A retrospective study in the journal Obstetrics & Gynecology and Reproductive Health has concluded that total laparoscopic retrograde hysterectomy (TLreH) for severe endometriosis with obliterated cul-de-sac is both feasible and safe.
However, the study found that performing TLreH on a large, immobile uterus is more difficult, in part because of the limited surgical field of view.
The operation time and blood loss were also significantly increased in uteri weighing 600 g or more (P < 0.01).
The case-control observational study was performed at the Yokohama Municipal Citizen's Hospital in Japan between January 2014 and December 2019.
All the enrolled 92 women underwent TLreH and had uterine fibroids or adenomyosis, or both, with obliterated cul-de-sac due to severe endometriosis.
The median operation time was 122 minutes (ranging from 54 to 312 minutes) and the median blood loss was 150 mL (ranging from 0 to 1420 mL).
Perioperative complications occurred in 3.3% (n = 3) of cases, defined as Clavien-Dindo classification ≥Ⅲ. There were no cases of transition to open surgery, and only one case of blood transfusion.
Patients were also divided into two groups: uteri weighing ≥600 g (n = 25) and those weighing <600 g (n = 67). In the heavier weight uteri group, the median operation time and median estimated blood loss volume were 130 minutes (ranging from 81 to 312 minutes) and 265 mL (ranging from 70 to 420) mL), respectively.
This compared to a median operation time and median estimated blood loss volume of 99 minutes (ranging from 54 to 219 minutes) and 100 mL (ranging from 0 to 1160 mL), respectively, in the lighter weight uteri group.
“Regardless of endometriosis, carrying the large uterus out of the vagina takes longer, which also contributes to a longer surgery time,” wrote the authors.
No differences were found in the frequency of perioperative complications or blood transfusions between the two groups.
Age, body mass index (BMI) and the rate of prior treatment of gonadotropin hormone-releasing hormone agonist or dienogest were also not significantly different between the two groups.
However, gravida and parity numbers were significantly lower in the heavier weight uteri group than the lighter weight uteri group(P = 0.008 vs. 0.010).
With TLreH, it is conceivable that hysterectomy can be safely performed by a routine surgical procedure, regardless of the severity of endometriosis. But for the study, TLreH did not actively remove deep endometriosis lesions. “Even if no endometriotic lesions remain macroscopically, they might remain at the microscopic level,” wrote the authors.
Similarly, laparoscopic modified radical hysterectomy (TLmRH) does not provide relief from rectal adhesions; for example, it would be difficult for a rectal probe to reach adhesions between the upper rectum or sigmoid colon and the uterus.
On the other hand, the risk of bowel damage and lower abdominal nerve damage can be avoided with TLreH, although chronic pelvic pain due to deep endometriosis may persist.
Besides being a retrospective study at a single institution, the study was not comparative; hence it is difficult to ascertain the usefulness of TLreH, according to the authors, adding that the procedure needs to be investigated as a curative treatment for endometriosis in the long term.
Yamamoto M, Yoshida H. Feasibility and safety of total laparoscopic retrograde hysterectomy in a large uterus with obliterated cul-de-sac due to severe endometriosis. Eur J Obstet Gynecol Reprod Biol. 2020 Dec 29;258:43-47. doi:10.1016/j.ejogrb.2020.12.042