Diagnosis & Therapy

Surgical excision of the most severe form of endometriosis

Surgical excision of the most severe form of endometriosis

Robot-assisted laparoscopic removal of endometriotic rectovaginal nodule

BY Obianuju Sandra Madueke-Laveaux, MD, MPH; Khara M. Simpson, MD; and Arnold Advincula, MD

Rectovaginal endometriosis (RVE) is the most severe form of endometriosis. Patients with RVE often present with severe or lower abdominal pain, backache, constipation, dyschezia, and dyspareunia. The use of transrectal or transvaginal ultrasound, computed tomography, colonography, and magnetic resonance imaging (MRI) can aid with diagnosis of RVE.

The gold standard for diagnosis remains laparoscopy with histologic confirmation.

Treatment options include use of analgesics for pain control; hormonal therapy, such as birth control pills, oral or injectable progestins, androgens, and GnRh agonists; and surgery, which can either be ablative or excisional, ranging from shaving of superficial lesions to lower anterior bowel resections.


Perspectives on Endometriosis Management

The literature suggests that, overall, surgery improves up to 70% of symptoms, and outcomes are generally favorable; however, postoperative complications do occur and are worse with more radical surgical approaches.

Excision of RVE is complex and poses a unique surgical challenge to the gynecologist.

In our video, we present the case of a healthy 23-year-old nulligravid woman with a 1-year history of dyschezia and dyspareunia. Speculum exam by her primary gynecologist revealed a nodule in her posterior fornix. MRI obtained showed a T1 and T2 intense multiseptated cystic mass at the posterior vaginal fornix, measuring 18 x 15 x 18 mm, with characteristics suggestive of blood products. Attempted laparoscopic excision at an outside hospital was aborted due to an anticipated complexity in the case. She was referred to our clinic for further surgical management.

The patient had no significant past medical history, and her surgical history only was significant for the previously mentioned diagnostic laparoscopy.

Speculum exam in the office confirmed the finding of a 3 x 3 cm rectovaginal nodule in the posterior fornix.

The nodule was palpated on bimanual exam, as was nodularity of the left uterosacral ligament; no rectal extension was palpated.

The decision was made to proceed with diagnostic robot-assisted laparoscopic excision of the rectovaginal nodule.
In the operating room, exam under anesthesia revealed findings as illustrated in the video.


Dr. Madueke-Laveaux is Assistant Attending, Department of Obstetrics & Gynecology, Columbia University Medical Center, New York, New York.

Dr. Simpson is Assistant Professor, Minimally Invasive Gynecology, Johns Hopkins Hospital, Baltimore, Maryland.

Dr. Advincula is the Levine Family Professor of Women’s Health and Vice Chair, Department of Obstetrics & Gynecology, Columbia University Medical Center and Chief of Gynecology, Sloane Hospital for Women at New York-Presbyterian Hospital/Columbia University. He serves on the OBG Management Board of Editors.


Dr. Advincula reports being a consultant to Intuitive Surgical and Titan Medical and having additional financial relationships with Applied Medical, ConMed, and CopperSurgical. The other authors report no relevant financial relationships relevant to this video.