The treatment of the rectovaginal endometriotic nodule continues to be controversial. While proponents of “shaving” the nodule are quick to point out that compared with segmental bowel resection, pelvic pain, dyspareunia, dysmenorrhea, and postoperative pregnancy rates are similarly reduced, most comparative studies are retrospective and are not randomized. That is, patients with larger nodules or multifocal disease with deep infiltration into the muscularis layer of the bowel, or involving more than half of the bowel wall circumference, with surrounding severe fibrosis, invariably are more likely to undergo segmental bowel resection. Even with performance of segmental bowel resection to treat more extensive disease, there is a trend toward greater improvement of pain-related symptoms when compared with the “shaving” technique. Furthermore, the risk of rectal recurrence is acknowledged to be greater in patients undergoing endometriotic rectal nodule shaving.

Concern must be raised with segmental bowel resection. Not only is the risk of temporary ileostomy increased, but subsequent anastomotic leakage and rectovaginal fistula is noted in up to 10% of women. Although reduced with nerve sparing techniques, bladder denervation secondary to damage of the parasympathetic plexus causes urinary retention. In a study of 436 cases of laparoscopic colorectal resection, 9.5% presented after 30 days with persistent urinary retention and 4.2% with constipation (Surg Endosc. 2010 Jan;24:63-7).

For the properly selected patient (based on symptoms, examination, and imaging), discoid resection provides the surgeon the ability to excise the endometriotic nodule with the benefit of less complications. As will be noted, when compared with segmental rectosigmoid resection for deep infiltrating endometriosis, the risk of temporary ileostomy, bowel complications, and rectal and bladder dysfunction are all decreased. Moreover, recurrence rates and subjective symptoms are similar.

For this edition of the Master Class in Gynecologic Surgery, I have invited Ted Lee, MD, director of minimally invasive gynecologic surgery, Magee-Womens Hospital of the University of Pittsburgh Medical Center, to discuss laparoscopic rectosigmoid resection for a deep endometriotic nodule. While many surgeons utilize a single-use curved circular stapler, I appreciate Dr. Lee’s innovative technique, for both its ease of use and its safety.

Dr. Lee has received multiple awards for his efforts, including best surgical video presentation by the AAGL. He is also the only five-time winner of the prestigious Golden Laparoscope Award for best surgical video from the AAGL.

A highly-regarded lecturer and surgeon, Dr. Lee has taught and performed live surgeries around the world.

Dr. Lee’s practice is entirely dedicated to minimally invasive surgical options for women. He is a firm believer that virtually all benign gynecologic surgical conditions should be treated using a minimally invasive approach. Dr. Lee’s clinical expertise includes minimally invasive surgery for treatments of endometriosis (including severe endometriosis involving bowel, bladder, and ureter); fibroids; abnormal uterine bleeding; urinary incontinence; and pelvic organ prolapse.

It is a great honor for the Master Class in Gynecologic Surgery to have Dr. Lee as guest author for this important area of our surgical arena.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.

Discoid resection of rectal endometriotic nodules