Endometriosis of the rectovaginal septum

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Endometriosis of the rectovaginal septum


Dr Rudy Leon de Wilde and Dr Johan van der Wat
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Lone Hummelshoj: We are at the 8th Regional Meeting of the International Society for Gynaecological Endoscopy. This meeting has been focusing specifically on endometriosis and was arranged by Dr. Johan van der Wat in Cape Town, South Africa. He’s with me this afternoon together with Dr. Rudy de Wilde from Germany and we are going to be talking about some of the congress highlights: in particular, some new data was presented on the prevalence of endometriosis in the rectovaginal septum.

Dr. Rudy Leon de Wilde: Johan, why do you think the incidence is increasing of rectovaginal endometriosis?

Dr. Johan van der Wat: Well, it was a very interesting observation that was made here that the incidence is increasing. I think there are two aspects: one is I think we diagnose it better and people think to examine the patients better, so they find the nodules. The second aspect is there may be an environmental factor or a genetic factor that is more prevalent now than it was before. There is a lot of talk, you know, dioxins and things like that. I think we have to investigate that to see if this is a real increase or may be just perceived because there are better diagnostic modalities. I think it has to be seriously investigated to find out why these ladies are presenting with rectovaginal septum endometriosis?

Dr. Rudy Leon de Wilde: So we know there are many women with rectal vaginal endometriosis that have severe pain. We saw that there are several treatment modalities that can be used in those patients, for example: resection, which means that the nodule will be taken out with a part of the bowel, but there was also a topic concerning shaving of this nodule. What do you think of those two treatment modalities?

Dr. Johan van der Wat: The topic was actually addressed as a debate. The speakers presented their own feelings. My personal opinion is that every patient is an individual; you have to individualise the treatment and some may just need shaving, and some may need resection. To me it is the amount of bowel wall involvement and the narrowing of the rectum or sigmoid that takes place. Surely, if you have got half your diameter you are likely to have symptoms, so it is mainly the narrowing. If the narrowing is relieved by shaving, well that is fine. But if it stays down, I think resection is mandated.

Dr. Rudy Leon de Wilde: Do you think medical therapy, such as GnRH-a should be given before or after the surgical therapy?

Dr. Johan van der Wat: I personally do not think it is necessary. I like to see in my operation all the disease, I want to see florid disease, and I want to know where my proper margins are. So we routinely will not use that.

Dr. Rudy Leon de Wilde: Do you think the best therapy, or the best way to go to the nodule is through the vagina, or through the abdominal wall? And is there still an indication for laparotomy in those cases?

Dr. Johan van der Wat: We do not go primarily from above. We will always start the procedure from below. That’s been our technique for up to five years now.

Dr. Rudy Leon de Wilde: You mean through the vagina?

Dr. Johan van der Wat: We start through the vagina. We mobilise the nodule, we then close the vagina very much like the keynote lecture has shown. Then once we have closed the vagina we can get a very good pneumoperitoneum, that is the stomach blown up, that will enable you to do the procedure. If you do it the other way you could lose the operating field by losing gas, so we would close it off and continue operating. We do not use the catheters as he has shown in his video.

Dr. Rudy Leon de Wilde: You are known as one of the experts here in South Africa. If I were a woman I would like to search for a good surgeon, how can I find a good surgeon?

Dr. Johan van der Wat: I think the best would be to stay on the website, www.EndometriosisZONE.org, Lone Hummelshoj will direct you. We have an Institute in South Africa where we handle mainly problems in the northern regions, but we have special doctors, which we have selected whom we will refer regional patients to. In Cape Town we have one. We are developing a site in Durban where we have surgeons that will be capable of looking after patients. So, we have a little referral base. But it is certainly a very specialised area and it needs very specialised people.

Dr. Rudy Leon de Wilde: Thank you very much Dr. Johan van der Wat for this interview.

Lone Hummelshoj: Thank you.

Dr. Johan van der Wat: Good to see you.


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