Excision of deep rectovaginal endometriosis nodules with large infiltration of both rectum and vagina: what is a reasonable rate of preventive stoma? A comparative study

Elsevier

Available online 17 November 2022

Journal of Minimally Invasive GynecologyAbstractStudy Objective

To compare postoperative complications and rectovaginal fistula rate in women undergoing excision of large rectovaginal endometriosis requiring concomitant excision of rectum and vagina during two time periods with differing policies for preventive stoma confection.

Design

Retrospective before-and-after comparative cohort study on data prospectively recorded in a database. Patients managed from September 2018 to March 2020 (first period) were compared to those managed from April 2020 to June 2022 (second period).

Setting

Endometriosis Institute.

Patients

168 patients presenting deep endometriosis infiltrating the rectum and vagina, with lesions more than 3 cm in diameter during 2 consecutive time periods with differing policies regarding use of preventive stoma.

Interventions

Rectal disc excision or colorectal resection, concomitantly with large vaginal excision.

Measurement and main results

87 and 81 women received surgery during the first and the second period respectively, during which the rate of preventive stoma was respectively 32.2% vs. 8.6%. Deep rectovaginal nodule characteristics were comparable. The mean height (SD) of rectal sutures after disc excision and colorectal resection were respectively 6.5 cm (2.3 cm) and 7.2 cm (3.8 cm). Rectovaginal fistula was recorded in 17 patients, corresponding to an overall rate of 10.1%. The rates of rectovaginal fistula in the group of patients with and without preventive stoma, regardless of the period in which surgery was performed, were respectively 11.4% vs. 9.8% (P=0.76). The rates of fistula recorded during the first and the second period were respectively 9.2% vs 11.1% (P=0.80), and that of overall early main complications 31% vs 29.6% (P=0.84). Regression logistic model identified an independent relationship between smoking and rectovaginal fistula (adjusted OR 3.9, 95%CI 1.1-14) after adjustment for the period (adjusted OR 1.4, 95% CI 0.4-4.9 related to the second period), stoma confection (adjusted OR 1.8, 95% CI 0.5-7.1 related to stoma confection), robotic surgery (adjusted OR 1.7, 95%CI 0.3-10.1 related to robotic assistance) and type of rectal surgery (adjusted OR 0.4, 95% CI 0.1-1.4 related to disc excision when compared to colorectal resection).

Conclusions

No statistically significant differences were found concerning risk of rectovaginal fistula in women with rectovaginal endometriosis requiring large rectal and vaginal excision following a decision to no longer routinely perform preventive stoma.

Keywords

deep endometriosis

rectum

disc excision

rectovaginal fistula

stoma

© 2022 Published by Elsevier Inc. on behalf of AAGL.

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