title: Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification.
abstract: BACKGROUND
  Deeply infiltrating endometriosis (DIE) is recognized as a specific entity responsible for pain. The distribution of locations and their contribution to surgical management has not been previously studied.
  
  
  METHODS
  Medical, operative and pathological reports of 241 consecutive patients with histologically proven DIE were analysed. DIE lesions were classified as: (i). bladder, defined as infiltration of the muscularis propria; (ii). uterosacral ligaments (USL), as DIE of the USL alone; (iii). vagina, as DIE of the anterior rectovaginal pouch, the posterior vaginal fornix and the retroperitoneal area in between, and (iv). intestine, as DIE of the muscularis propria.
  
  
  RESULTS
  A total of 241 patients presented 344 DIE lesions: USL (69.2%; 238); vaginal (14.5%; 50); bladder (6.4%; 22); intestinal (9.9%; 34). The proportion of isolated lesions differed significantly according to the DIE location: 83.2% (198) for USL DIE; 56.0% (28) for vaginal DIE; 59.0% (13) for bladder DIE; 29.4% (10) for intestinal DIE (P < 0.0001). The total number of DIE lesions varied significantly according to the location (P < 0.0001). In 39.1% of cases (9/23) intestinal lesions were multifocal. Only 20.6% (seven cases) of intestinal DIE were isolated and unifocal.
  
  
  CONCLUSIONS
  Multifocality must be considered during the pre-operative work-up and surgical treatment of DIE. We propose a surgical classification based on the locations of DIE. Operative laparoscopy is efficient for bladder, USL and vaginal DIE. However, indications for laparotomy still exist, notably for bowel lesions.
authors.affiliation: Service de Chirurgie Gynécologique, Service de Chirurgie Digestive and Service Central d'Anatomie et Cytologie Pathologiques, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France. charles.chapron@cch.ap-hop-paris.fr
authors.forename: Charles
authors.initials: C
authors.lastname: Chapron
authors.forename: Arnaud
authors.initials: A
authors.lastname: Fauconnier
authors.forename: Marco
authors.initials: M
authors.lastname: Vieira
authors.forename: Habib
authors.initials: H
authors.lastname: Barakat
authors.forename: B
authors.initials: B
authors.lastname: Dousset
authors.forename: Valeria
authors.initials: V
authors.lastname: Pansini
authors.forename: M C
authors.initials: MC
authors.lastname: Vacher-Lavenu
authors.forename: J B
authors.initials: JB
authors.lastname: Dubuisson
mesh_terms: D000291:Adnexal Diseases / Q000150:complications / Q000473:pathology* / Q000601:surgery; D000328:Adult; D004715:Endometriosis / Q000145:classification / Q000150:complications / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D007410:Intestinal Diseases / Q000150:complications / Q000473:pathology* / Q000601:surgery; D008875:Middle Aged; D017699:Pelvic Pain / Q000209:etiology; D001745:Urinary Bladder Diseases / Q000150:complications / Q000473:pathology* / Q000601:surgery; D014623:Vaginal Diseases / Q000150:complications / Q000473:pathology* / Q000601:surgery