Preoperative imaging is necessary to assess bowel and urological impact of deeply infiltrative endometriosis, as described above. CT urogram to exclude ureteral endometriosis and ﬂexible sigmoidoscopy or double-contrast colon radiography to exclude transmural rectosigmoidal endometriosis, supplemented with MRI in selected cases, are preferred (285). As endometriosis sometimes involves nongynecologic organs (i.e., the bowel, the urinary tract, or pelvic bones), other surgical specialists should be consulted as appropriate. These severe cases should be handled in centers with special expertise. Preoperative intestinal preparation may be recommended. Placement of ureteric catheters may facilitate the excision of periureteral endometriosis to facilitate ureterolysis and end-to-end ureteral reanastomosis that may be needed in cases of infiltrative periureteral endometriosis causing ureteral obstruction. The pattern of pain in endometriosis is complicated and pain does not always respond to treatment, so consultation with pain specialists may be useful.
Removal of full-thickness bladder detrusor endometriosis entails excision of the bladder dome or posterior wall, generally well above the trigone. Transurethral resection is contraindicated. A radical approach to obstructive uropathy is suggested, with resection of the stenotic ureteral tract and reimplantation with antireﬂux vesicoureteral plasty (309).
Surgical excision of deep rectovaginal and rectosigmoidal endometriosis is difficult and can be associated with major complications such as bowel perforations with resulting peritonitis (310). It is debated whether this type of endometriosis is best treated by shaving, conservative excision or resection reanastomosis, by laparoscopy and laparotomy, or laparoscopically assisted vaginal technique (311).
In a randomized study comparing colorectal resection for endometriosis by laparoscopy or laparotomy, clinical outcome was similar with respect to dyschezia, bowel pain and cramping, and dysmenorrhea and dyspareunia, but laparoscopy was associated with less blood loss, fewer complications, and a higher pregnancy rate than laparotomy (312).