Aplastic Nodules: Surgical Interventions - Practical Approaches

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Professor Jacques Donnez: "This morning, Professor Mettler, you showed us a beautiful picture of an endorecto-sonography and it showed that we're not very experienced in this type of gynecology. It was one of your questions, and I think these exams are really helpful to detect, as you call it, the peritumoral infiltration of the rectal wall. Sometimes it's a fibrotic invasion by the fibrosis and in some case it's not necessary to remove the rectum, as you mentioned this morning."

Professor Liselotte Mettler: "Yes, endorecto-sonography is a technique that rectal surgeons are applying a lot. It shows exactly if the mucosa is infiltrated or not or if it's a perirectal lesion but for the patient this mostly fibrotic invasion is a typical example of a new disease that you are now calling RAD. It is one that we have to attack either surgically or by hormonal treatment. Of the different techniques that are available diagnostically of the retroperitoneal space including the ureteric area, which techniques do you think are the most suitable ones and which ones are you applying?"

Professor Jacques Donnez: “In fact, in case of a big nodule, I will systematically ask for a barium enema and intravenous pyelography. A CT scan can be helpful to see the lateral extension but don’t forget that the first tool for diagnosis is the pelvic, vaginal, and rectal examinations. I’m not sure that we have to examine the patient during menstruation, if we look very well in this space and we explore the rectovaginal septum with the fingers, if a nodule is present we will surely feel it.”

Professor Liselotte Mettler: "Now my last question to you is what do you think about treating these patients not surgically? We both agree that it is the method of choice for a young patient. In little advanced aged patients with severe pain that want to avoid the surgery, would you give them a trial with an endocrine approach?"

Professor Jacques Donnez: "As you said, in young patients that are less than thirty-five years of age and in the majority of the patients who experience this type of pathology, I would recommend laparoscopic excision, not the very aggressive one with rectal excision, I prefer a debulking surgery. I would take care of the lateral extension because already in my series so far five patients have experienced the loss of a kidney because it was completely silent. They had pain in the pelvis, severe dysmenorrhea, and dyspareunia but never pain in the back. Nevertheless, they lost a kidney so I should recommend surgery but should I also agree that in some instances in older patients or patients with recurrent disease who have symptomatic impression of pelvic pain of deep dyspareunia, I should have endocrine therapy, as you mentioned, long term therapy with GnRH agonists and progestogens combined. Nevertheless, we have to know that these progestogen receptors even if present are probably inactive so that we don't reduce it by endocrine therapy. We don't reduce the size of the nodule but we stop the symptoms and it depends on what the best benefits are for the patient."

Professor Liselotte Mettler: "You mentioned that you mainly use laparoscopic surgery for these lesions. If it's a nodule of 3 cm in extension and going into the rectal wall, it may not be possible to avoid a rectal resection. Do you then do this by laparoscopy or in combination or how do you do this surgery?"

Professor Jacques Donnez: "When we decide to do a resection of a part of the rectum it's because a complete invasion includes the rectal mucosa; if there is no rectal mucosa involvement, we don't do a resection of the rectum even if the tubal wall shows signs of perivisceritis. If there is invasion of the rectum, we will perform a laparotomy but I agree with you, like in your video, probably with the collaboration of the rectal surgeon we can in the future do the resection on this part of the rectum by laparoscopy also."

Professor Liselotte Mettler: "Jacques, thank you for the nice interview. OBGYN.net has a good future and we're happy to have interviewed Professor Donnez today."

Professor Jacques Donnez: "Thank you."