The depth of the iceberg: Parametrial involvement in deep endometriosis

The depth of the iceberg: Parametrial involvement in deep endometriosis

Parametrial endometriosis needs intricate surgical intervention

Key Points


  • Deep endometriosis is troublesome due to its invasion under the peritoneal surface or penetration through the muscular layer of visceral organs.
  • Parametrial deep endometriosis is more complex as it has intricate surgical anatomic features.


  • Many endometriosis surgeons have misconceptions about the surgical anatomy of the parametrium and related structures, and this particular area has heterogeneous definitions.

What's done here:

  • In this comprehensive review, the authors have tried to explain the surgical anatomy of the parametrium, emphasize the essential preoperative evaluations, and define the surgical approaches for deep endometriosis.

Main key feature :

  • Nerve-sparing surgery is essential in parametrial involvement of deep endometriosis to prevent iatrogenic damage and minimize the risk of functional complications.

Lay Summary

Academicians led by members of the International School of Surgical Anatomy from Italy have published their paper on parametrial involvement of deep endometriosis in the medical periodical named Best Practice & Research Clinical Obstetrics & Gynecology”. 

Deep endometriosis is troublesome when compared to the other endometriosis types due to the invasive properties beneath the peritoneum and also through the muscular layer of visceral organs. Few studies emphasize parametrial involvement is not a rare finding in patients with deep endometriosis who undergo surgery. This problem is more important when the disease is in the parametrium, due to its complex anatomy. There is a need for utmost surgical expertise in managing the potential involvement of autonomic nerves, uterine arteries, and ureters.

Surgeons need a comprehensive diagnostic parametrial evaluation preoperatively for optimal management of patients with suspected deep endometriosis. Parametrial involvement at surgery without preoperative delicate assessments may be undetected if the operator lacks the appropriate diagnostic approaches.

The recent account of the role of TVS in evaluating parametrial endometriosis has revealed distinctive features that increase the feasibility of this non-invasive diagnostic procedure. The absence of standardization concerning pelvic anatomic nomenclature especially for the paracervical region and the appropriate ultrasound and surgical methodology for examination of this complex anatomical structure seem to be the major obstacles.

There is a need for further studies to elucidate the particular impact of parametrectomy on patient outcomes since observational studies have mainly examined this procedure in combination with radical treatment of other anatomic involvements, such as rectosigmoid endometriosis.

Since the clinical presentation is not straightforward, a comprehensive diagnostic assessment of the parametrium is essential, particularly in centers with advanced diagnostic and surgical capabilities.

Research Source:

parametrium endometriosis parametrectomy nerve-sparing surgery


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