Operative Therapie der Endometriose: radikal und schonend zugleich

Operative therapy of endometriosis: radical and gentle at the same time

Zusammenfassung

Hintergrund

Endometriose ist die zweithäufigste benigne Erkrankung des weiblichen Genitale nach der Leiomyomatose.

Ziel

Schwerpunkte dieser Übersicht sind die präoperative Diagnostik sowie die Planung der Operationsradikalität in Abhängigkeit des Leidensdrucks sowie des Kinderwunsches der Patientin. Zu den typischen Symptomen der Endometriose gehören Dysmenorrhö, chronische Unterbauchschmerzen, Dyspareunie, Subfertilität, unspezifische Unterbauchschmerzen, zyklische Darm- oder Blasensymptome (z. B. Dyschezie, Meteorismus, Obstipation, rektaler Blutabgang, Diarrhöen, Hämaturie), Blutungsstörungen und chronische Müdigkeit.

Ergebnisse

Etwa 50 % aller weiblichen Jugendlichen und bis zu 32 % aller Frauen im reproduktionsfähigen Alter, die aufgrund chronischer Unterbauchschmerzen oder Dysmenorrhö operiert werden, leiden an Endometriose. Das Zeitintervall zwischen den ersten unspezifischen Symptomen und der definitiven Diagnose beträgt bei der Endometriose etwa 7 Jahre. Hierfür ist nicht nur die ganz unspezifische Symptomatik verantwortlich, sondern vor allem auch die häufig fehlende Sensibilisierung der kooperierenden Fachdisziplinen, an die sich die Patientinnen im Erstkontakt wenden. Die Therapieoptionen beinhalten abwartendes Verhalten, Analgesie, hormonelle Behandlung, operative Intervention und die Kombination aus Operation und medikamentöser Therapie. Die Rezidivrate für therapierte Endometriose liegt zwischen 5% und > 60 %, sie ist in hohem Maße abhängig von einem ganzheitlichen Management und der operativen Qualität.

Diskussion

Zur Optimierung der individuellen Endometriosetherapie ist Interdisziplinarität in Diagnostik und Therapie wegweisend, sie sollte vor allem bei der tief infiltrierenden Endometriose entsprechenden Zentren vorbehalten bleiben.

Abstract

Background

Endometriosis is the second most common benign female genital disease after uterine leiomyoma.

Objectives

This review discusses the individual management for each patient which should take into account the severity of the disease and whether the patient desires to have children. Endometriosis is defined as the presence of endometrial glands and stroma outside the internal epithelial lining of the cavity of the uterus. As a consequence, endometriosis can cause a wide range of symptoms, such as chronic pelvic pain, subfertility, dysmenorrhea, deep dyspareunia, cyclical bowel or bladder symptoms (e.g. dyschezia, bloating, constipation, rectal bleeding, diarrhea and hematuria), abnormal menstrual bleeding, chronic fatigue and low back pain.

Results

Approximately 50 % of teenage women and up to 32 % of women of reproductive age operated on for chronic pelvic pain or dysmenorrhea, suffer from endometriosis. The time interval between the first unspecific symptoms and the medical diagnosis of endometriosis is approximately 7 years. This is caused not only by the non-specific nature of the symptoms but also by the frequent lack of awareness on the part of the cooperating disciplines with which the patients have first contact. As the pathogenesis of endometriosis is not clearly understood, a causal treatment is still not possible. Treatment options include watchful waiting, analgesia, hormonal medical therapy, surgical intervention and the combination of medical treatment before and/or after surgery. The treatment should be as radical as necessary and as minimal as possible. The recurrence rate among treated patients lies between 5 % and > 60 % and is very much dependent on the integrated management and surgical skills.

Conclusion

To optimize the individual patient treatment a high degree of interdisciplinary cooperation in the diagnosis and treatment is crucial and should be reserved for appropriate centres especially in the case of deep infiltrating endometriosis.

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Danksagung

Die Autoren danken für die Bereitstellung von Abb. 1 Mathias Podlovics (a, b) und Professor Dr. Thilo Wedel (c, d).

Einhaltung ethischer Richtlinien

Interessenkonflikt, I. Alkatout, I. Meinhold-Heerlein, I. von Leffern und N. Maass gebem an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen der Tieren.

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Correspondence to PD Dr. I. Alkatout M.A..

Zusatzmaterial online

Video 1: Ureterolyse bei tief infiltrierender Endometriose der Sakrouterinligamente (WMV 46KB)

Video 2: Partielle Resektion eines die Harnblase infiltrierenden Endometrioseknotens (AVI 26KB)

Video 3: End-zu-End Anastomose nach laparoskopischer anteriorer Rektumresektion eines transmural gewachsenen Endometrioseknotens (AVI 22KB)

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Alkatout, I., Meinhold-Heerlein, I., von Leffern, I. et al. Operative Therapie der Endometriose: radikal und schonend zugleich. Gynäkologe 48, 228–236 (2015). https://doi.org/10.1007/s00129-014-3419-8

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Schlüsselwörter

  • Adenomyosis uteri
  • Laparoskopie
  • Interdisziplinäre Chirurgie
  • Subfertilität
  • Dysmenorrhö

Keywords

  • Adenomyosis
  • Laparoscopy
  • Interdisciplinary surgery
  • Subfertility
  • Dysmenorrhea