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ObjectiveTo estimate the effectiveness and safety of laparoscopic surgical excision of rectovaginal endometriosis.DesignA multicentre, prospective cohort study.Setting51 hospitals accredited as specialist endometriosis centres.Participants5162 women of reproductive age with rectovaginal endometriosis of which 4721 women had planned laparoscopic excision.InterventionsLaparoscopic surgical excision of rectovaginal endometriosis requiring dissection of the pararectal space.Main outcome measuresStandardised symptom questionnaires enquiring about chronic pelvic pain, bladder and bowel symptoms, analgesia use and quality of life (EuroQol) completed prior to surgery and at 6, 12 and 24 months postoperatively. Serious perioperative and postoperative complications including major haemorrhage, infection and visceral injury were recorded.ResultsAt 6 months postsurgery, there were significant reductions in premenstrual, menstrual and non-cyclical pelvic pain, deep dyspareunia, dyschezia, low back pain and bladder pain. In addition, there were significant reductions in voiding difficulty, bowel frequency, urgency, incomplete emptying, constipation and passing blood. These reductions were maintained at 2 years, with the exception of voiding difficulty. Global quality of life significantly improved from a median pretreatment score of 55/100 to 80/100 at 6 months. There was a significant improvement in quality of life in all measured domains and in quality-adjusted life years. These improvements were sustained at 2 years. All analgesia use was reduced and, in particular, opiate use fell from 28.1% prior to surgery to 16.1% at 6 months. The overall incidence of complications was 6.8% (321/4721). Gastrointestinal complications (enterotomy, anastomotic leak or fistula) occurred in 52 (1.1%) operations and of the urinary tract (ureteric/bladder injury or leak) in 49 (1.0%) procedures.ConclusionLaparoscopic surgical excision of rectovaginal endometriosis appears to be effective in treating pelvic pain and bowel symptoms and improving health-related quality of life and has a low rate of major complications when performed in specialist centres.

We report two cases of large bowel cancer adjacent to mesh following previous abdominal sacrocolpopexy. As far as we are aware, there have been no previous reports of bowel cancer associated with mesh either in the form of a rectal erosion or mesorectal migration. In both cases, the mesh was part of the surgical field when operating for the large bowel cancer and had to be completely removed as it was intimately entangled with the surgical specimen to be removed. When carrying out procedures using mesh, it is important that we keep in mind that mesh surgery, especially for prolapse procedures, has been used for a relatively short duration of time, and there may still be unknown long-term complications associated with their usage. It is unlikely that the mesh is a causative agent in the above cases.

Uterine fibroids are one of the commonest tumours found in women of reproductive age. Due to their high prevalence they are frequently found incidentally during routine pelvic examinations or pelvic ultrasound - in a study, fibroids were detectable in 77 per cent of hysterectomy pathology specimens removed for any reason both pre- and pos-tmenopausally.1 Rightly or wrongly, many pelvic or gynaecological symptoms are attributed to fibroids. As doctors, therefore, we have to make sure that the fibroids are responsible for the symptomatology, especially as they are a very common indication for hysterectomy (in one large study of hysterectomy in the UK they were shown to be the commonest, at 38.5 per cent2). Abdominal hysterectomy and myomectomy have been the mainstay of treatment for many years, but over the past ten years improvements in ultrasound as well as new techniques have allowed women and their doctors a greater confidence in the diagnosis, and a greater range of therapeutic options. These now include conservative treatments such as gonadotrophin hormone-releasing hormone analogues (GnRHa) with or without `addback' therapy, and embolisation (which avoids surgery altogether), as well as minimal access techniques allowing myomectomy and hysterectomy to be done vaginally or endoscopically.