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Preferred Treatment for Rectovaginal Endometriosis: Surgery versus Medical Therapy
K.-W. Schweppe
Frauenklinik Ammerland, Teaching Hospital of the University of G‫צ‬ttingen, Westerstede,
Germany
Deep infiltrating, retroperitoneale endometriosis is considered as a special entity of endometriosis with respect to the histological characteristics. The nodules are containing glands,
stroma,and muscle cells resembling adenomyotic foci (1,2). For the clinician the question is
of importance, whether this endometriotic nodules react to hormonal therapy or surgery is the
only option of choice as known from adenomyosis of the uterus.
Material and Methods
We performed a retrospective analysis of 78 cases treated in our clinic between 1988 and
1998 for rectovaginal endometriosis, of which we have follow up data between two and
thirteen years, with a mean follow up period of 5,2 years. Four different treatment options
were performed:
1.) Medical treatment with Danazol or GnRH-agonists for 6 months;
2.) permanent medical therapy i.e. low dose progestins or GnRH-agonists with add back
medication -continuously or intermittent (3),
3.) primary surgical treatment, i.e. resection of the nodule with disc resection of the rectum, or
rectum resection with anastomosis (4), and
4.) preoperative medical therapy with GnRH-agonists for reduction of the implants and the
blood supply for 3 to 6 months followed by surgery.
Results
24 patients were treated medically (8 with Danazol 600 mg/d and 16 with GnRH-agonists for
6 months); 22 reported reduction of symptoms and improvement of their quality of life
despite of different side effects. But all claimed recurrence of the disease within 3 to 12
months after cessation of therapy. Of these group 16 were than put on GnRH-agonists with
add back medication for permanent medical treatment; all responded again. Two were lost of
follow up, two relapsed and had surgery but 14 are still on this therapy.
Primary surgical treatment were performed in 19 cases and in the 6 women with recurrence
after medical therapy. Resection of the tumor was sufficient in 4 cases, disc resection of the
rectum was necessary in 9 cases and resection of the bowl with anastomosis was done in the
remaining 12 patients. During the follow up period we observed 7 recurrences (2 after resection of the nodule, 3 after resection of the anterior wall of the bowl, and 2 after resection and
anastomosis of the rectum). The last group of preoperative medication contains 35 patients; 6
of them received 6 months of danazol 600 mg/d, 9 patient were pre-treated with GnRH-agonists for 6 months (7 of them with add-back medication) and 20 were operated after 3 months
of GnRH-Agonist medication. During the follow up period the following recurrences were
observed: 1 of 3 cases with resection of the tumor only; 0 of 7 cases with resection of the
nodule including resection of the anterior wall of the rectum; and 2 of 27 patients with bowl
resection and anastomosis.
Conclusion
In case of rectovaginal endometriosis sufficient radical surgery is the preferred treatment. It is
necessary to remove all nodules completely and preoperative medical treatment with GnRHAgonists seems to reduce the recurrence rates. Medical treatment is insufficient with a 100
percent recurrence rate. Permanent medication however is an alternative to surgery, if the
patient accepts that treatment has to last until menopause.
Literature
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