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BackTable / OBGYN / Article
Deep Infiltrating Endometriosis: Imaging, Surgery & The Art of Knowing When to Pause
Sam Strauss • Updated Apr 16, 2025 • 35 hits
Deep endometriosis can be a complex and challenging part of the endometriosis “umbrella”. It involves lesions that can infiltrate the bladder, bowel, or vaginal cuff. Not only are these lesions painful, but they are also often difficult to detect through standard examinations, making accurate and thorough imaging essential for proper diagnosis and effective treatment planning. While surgical intervention is sometimes required, the intricacies of deep endometriosis necessitate careful consideration, particularly when it comes to decision-making during surgery. Surgeons must be prepared to address these lesions with precision and caution, as incomplete excision or improper management can lead to recurrence or additional complications.
In this article, Dr. Emad Mikhail offers his expertise on the evaluation and surgical management of deep endometriosis. He outlines the importance of advanced imaging, the role of a multidisciplinary team, and the surgical judgment required to navigate complex cases of deep endometriosis. Dr. Mikhail also provides his point of view on the delicate balance of knowing when to proceed with aggressive surgery and when to pause, acknowledging that sometimes the best decision is to stop rather than risk unnecessary complications.
This article features excerpts from the BackTable OBGYN Podcast. You can listen to the full episode below.
The BackTable OBGYN Brief
• Deep endometriosis lesions typically involve the bladder, bowel, or vaginal cuff. These lesions are often missed on standard exams, so advanced imaging like high-resolution ultrasound and MRI are essential for accurate diagnosis and determining the extent of disease.
• Specialized imaging techniques, such as MRIs with vaginal or rectal dye, can highlight deep lesions that may not be visible with standard MRI. This is critical for visualizing lesions in hard-to-see areas like the bowel or bladder, which helps guide precise surgical planning.
• Preoperative workup should include a detailed history to identify symptoms linked to deep endometriosis, a physical exam to detect signs of deep pelvic involvement, and targeted imaging (ultrasound/MRI) to map lesion locations and plan surgical access.
• Collaboration across multiple specialties is essential in managing deep endometriosis. Surgeons must work closely with radiologists skilled in endometriosis imaging and colorectal specialists to ensure all lesions, including those in complex areas like the rectum or bladder, are identified and addressed.
•Surgical judgment is crucial to assess whether excision should proceed aggressively or if pausing is necessary. Surgeons must evaluate the anatomy and extent of disease in real-time to avoid damage to critical structures such as the bowel, bladder, or ureters.
Table of Contents
(1) Evaluating Deep Endometriosis: Obtaining an Accurate Diagnosis with Advanced Imaging
(2) Collaborative Care: The Role of a Multidisciplinary Team in Deep Endometriosis Treatment
(3) Navigating the Challenges of Deep Endometriosis Surgery & The Art of Knowing When to Pause
Evaluating Deep Endometriosis: Obtaining an Accurate Diagnosis with Advanced Imaging
Accurately diagnosing deep endometriosis is a critical step in developing an effective treatment plan. As stated in the BackTable brief, standard physical exams often miss deep lesions, especially those involving organs such as the bladder, bowel, and vaginal cuff. Although advanced imaging is sometimes overlooked, it is highly recommended due to these lesions often being located in challenging anatomical spaces. High-resolution ultrasound is the most advanced option for visualizing deep endometriotic lesions, particularly when it’s combined with MRI for further assessment. MRI with specific protocols, such as vaginal and rectal dye-enhanced imaging, allows for better delineation of disease extent, improving surgical planning and ensuring that no areas are overlooked during surgery.
Along with imaging, a thorough preoperative workup should include a comprehensive patient history to understand the full spectrum of symptoms, such as cyclic pelvic pain, urinary or bowel issues, and dyspareunia, which may signal deeper disease involvement. Detailed history-taking allows surgeons to form a mental model of the likely locations of deep lesions, guiding the selection of imaging modalities. In Dr. Mikhail's experience, he has found that advanced imaging should be supplemented by a physical exam, where possible, to corroborate the clinical findings and support decision-making.
Collaborating with a multidisciplinary team—particularly radiologists skilled in endometriosis imaging and colorectal specialists—ensures that all potential lesion sites, especially those affecting the bowel or bladder, are identified. This team-based approach allows for a more accurate assessment, ultimately leading to a more tailored surgical strategy that minimizes the risks of complications during surgery.
[Dr. Mark Hoffman]
How do you evaluate for deep disease? What's your workup?
[Dr. Emad Mikhail]
First thing is I listen to your show, and I remember your conversation with Dr. Ted Lee about the value of history taking. I still remember that. I cannot emphasize this very well that how much you listen to the symptoms and try to think about which symptom can be translated in what anatomical location. By listening to the patient, you almost are painting a mental model of the anatomy, where is the location of the disease. Then you can- examination, this is something that we all have been trained during our training about, but utilizing expert imaging, and I cannot emphasize this enough, ultrasounds are not created equal. MRIs are not created equal. If you are a GYN surgeon who decides that you're going to treat patients with deep endometriosis, you have to have access to expert imaging. Either you learn how to do ultrasound for endometriosis yourself or you have a partner or somebody you can access who knows how to do, deep endometriosis ultrasound examinations, and you have also a radiologist who is trained and is interested to develop MRI experience in deep endometriosis.
We have great radiologists, but some of them, they really want to excel in imaging of endometriosis and some not so much, which is okay. But if you are going to tackle deep disease, you have to have those two team members, an expert sonologist and an expert radiologist.
[Dr. Mark Hoffman]
Do you read your own ultrasounds?
[Dr. Emad Mikhail]
I have a partner who is a GYN sonologist and she does all my ultrasounds.
[Dr. Mark Hoffman]
That's great.
[Dr. Emad Mikhail]
We actually have a multi-disciplinary team meeting for pre-op and post op patients. In this meeting we have mixed surgeons. We have RDI specialists, we have the GYN sonologists, we have the radiologists who are the team who are interested in endometriosis imaging. We have our colorectal surgeon. We do this, maybe, every other month and then we go over cases and for surgical planning. Actually, we come back and present the cases post operatively, showing them the laparoscopy or the robotic images. Actually, everybody learns. We learn together and get better together.
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Collaborative Care: The Role of a Multidisciplinary Team in Deep Endometriosis Treatment
Managing deep endometriosis requires a comprehensive, team-based approach. When lesions infiltrate deeper organs, surgical planning and treatment need to account for the potential involvement of multiple specialties. Dr. Mikhail says that collaborating with experts from various fields—including gynecologists, colorectal surgeons, urologists, and radiologists—is essential to ensure all aspects of the disease are addressed effectively. A multidisciplinary team makes it much less likely for any aspect of the disease to be overlooked, from accurate preoperative imaging to complex surgical interventions.
Failure to involve all necessary specialists can complicate surgery, as critical lesions may be missed, or vital structures may be inadvertently damaged. Dr. Mikhail stresses the importance of surgical judgment, particularly knowing when to stop and when to proceed with excision. The collaboration of a multidisciplinary team ensures that surgical decisions are informed, reducing the likelihood of making decisions that could lead to complications during the procedure.
Such collaboration starts well before surgery, with preoperative meetings that include all involved specialists. These team discussions allow for the review of imaging, the identification of potential complications, and the development of a comprehensive surgical plan. Dr. Mikhail highlights the importance of working with radiologists who specialize in endometriosis imaging, as their expertise helps identify deep lesions that might otherwise go unnoticed. In addition to radiologists, colorectal surgeons play a vital role, particularly when lesions affect the bowel. Their input during both the diagnostic and surgical phases ensures that the most appropriate surgical approaches are selected, minimizing risks and improving overall patient outcomes.
[Dr. Emad Mikhail]
We actually have a multi-disciplinary team meeting for pre-op and post op patients. In this meeting we have mixed surgeons. We have RDI specialists, we have the GYN sonologists, we have the radiologists who are the team who are interested in endometriosis imaging. We have our colorectal surgeon. We do this, maybe, every other month and then we go over cases and for surgical planning. Actually, we come back and present the cases post operatively, showing them the laparoscopy or the robotic images…. We learn together and get better together.
One of the things that I really want to mention, that if you really want to do deep endometriosis surgery, you have to devote a lot of your practice to that. I would say, at this point, I- maybe 75% of what I do is endometriosis. If you like something and you feel that you are actually have passion, it gives you the time and energy to learn more and get better and spend time and not just do it once in a little bit. You do it all the time.
One other thing that I really found very important is that you try to fight your ego. Because if you are the endometriosis person in the department, everybody will say, oh, I'm going to send it to Mark, he will just do it. But every single one of us will have a case that they should not do. For example, it is very hard for me to say, I'm going to stop or I'm not going to start a dissection where I don't see the end clear. You start when the end in your mind. I had patients where there is lesions invading the internal iliac vein. I say, I'm going to stop. This is something that, I don't know, some people have a hard time taking that call.
[Dr. Mark Hoffman]
No, and I think that's true, and our fellowships are pretty variable…. I've had some good partners I've worked with over the years and I've had to develop that skillset…Sometimes you say, listen, this is a challenging case. I've certainly referred
patients to my colleagues outside of my institution, because it's not about me.
Navigating the Challenges of Deep Endometriosis Surgery & The Art of Knowing When to Pause
Surgical intervention is often the most effective treatment option for deep endometriosis, but it comes with significant challenges. Deep lesions can be located in complex anatomical areas (bowel, bladder, vaginal cuff). Successfully navigating these areas requires precise surgical techniques and a high level of experience. Surgeons must weigh the potential benefits of excision against the risks of damaging vital structures, such as the ureters, bowel, or bladder, which can result in long-term consequences for the patient.
When is it best to proceed with aggressive excision versus a more conservative approach?
Deep endometriosis often involves areas that have been significantly altered by previous surgeries, making the dissection more challenging. Dr. Mikhail believes that in cases of extensive disease, such as when lesions invade the pelvic sidewalls or bowel, a more aggressive approach may be necessary to achieve complete excision. However, in cases where the anatomy is less clear or when there is risk of significant injury, surgeons must exercise caution and carefully consider whether continuing excision is in the patient’s best interest.
In cases of deep endometriosis where lesions involve delicate structures like the bladder or bowel, laparoscopic or robotic-assisted surgery offers superior visualization, allowing for more targeted dissection. Techniques such as using a vaginal cuff manipulator and rectal probes are standard in his practice, particularly when operating in post-hysterectomy patients, to help identify and separate deeply embedded lesions.
For ureteral involvement, Dr. Mikhail has integrated ICG (indocyanine green) fluorescence, which enhances ureteral visualization in real-time, reducing the risk of injury. He also notes that in some cases, ureterolysis is necessary, but only when the ureter is at risk of being inadvertently dissected.
In addition to the technical aspects of surgery, the emotional and psychological considerations of the patient must be taken into account. Dr. Mikahil and Dr. Hoffman both emphasize the importance of providing patients with a clear understanding of the potential risks and benefits of surgery. This includes discussing the possibility of needing further procedures if complications arise or if some lesions are not amenable to excision. Ensuring that patients are fully informed and have realistic expectations is needed in order to create a trusting relationship with the patient, and facilitating better overall outcomes.
[Dr. Mark Hoffman]
Talk about your {surgical} process. Is it the same thing every time you have ureterolysis? Do you start higher up in the pelvis where it's been undisturbed? Are you just doing- opening everything up first and then going after the lesion? Are you focusing on the lesion, leaving other stuff behind? What's your approach? I know everybody's a little different.
[Dr. Emad Mikhail]
Yes, I start high, I start at the brim. It is almost the same thing if there is adnexa still there, the adnexa get dissected and it moves out of the way. If I dissect the ureters in all those cases, because the ureter is probably stuck either to the lesion or to the bowel or to the residual adnexa. Freeing off the ovary and freeing off the ureter, this is the start. It's a bowel disease, so I free the bowel. If it's a bladder disease, I free the bladder…
I have a vaginal cuff manipulator. .. You use a rectal probe in all cases. You have to use a rectal probe. Most commonly and easily available is to use an incisor as a rectal probe. For the bladder, in all these cases, I backfill the bladder to see the contour of the bladder. Sometimes I use a fully catheter guide. A guide inside the fully catheter metals... Then I push it so I can see the borders of the bladder. For the ureters, I'm becoming a big fan of ICG. Now, in all repeat endo, retrograde ICG, it takes three minutes and you see the ureters so amazingly.
The beauty about this is that, do we need to do ureterolysis in every single case? Probably not. If we don't see the ureter, we have to do ureterolysis because you're going to injure it. If you have ICG and the ureter is very far from the lesion, you don't have to fully strip the ureter and risk its vascularity just because….Think about this. In redo surgery, I technically manipulate all organs of somehow. You know what I mean?
[Dr. Mark Hoffman]
Wow. There's so many different things that we can do. It just shows the value of doing tons of endometriosis surgery. I've operated a lot in the last 12 years, but there's always somebody doing more. There's always somebody who's thought of things you haven't thought of. That's the beauty of, not just the show, but meetings and keeping in touch with our colleagues who do this, because there's always a way to do it better than we're doing it. You have to be open to the idea that there's-- Even if you're doing great work, there's always that opportunity to think, oh, man, let me think about how I can try something new or better. Not that we all have to change everything all at once, but every one of us has hard cases. When you get into a situation where it's challenging, oh, that idea you had would be really helpful right here.
That's something I haven't done. I've never used retrograde ICGs, so that's really interesting. The idea of using a probe every time, the vaginal cuff manipulator, and the bladder, refilling every single time, really is those extra steps that you think, ah, should I do it? Should I not? If you're doing it every single time, you get used to it, you recognize those visual cues. It really allows you to be a little bit more certain in those areas where there isn't a lot of certainty if you're not really using something to identify those organs.
[Dr. Emad Mikhail]
Yes… Endometriosis itself is a scar-forming disease. Dissection that was done, especially if you have done a lot of dissection, all these factors makes the surgery way harder. Actually, you are 100% right, this is the value of discussing with your colleagues.
One other thing that I really found very important is that you try to fight your ego... Because if you are the endometriosis person in the department, everybody will say, oh, I'm going to send it to Mark, he will just do it. But every single one of us will have a case that they should not do. For example, it is very hard for me to say, I'm going to stop or I'm not going to start a dissection where I don't see the end clear. You start when the end in your mind. I had patients where there is lesions invading the internal iliac vein. I say, I'm going to stop. This is something that some people have a hard time taking that call.
[Dr. Mark Hoffman]
No, it takes being self-aware. It takes being humble…I tell patients all the time, when you're talking about hysterectomy or some other IUD or pills that you can stop, or, hey, I can take your IUD out. I cannot put your uterus back. Just thinking about, how you get to these points and decisions for surgery, we're really good at taking stuff out. We're really bad at putting it back. Being able to have the self-awareness, take a step back, big picture, okay, what are we actually trying to accomplish here? What's the end goal? Will we still accomplish our goal? If the goal ultimately is patient safety and good outcomes, we have to weigh all of that. Yes, it does take some humility. It does take some ego. You don't want to be scared either, right? You don't want to take patients at OR and just dabble around, and they've gotten a surgery they didn't need.
Knowing your skill level and knowing the surgeries you want to do and committing to it, because I think one of the challenges we have in our profession is folks that operate a little bit. When you're operating a little bit, just like if you did a little bit of OB, it's not fun when you're dabbling in something and get into really challenging things.
Podcast Contributors
Dr. Emad Mikhail
Dr. Emad Mikhail is a gynecologic surgeon at Tampa General Hospital in Tampa, Florida.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2025, January 14). Ep. 76 – Clinical Pearls: Managing Endometriosis Post-Hysterectomy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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