeaux) each following differing policies concerning the use of stoma. The prevalence of rectovaginal fistula was assessed, and risk factors analysed. Results: 241 and 122 women received surgery in respectively Rouen and Bordeaux. The rate of preventive stoma was 71.4% in Rouen (N=172) and 30.3% in Bordeaux (N=37). Rectovaginal fistula were recorded in 31 cases (8.5%): 19 women in Rouen and 12 women in Bordeaux. Performing rectal sutures less than 8 cm above the anal verge increased the risk of rectovaginal fistula more than 3-fold, independently of other risk factors (OR 3.4, 95%CI 1.3-9.1). Conclusions: No statistically significant differences were found in terms of risk of rectovaginal fistula between women with rectovaginal endometriosis managed respectively by a generalized or restrictive use of preventive stoma. A higher risk of rectovaginal fistula independently related to a low rectal stapled line, less than 8 cm above the anal verge.

This opinion article is endorsed by the World Endometriosis Society (WES) and the International Federation of Fertility Societies (IFFS)The COVID-19 pandemic has led to a dramatic shift in the clinical practice of women’s health and routine care for endometriosis has been severely disrupted. Endometriosis is defined as an inflammatory disease characterised by lesions of endometrial-like tissue outside the uterus that is associated with pelvic pain and/or infertility.1 It affects approximately 10% of reproductive age women worldwide, is diagnosed by surgically visualisation or by radiological imaging, and is treated with hormone treatments or by laparoscopic removal of lesions.2,3Under the guidance of international gynaecological organisations4–6, many centres have temporarily ceased offering outpatient appointments, diagnostic imaging for non-acute pelvic pain, surgery for endometriosis, and fertility treatments. This means that endometriosis sufferers are be feeling particularly vulnerable and that resultant stress and anxiety may contribute to a worsening of symptoms. The pandemic poses several important questions for healthcare providers on how best to deliver care with these restrictions. Herein, we present clinical guidance on the management of endometriosis during the COVID-19 pandemic (Fig. 1).