Kombinierte Therapie der Endometriose: Radikal und schonend zugleich

Zusammenfassung

Endometriose ist die zweithäufigste benigne Erkrankung des weiblichen Genitals nach der Leiomyomatose. Schwerpunkt dieser Übersicht ist die Darstellung des gynäkologischen Dilemmas zwischen medizinisch machbarem und für die individuelle Patientin sinnvollem Management. Im Vordergrund stehen die präoperative Diagnostik sowie die Planung der Operationsradikalität in Abhängigkeit des Leidensdruckes sowie des Kinderwunsches. Besonders herausgearbeitet werden die anatomischen Schnittmengenbereiche, die bei Verletzung zu (anhaltenden) Schädigungen des vorderen, mittleren und hinteren Kompartimentes führen können und damit nicht selten Ursache für urologische und urogynäkologische Folgemaßnahmen sind.

Zu den typischen Symptomen der Endometriose gehören: Dysmenorrhoe, chronische Unterbauchschmerzen, Dyspareunie, Subfertilität, unspezifische Unterbauchschmerzen, zyklische Darm- oder Blasensymptome (z. B. Dyschezie, Meteorismus, Obstipation, rektaler Blutabgang, Diarrhoen, Hämaturie), Blutungsstörungen oder chronische Müdigkeit.

Etwa 50 % aller weiblichen Jugendlichen und bis zu 32 % aller Frauen im reproduktionsfähigen Alter, die aufgrund chronischer Unterbauchschmerzen oder Dysmenorrhoe operiert werden; leiden an Endometriose. Das Zeitintervall zwischen den ersten unspezifischen Symptomen und der festen Diagnose beträgt bei der Endometriose etwa 7 Jahre. Hierfür ist nicht nur die ganz unspezifische Symptomatik verantwortlich, sondern v. a. auch die häufig fehlende Sensibilisierung der kooperierenden Fachdisziplinen, an die sich die Patientinnen im Erstkontakt wenden. Die Therapieoptionen beinhalten: Abwartendes Verhalten, Analgesie, hormonelle Therapie, operative Intervention und die Kombination aus Operation und medikamentöser Therapie. Die Rezidivrate für therapierte Endometriose liegt zwischen 5 % und > 60 % und ist stark abhängig von dem ganzheitlichen Management sowie der operativen Qualität. Zur Optimierung der individuellen Endometriosetherapie ist folglich Interdisziplinarität in Diagnostik und Therapie wegweisend und sollte v. a. bei der tief infiltrierenden Endometriose entsprechenden Zentren vorbehalten bleiben.

Abstract

Endometriosis is the second most common benign female genital disease after uterine myoma. This review discusses the management of individual patients. This should take into account the severity of the disease and whether the patient desires to have children. Particular emphasis is laid on the anatomical intersections which, when injured, can lead to persistent damage of the anterior, middle or posterior compartment and are not infrequently the cause of urological and urogynaecological follow-up measures.

Typical symptoms of endometriosis include chronic pelvic pain, subfertility, dysmenorrhoea, deep dyspareunia, cyclical bowel or bladder symptoms (e. g. dyschezia, bloating, constipation, rectal bleeding, diarrhoea and haematuria), abnormal menstrual bleeding, chronic fatigue and low back pain. Approx. 50 % of all female teenagers and up to 32 % of all women of reproductive age who have been operated for chronic pelvic pain or dysmenorrhoea suffer from endometriosis. The time interval between the first unspecific symptoms and the medical diagnosis of endometriosis is about 7 years. This is caused not only by the non-specific nature of the symptoms but also by the frequent lack of awareness on the part of the cooperating disciplines with which the patients have first contact. As the pathogenesis of endometriosis is not clearly understood, causal treatment is still impossible. Treatment options include expectant management, analgesia, hormonal medical therapy, surgical intervention and the combination of medical treatment before and/or after surgery. The treatment should be as radical as necessary and as minimal as possible. The recurrence rate among treated patients lies between 5 % and > 60 % and is very much dependent on integrated management and surgical skills. Consequently, to optimise the individual patient’s treatment, a high degree of interdisciplinary cooperation in diagnosis and treatment is crucial and should be reserved to appropriate centres – especially in the case of deep infiltrating endometriosis.

Schlüsselwörter

Endometriose - Laparoskopie - interdisziplinäre Chirurgie - Subfertilität - Unterbauchschmerzen

Keywords

endometriosis - laparoscopy - Interdisciplinary surgery - subfertility - lower abdominal pain

• Literaturverzeichnis

• 1 Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993; 328: 1759-1769
• 2 Possover M. Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 2014; 101: 754-758
• 3 Roman H, Vassilieff M, Tuech JJ. et al. Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril 2013; 99: 1695-1704
• 4 Alkatout I. [Communicative and ethical aspects of physician-patient relationship in extreme situations]. Wien Med Wochenschr 2015; 165: 491-498
• 5 Alkatout I. Complications of Laparoscopy in Connection with Entry Techniques. J Gynecol Surg 2017; 33: 81-91
• 6 Clement PB. The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol 2007; 14: 241-260
• 7 Engemise S, Gordon C, Konje JC. Endometriosis. BMJ 2010; 340: c2168
• 8 Alkatout I, Mettler L, Beteta C. et al. Combined surgical and hormone therapy for endometriosis is the most effective treatment: prospective, randomized, controlled trial. J Minim Invasive Gynecol 2013; 20: 473-481
• 9 Mol BW, Bayram N, Lijmer JG. et al. The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis. Fertil Steril 1998; 70: 1101-1108
• 10 Vercellini P, Pietropaolo G, De Giorgi O. et al. Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile?. Am J Obstet Gynecol 2006; 195: 1303-1310
• 11 Mahmood TA, Templeton A. The impact of treatment on the natural history of endometriosis. Hum Reprod 1990; 5: 965-970
• 12 Hughes E, Brown J, Collins JJ. et al. Ovulation suppression for endometriosis. Cochrane Database Syst Rev; 2007 DOI: 10.1002/14651858.CD000155.pub2 CD000155
• 13 Medicine PCoASfR. Treatment of pelvic pain associated with endometriosis. Fertil Steril 2008; 90: S260-269
• 14 Vercellini P, De Matteis S, Somigliana E. et al. Long-term adjuvant therapy for the prevention of postoperative endometrioma recurrence: a systematic review and meta-analysis. Obstet Gynecol Scand 2013; 92: 8-16
• 15 Kennedy S, Bergqvist A, Chapron C. et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005; 20: 2698-2704
• 16 Soares SR, Martinez-Varea A, Hidalgo-Mora JJ. et al. Pharmacologic therapies in endometriosis: a systematic review. Fertil Steril 2012; 98: 529-555
• 17 Dousset B, Leconte M, Borghese B. et al. Complete surgery for low rectal endometriosis: long-term results of a 100-case prospective study. Ann Surg 2010; 251: 887-895
• 18 Mabrouk M, Montanari G, Guerrini M. et al. Does laparoscopic management of deep infiltrating endometriosis improve quality of life? A prospective study. Health Qual Life Outcomes 2011; 9: 98
• 19 Meuleman C, Tomassetti C, Wolthuis A. et al. Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis: a prospective cohort study. Ann Surg 2014; 259: 522-531
• 20 Fritzer N, Tammaa A, Salzer H. et al. Dyspareunia and quality of sex life after surgical excision of endometriosis: a systematic review. Eur J Obstet Gynecol Reprod Biol 2014; 173: 1-6
• 21 Alkatout I, Bojahr B, Dittmann L. et al. Precarious preoperative diagnostics and hints for the laparoscopic excision of uterine adenomatoid tumors: two exemplary cases and literature review. Fertil Steril 2011; 95: 1115-1118 1119 e
• 22 Meuleman C, Tomassetti C, D'Hoore A. et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011; 17: 311-326
• 23 Alkatout I, Schollmeyer T, Hawaldar NA. et al. Principles and safety measures of electrosurgery in laparoscopy. JSLS 2012; 16: 130-139
• 24 Lin SY, Lee RK, Hwu YM. et al. Reproducibility of the revised American Fertility Society classification of endometriosis using laparoscopy or laparotomy. Int J Gynaecol Obstet 1998; 60: 265-269
• 25 Donnez J, Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules. Hum Reprod 2010; 25: 1949-1958
• 26 De Cicco C, Corona R, Schonman R. et al. Bowel resection for deep endometriosis: a systematic review. BJOG 2010; 118: 285-291
• 27 Meuleman C, Tomassetti C, D'Hooghe TM. Clinical outcome after laparoscopic radical excision of endometriosis and laparoscopic segmental bowel resection. Curr Opin Obstet Gynecol 2012; 24: 245-252
• 28 Ruffo G, Scopelliti F, Manzoni A. et al. Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases. Biomed Res Int 2014; 2014: 463058