Combined vaginal-laparoscopic-transanal approach for reducing bladder dysfunction after conservative surgery in large deep rectovaginal endometriosis.

IntroductionAs far back as 2000, Possover et al. reported a mixed vagi-nal and laparoscopic route in colorectal resection for deependometriosis, aiming at a better preservation of bladderand rectal nerves [1]. The number of scientific articlesreporting series of patients managed for deep endometriosisworldwide has progressively increased for the last 15 years.However, the combined vaginal-laparoscopic approach wasrather overlooked. Alternative techniques have been pro-posed to resect vaginal infiltrations, such as the reversetechnique [2], however, the risk of bladder dysfunction byinadvertent section of the splanchnic nerves or the inferiorhypogastric plexus continues to exist. Depending on deependometriosis’ features, the risk of bladder dysfunction mayreach up to more than 25%, especially in large nodulesinvolving the lateral vaginal cul-de-sac and both utero-sacral ligaments. In these circumstances, ‘‘nerve sparingtechniques’’ employing proximal dissection of hypogastricnerves are really not worthwhile, because the nerves areusually injured distally, at the level of the lateral cul-de-sacof the vagina. Even though the surgeon does not specifically section the nerves, they may be injured by merely lateralthermal spread of energies used in tissue section and vesselhemostasis.In order to attempt a reduction of the risk of post-operative bladder dysfunction, we introduced in February2014 a combined vaginal-laparoscopic route to systemat-ically resect deep nodules responsible for large vaginalinfiltrations with a diameter of over 30 mm. In these cases,both sides of the cul-de-sac are usually involved and therisk of bladder dysfunction cannot be overlooked. An addi-tional Transanal approach may be performed, when thedisease infiltrates the rectum located immediately behind.To reduce the risk of thermal spread, we use plasma energy(Plasmajet®, PlasmaSurgical Inc, Roswell, GA, USA) to sec-tion, dissect and coagulate the tissues