Urodynamic observations and lower urinary tract symptoms associated with endometriosis: a prospective cross-sectional observational study assessing women with deep infiltrating disease

Urodynamic Profile and Impact of Surgery in Women Affected by Deep Infiltrating Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection.

DATA SOURCES

A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: April 30, 2024).

METHODS OF STUDY SELECTION

We included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials, observational prospective or retrospective studies, and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included.

TABULATION, INTEGRATION, AND RESULTS

Nine studies, including 574 women affected by DIE and submitted to urodynamic assessment, were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% confidence interval [CI] 3, 26; I2 = 93.9%, p <.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2 = 78.1%, p <.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2 = 97.2%, p <.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2 = 86%, p <.001), low preoperative bladder compliance was reported in 35% of patients (95% CI 30, 40; I2 = 0%, p = .66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2 = 0%, p = .58). No difference between preoperative and postoperative UDS detrusor overactivity was reported (odds ratio [OR] 0.45; 95% CI -0.10, 1.0, I2 = 0%; p = .66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2 = 49.6%; p = .12).

CONCLUSION

Abnormal urodynamic findings before surgery are prevalent in women with DIE. Surgery seems not to affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings.

Nerve-sparing surgery in deep endometriosis: Has its time come?

Nerve-sparing (NS) surgery was first introduced for the treatment of deep endometriosis (DE) 20 years ago, drawing on established neuroanatomy and success from oncological applications. It aims to identify and preserve autonomic nerve fibres, reduce iatrogenic nerve injury, and minimize postoperative visceral dysfunction, without compromising the therapeutic effectiveness against endometriosis. The evolution of NS surgical techniques over the past two decades has been supported by an expanding body of literature on anatomical details, dissection techniques, and functional outcomes. Recent evidence suggests that NS surgery results in reduced postoperative voiding dysfunction (POVD). Transient POVD may be influenced by preoperative dysfunction, with parametrial infiltration being a strong predictive factor for POVD. While the benefits in bowel and sexual functions are less pronounced and consistent, NS surgery potentially prevents de novo dysfunctions in these areas. Furthermore, perioperative complication rates, effectiveness in pain relief, and fertility outcomes are reportedly on par with conventional surgery.

"From the tip to the deep of the iceberg": Parametrial involvement in endometriosis

Deep endometriosis (DE) can be localized in the parametrium, a complex bilateral anatomical structure, sometimes necessitating intricate surgical intervention due to the potential involvement of autonomic nerves, uterine artery, and ureter. If endometriotic ovarian cysts have been considered metaphorically representative of "the tip of the iceberg" concerning concealed DE lesions, it is reasonable to assert that parametrial lesions should be construed as the most profound region of this iceberg. Also, based on a subdual clinical presentation, a comprehensive diagnostic parametrial evaluation becomes imperative to strategize optimal management for patients with suspected DE. Recently, the ULTRAPARAMETRENDO studies aimed to evaluate the role of transvaginal ultrasound for parametrial endometriosis, showing distinctive features, such as a mild hypoechoic appearance, starry morphology, irregular margins, and limited vascularization. The impact of medical therapy on parametrial lesions has not been described in the current literature, primarily due to the lack of adequate detection at imaging. The extension of DE into the parametrium poses significant challenges during the surgical approach, thereby increasing the risk of intra- and postoperative complications, mainly if performed by centers with low expertise and following multiple surgical procedures where parametrial involvement has gone unrecognized. Over time, the principles of nerve-sparing surgery have been incorporated into the surgical DE treatment to minimize iatrogenic damage and potentially reduce the risk of functional complications.

Changes in lower urinary tract function after minimally invasive nerve-sparing for complete excision of endometriosis: An observational study

OBJECTIVES

The objective of this paper is to evaluate changes in lower urinary tract symptoms (LUTS), severity of pain and urodynamic parameters after minimally invasive nerve-sparing surgery for patients with endometriosis.

METHODS

We analyzed 143 patients undergoing minimally invasive nerve-sparing surgery for endometriosis excision (laparoscopy/robot-assisted). The endometriosis was confirmed by preoperative clinical evaluation, magnetic resonance imaging (MRI) showing at least one lesion deeper than 5 mm, and histological confirmation after laparoscopy. We evaluated three points prior and after surgery: LUTS parameters according to the International Urogynecological Association; urodynamic measures of storage and voiding and the severity of the dyspareunia, dyschezia and dysmenorrhea assessed on a self-reported 11-point numeric rating scale. The Wilcoxon signed rank and McNemar tests were used for statistical analyses (p < 0.05).

RESULTS

We observed significant improvements in LUTS after the surgery with postoperative symptom-free probabilities in urgency (64.5%), daytime frequency (38.5%), and dysuria (87.1%). However, slow stream prevalence increased significantly postsurgery (p = 0.022), with a 20.5% risk of asymptomatic patients developing this symptom. Urodynamic responses varied; for instance, maximum cystometric capacity improved significantly (p = 0.004), while postvoiding residual worsened (p = 0.006). Significant worsening in postvoiding residual occurred in women with normal preoperative values (p = 0.002), with a 17.7% risk of normal values becoming abnormal. Compliance or maximum cystometric capacity not considered normal preoperatively showed significant improvements (p < 0.001), but the risk of normal values becoming abnormal after surgery was 14.5%.

CONCLUSION

The minimally invasive nerve-sparing surgery for endometriosis excision shows improvement in lower urinary tract symptoms, urodynamics parameters and severity of pain. The majority of patients became asymptomatic in the postoperative period. When compared to the benefits of the patients' surgical treatment, particularly when considering the reduction of pain, the risks of the lower urinary tract treatment seem to be acceptable. The surgical intervention seems to be a safe alternative in patients with endometriosis, although studies with larger samples are needed to confirm these findings.

Impact of deep resection of endometriosis in the pelvis on urodynamic parameters

PURPOSE

To evaluate the effects of deep resection of endometriosis in the posterior pelvic region on urodynamic parameters.

METHODS

A prospective observational study conducted with female patients diagnosed with deep pelvic endometriosis before and after endometriosis resection surgery. Clinical history, image exams, the Female Lower Urinary Tract Symptoms questionnaire, urodynamic examination, cystometry, and voiding study were evaluated.

RESULTS

Patients aged 30-39 years old, operative duration of 132.5 minutes, and 2.7 days of hospital stay. Uroflowmetry and cystometry showed tendency for an increase after the surgery in the flow duration, time to maximum flow, and first voiding desire and decreased residual volume and maximum cystometric capacity. Opening, maximum urinary flow, and maximum flow pressure decreased at T1, and the closing parameters increased, although statistically non significant. The variables decreased at T1 in the urodynamic, except for detrusor overactivity. Although we observed a reasonable number of low bladder compliance and abnormal bladder sensation, the results were maintained at T1. General scores for filling and incontinence showed a significant decrease after surgery.

CONCLUSIONS

A significant response in the patient's perception of urinary function was demonstrated after surgery. It is observed that the surgical procedure did not affect the uroflowmetric and cystometric characteristics of the evaluated patients.

Urological knowledge and tools applied to diagnosis and surgery in deep infiltrating endometriosis - a narrative review

OBJECTIVES

This review discusses deep infiltrating endometriosis (DIE) diagnosis and surgery using current urological knowledge and technologies.

MATERIALS AND METHODS

Narrative review of deep infiltrating endometriosis that result in urological issues. We examined manuscripts from Pubmed, Embase, and Scielo's database using the following MeSH terms: ('endometriosis') AND ('urology' OR 'urological' OR 'urologist') AND ('bladder' OR'vesical') AND ('ureteral' OR 'ureter').Selection followed PRISMA guidelines. Sample images from our records were brought to endorse the findings.

RESULTS

Thirty four related articles were chosen from 105. DIE may affect the urinary system in 52.6% of patients. Lower urinary tract symptoms may require urodynamic examination. Ultrasonography offers strong statistical yields for detecting urinary tract lesions or distortions, but magnetic resonance will confirm the diagnosis. Cystoscopy can detect active lesions, although any macroscopic visual appeal is pathognomonic. Endourology is utilized intraoperatively for bladder and ureteral assessment, however transurethral endoscopic excision of bladder lesions had higher recurrence rates. Laparoscopy is the route of choice for treatment; partial cystectomy, and bladder shaving were the most prevalent surgical treatments for bladder endometriosis. Regarding the ureteral treatment, the simple ureterolysis and complex reconstructive techniques were described in most papers. Using anatomical landmarks or neuronavigation, pelvic surgical systematization allows intraoperative neural structure identification.

CONCLUSIONS

DIE in the urinary system is common, however the number of publications with high level of evidence is limited. The initial tools for diagnosis are ultrasonography and cystoscopy, but magnetic resonance is the most reliable tool. When the patient has voiding symptoms, the urodynamic examination is crucial. Laparoscopy improves lesion detection and anatomical understanding. This approach must be carried out by professionals with high expertise, since the surgery goes beyond the resection of lesions and includes the preservation of nerve structures and urinary tract reconstruction techniques.

"A Space Odyssey" on Laparoscopic Segmental Rectosigmoid Resection for Deep Endometriosis: A Seventeen-year Retrospective Analysis of Outcomes and Postoperative Complications among 3050 Patients Treated in a Referral Center

STUDY OBJECTIVE

To evaluate the feasibility of laparoscopic rectosigmoid resection for bowel endometriosis (RSE), reporting surgical and short-term postoperative outcomes in a consecutive large series of patients.

DESIGN

A retrospective cohort study.

SETTING

Third-level national referral center for deep endometriosis (DE).

PATIENTS

3050 patients with symptomatic RSE requiring surgical treatment.

INTERVENTIONS

Nerve-sparing laparoscopic resection for RSE perfomed by a multidisciplinary team. After collecting intraoperative surgical characteristics, postoperative complications were collected by evaluating the risk factors associated with their onset.

MEASUREMENTS AND MAIN RESULTS

Clavien-Dindo IIIb postoperative complications were noted in 13.1% of patients, with anastomotic leakage and rectovaginal fistula accounting for 3.0% and 1.9%, respectively. Postoperative bladder impairment was observed in 13.9% of patients during hospital discharge but spontaneously decreased to 4.5% at the first evaluation after 30 days, alongside a statistically significant change towards global symptom improvement. Multivariate analyses were done to identify the risk factors for segmental bowel resection in terms of occurrence of postoperative major complications. Ultralow (≤5 cm from the anal verge), low rectal anastomosis (<8 cm, >5 cm), parametrectomy, vaginal resection, and previous surgeries seemed more related to anastomotic leakage, rectovaginal fistula, and bladder retention.

CONCLUSIONS

Laparoscopic rectosigmoid resection for RSE seems an effective and feasible procedure. The surgical complication rate is not negligible but could be reduced by implementing a multidisciplinary approach, an endless improvement in nerve-sparing techniques and surgical anatomy, as well as technological enhancements. Real future challenges will be to reduce the time for the first diagnosis of DE and the likelihood of surgical indications.

Effect of Surgical Treatment for Deep Infiltrating Endometriosis on Pelvic Floor Disorders: A Systematic Review with Meta-analysis

OBJECTIVES

 To evaluate the impact of surgical treatment of deep infiltrative endometriosis (DIE) on pelvic floor dysfunction (urinary incontinence [UI], pelvic organ prolapse [POP], fecal incontinence [FI)] or constipation, and sexual function [dyspareunia]).

DATA SOURCE

 The present systematic review was performed in the PubMed database. For the selection of studies, articles should be published by January 5, 2021, without language restriction.

STUDY SELECTION

 Six randomized controlled studies that evaluated surgical treatment for DIE and the comparison of different surgical techniques were included.

DATA COLLECTION

 The studies were selected independently by title and abstract by two authors. Disagreements were resolved by a third author. All included studies were also evaluated according to the Cochrane risk of bias tool and the quality of the evidence was analyzed using the GRADE criteria. Subgroup analysis by different treatments and follow-up periods was also performed.

RESULTS

 Six studies were included in the quantitative analysis. The risk of bias between studies showed an uncertain risk of bias for most studies, with concealment of allocation being the least reported category. The quality of the evidence was considered low. High heterogeneity was found between the studies. No study has evaluated UI or POP comparatively before and after surgery.

CONCLUSION

 Dyspareunia and FI have improved after the surgical procedure, but it was not possible to demonstrate which surgical technique was related to these outcomes as there was surgical heterogeneity. This diversity was found across data, with the recommendation of future prospective studies addressing pelvic floor disorders with DIE.

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?

STUDY OBJECTIVE

To assess if deep endometriosis surgery affects the bladder function.

DESIGN

Prospective multicenter observational study (Canadian Task Force classification II-2).

SETTING

Academic researches centers.

PATIENTS

Thirty-two patients with diagnosis of deep endometriosis requiring surgery.

INTERVENTIONS

Women were evaluated with urodynamic studies, ICIQ-UI SF and ICIQ-OAB questionnaires before and 3 months after surgery.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was the impact of deep endometriosis surgery on urodynamic parameters. All cystomanometric parameters showed an improvement postoperatively: in particular, the first desire to void (120 vs 204 ml, p<0.001) and the bladder capacity (358 vs 409 ml, p=0.011) increased significantly after surgery. Of the uroflow parameters, the maximal voiding flow improved significantly postoperatively (19 vs 25 ml/sec, p=0.026). The ICIQ-UI SF (2.5 vs 0, p=0.0005) and ICIQ-OAB (4.3 vs 1.2, p<0.001) questionnaires showed a significant postoperative improvement too.

CONCLUSIONS

Our data show that in a selected population of patients with DE (not requiring bowel or urethral resection), the bladder function improves after surgery, both during filling and on voiding urodynamic phases. Postoperatively, patients with DE become aware of bladder filling later, have a higher bladder capacity and have a higher maximal flow. The postoperative urodynamic results are corroborated by the improved scores on the bladder questionnaires.

Endometriosis Surgery during the First Wave of the COVID-19 Pandemic: A Brazilian Single Institution Experience

Introduction. Early in the 2020 Coronavirus pandemic stay-at-home guidelines, there were public health orders that elective surgeries be deferred to prioritize hospital beds for critically ill COVID-19 patients. Besides, several reasons led to the postponement of consultations, diagnostic tests, and elective therapeutic procedures. As a result, some women with endometriosis faced chronification of their pain and decreased prospects for pregnancy. The aim of this study was to describe individual responses to minimally invasive complete excision of endometriosis through 40 days of follow-up of women whose endometriosis was considered severe enough to proceed with surgery during the fourth, fifth, and sixth months of constraints imposed by the pandemic. Preventive strategies and safety measures employed to protect patients and staff from acquiring or transmitting Coronavirus infection are presented. Case Presentation. This case series report enrolled 11 consecutive Brazilian women (ages 22 to 47 y) who underwent minimally invasive surgical treatment of endometriosis between June 26 and August 17, 2020. Cases of endometriosis requiring more urgent surgery were promptly identified and considered individually. The strict safety measures were well accepted by patients. No women developed any flu-like or COVID-19-related symptoms (cough, dyspnea, fever, or anosmia) in the 40 days of postoperative follow-up. One of the most praised measures reported by patients was the routine testing of the patient, the person who would accompany her in the hospital, and all medical staff and employees. Discussion. It is feasible to safely perform elective endometriosis surgery in selected cases during a pandemic.

Lateral Compartment Endometriosis is Associated with Retraction of the Obliterated Umbilical Artery

Background and Objectives:

Based on laparoscopic views, we hypothesized that the involvement of the lateral compartment of the pelvis (LCP) by deep infiltrating endometriosis can be inferred by observing retraction of the obliterated umbilical artery (OUA) toward the abdominal cavity. We sought to verify the association between the retraction of the OUA and the presence of endometriosis in the ipsilateral LCP (parametrium, paracervix, or paracolpium).

Methods:

This preplanned, retrospective, cross-sectional study evaluated 76 women with deep endometriosis at a private referral center. Using magnetic resonance imaging, the retraction of OUA was represented by its distance from the rectus abdominis (four different measurements were used). The diameter of the OUA was also measured and considered. T2-weighted imaging of the pelvis were obtained in two planes (sagittal and axial) and from two reference points: the proximal angle of the artery (measurement 1) and a point immediately above (measurement 2). The measurements were assessed through an exploratory multivariate principal component analysis. The associations were tested using the bivariate, non-parametric statistical Mann-Whitney U test.

Results:

The presence of endometriosis of all LCP examined was 34.2% (95% confidence interval: 26.8–41.7) with the highest percentage in the paracervix. The retraction of the OUA was greater in women with endometriosis in the ipsilateral LCP for all four measurements and was statistically significant for three of them: Sagittal 1 (p = .011), Sagittal 2 (p = .015), Axial 1 (p = .021), and Axial 2 (p = .093). The OUA diameter was not associated with its retraction (p = .392).

Conclusion:

Retraction of the OUA toward the abdominal cavity is associated with the presence of endometriosis in the ipsilateral paracervix.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition)

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

STUDY OBJECTIVE

To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance.

METHODS

This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail.

RESULTS

Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region.

CONCLUSION

Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.

Sonographic features of endometriosis infiltrating the lateral parametrium

OBJECTIVE

Lateral parametrium endometriosis (LPE) can be associated with infiltration of ureters and hypogastric plexus, causing severe painful symptoms and functional impairment, and requiring complex and extensive surgery. The aim of this study was to evaluate the presentation of LPE lesions at transvaginal ultrasound, identifying sonographic features for disease recognition and mapping.

METHODS

This was a retrospective case-series of women with sonographic suspect of LPE confirmed at surgical exploration. We carried out a descriptive analysis of the ultrasound patterns of presentation and compared the features of the lesions according to their location cranially or caudally to the uterine artery.

RESULTS

Our population included 23 women, with a total of 26 parametrial lesions: all of them were hypoechoic, with absence of vascularization. Lesions lying above the uterine artery presented more frequently as ill-defined nodules (78.6 %, p < 0.01) and were associated with ipsilateral reduced or absent ovarian mobility (92.9 %, p < 0.01); the ones located below the uterine artery appeared more frequently as fan-shaped lesions with retraction of the surrounding tissues (83.3 %). Ureteral involvement was observed at surgery in 43.5 % of cases. In all patients, deep infiltrating endometriosis of the posterior compartment was observed: the utero-sacral ligaments were the most common location affected concurrently.

CONCLUSIONS

LPE may present at transvaginal sonography as hypoechoic, not vascularized lesions, most frequently with a nodular or with a fan-shaped appearance, respectively cranially or caudally to the uterine artery. Reduced ovarian sliding and ureteral involvement are commonly associated.

Predictive Factors for Voiding Dysfunction after Surgery for Deep Infiltrating Endometriosis

STUDY OBJECTIVE

To evaluate the prognostic value of pre- and perioperative factors for voiding dysfunction after surgery for deep infiltrating endometriosis (DIE).

DESIGN

Single-center retrospective cohort study.

SETTING

University hospital.

PATIENTS

A total of 198 women with DIE in the posterior compartment who underwent surgery and a postoperative bladder scan.

INTERVENTIONS

Surgical resection of the DIE nodule from the dorsal compartment.

MEASUREMENTS AND MAIN RESULTS

After surgery, 41% of the patients initially experienced voiding dysfunction (defined as >100 mL postvoid residual urine volume at second bladder scan). The number decreased to 11% by the time of hospital discharge. Among those with a need for self-catheterization after discharge (n = 17), voiding dysfunction lasted for a median of 41 days before a return to normal bladder function, with a residual urine volume of <100 mL. The preoperative presence of DIE nodules in the ENZIAN compartment B was associated with postoperative voiding dysfunction (p = .001). The hazard ratio for elevated residual urine volume was highest when the disease stage was B3 (hazard ratio 6.43; CI, 2.3-18.2; p <.001), describing a nodule diameter of >3 cm in lateral distension. Receiver operating characteristic curve analyses showed that a first residual urine volume >220 mL has a good predictive value for the risk of intermittent self-catheterization (area under the receiver operating characteristic curve 0.893; p <.001).

CONCLUSION

Postoperative voiding dysfunction is frequent; of note, in most cases the problem is temporary. When DIE with an ENZIAN classification B is noted intraoperatively and, most of all, when the diameter of the lesion is >3 cm, a higher risk of postoperative voiding dysfunction is to be expected.

Nerve-sparing laparoscopic disc excision of deep endometriosis involving the bowel: a single-center experience on 371 consecutives cases

BACKGROUND

Bowel endometriosis is the most common pattern of Deep Endometriosis (DE). Arising from the posterior portion of the cervix and spreading to the recto-vaginal septum, utero-sacral and parametrial ligaments could lead to a distortion of normal pelvic anatomy, causing pain and infertility. Hormonal therapy is the first-line treatment in non-symptomatic patient. Conversely, laparoscopic surgical treatment has to be considered when symptoms relief are not optimal or with signs of bowel occlusion.

METHODS

Retrospective experience of consecutive series of patients who referred to a third-level referral center with suspected bowel DE and failure of multiple medical treatments. After an intraoperative evaluation of nodule size with a rectal shaving of its external portion, patients underwent radical DE eradication with concomitant disc excision in rectal nodules < 3 cm with no signs of substantial full-thickness infiltration.

RESULTS

A total of 371 patients were considered eligible for analysis, with a median age of 37 years. The median operative time of was 180 min, with an estimated blood loss of 100 mL and a median diameter of removed rectal nodule of 25 mm. Early postoperative procedure-related complications were 47 cases of acute rectal bleeding (12.7%), that were managed by rectal endoscopy, 3 bowel anastomotic dehiscence (0.8%), 8 hemoperitoneum (2.2%) and 3 ureteral fistula (0.8%). 22 patients experienced postoperative hyperpyrexia (5.9%), while 17 women underwent transient bladder deficiency (4.6%). Median follow-up was 60 months with a bowel recurrence rate of 2.2%. There was an improvement of all symptoms in the immediate postoperative follow-up (p < 0.0001). Among all patients with childbearing desire, the pregnancy rate found was 42.2% and was obtained by in vitro fertilization (IVF) techniques in 32% of cases.

CONCLUSIONS

Laparoscopic disc excision for bowel endometriosis is an effective surgical treatment in selected residual rectal nodules < 3.0 cm. The concomitant radical DE excision contributes to a significant improvement of symptoms with an acceptable complications' rate.

Five-Month Follow-Up Assessing Defecography and Urodynamics after Laparoscopic Nerve-Sparing Colorectal Resection for Endometriosis

Introduction

Large resections may be necessary in cytoreductive surgery for endometriosis, which present risk of urinary and bowel complications. Presentation of Case. A 29-year-old woman underwent multidisciplinary laparoscopy for endometriosis in a private practice setting for acyclic pelvic pain and cyclic abdominal distension with changes in bowel habits and frequent sensation of incomplete defecation. After surgery, urodynamics remained normal and bowel function improved subjectively and objectively per dynamic magnetic resonance defecography (DMRD). The five-month follow-up found improvements in pain scores, bowel function, and health-related quality of life (assessed by the full versions of the Short Form 36 and Endometriosis Health Profile 30 scales). Discussion. Animus may contribute to the bowel symptoms in women with endometriosis. DMRD provides additional objective parameters for comparing pre- and postoperative functions.

Conclusion

A nerve-sparing segmental rectosigmoidectomy for endometriosis carefully executed by a multidisciplinary team can preserve the function of different pelvic organs.

Sacral neuromodulation to treat voiding dysfunction in patients with previous pelvic surgery for deep infiltrating endometriosis: our centre's experience

Introduction and hypothesis

Voiding symptoms/dysfunctions (VS/Ds) after surgery for deep-infiltrating endometriosis (DIE) are frequent (20% of patients) and, together with bowel dysfunctions, may represent a de novo disorder due to surgical damage of the pelvic plexus or a worsening of pre-existent functional damage. Sacral neuromodulation (SNM) might improve voiding symptoms by treating dysfunctional voiding. The aim of this study is to report our experience with SNM in patients treated with surgery for DIE.

Methods

We retrospectively enrolled 13 patients with VS/Ds after surgery for DIE. All patients were investigated with urodynamic studies (UDS) and agreed to undergo SNM. Pre-existing VS/Ds, bowel disorders and pelvic pain, DIE surgical procedures, UDS and SNM test results were recorded.

Results

After surgery for DIE, functional bladder outflow obstruction and detrusor acontractility were observed in nine and four patients, respectively. Chronic pelvic pain was present in seven cases. Twelve patients developed constipation, whilst one patient had de novo faecal incontinence. After the SNM testing period, nine patients (69.2%) experienced a significant improvement of symptoms that led to definitive implant. Four patients (30.8%) had no symptom relief and the system was removed.

Conclusions

Functional bladder outflow obstruction and urinary retention are the most common VS/Ds after surgery for DIE. SNM may be an effective option for these patients, probably due to its action in improving the dysfunctional voiding, which was likely to be already present as part of the “endometriotic syndrome” and got worse after pelvic surgery. Results for pelvic pain control and gastrointestinal disorders should not be underestimated.

Combined vaginal-laparoscopic approach vs. laparoscopy alone for prevention of bladder voiding dysfunction after removal of large rectovaginal endometriosis

STUDY OBJECTIVE

To assess whether the combined vaginal-laparoscopic route may reduce the risk of postoperative bladder atony, when compared to an exclusively laparoscopic approach, in patients presenting with deeply infiltrating rectovaginal endometriosis with extensive vaginal infiltration.

DESIGN

Retrospective comparative cohort study using data prospectively recorded in the CIRENDO database.

SETTING

Academic Tertiary Care Centre.

PATIENTS

One hundred and thirty-two consecutive patients who underwent surgery of rectovaginal endometriosis with vaginal infiltration measuring greater than 3cm diameter.

INTERVENTIONS

Combined vaginal-laparoscopic versus laparoscopic approach.

MEASUREMENT AND MAIN RESULTS

Sixty-two patients underwent excision of endometriosis via a combined vaginal-laparoscopic approach (study group, or cases), while 71 patients underwent surgery via an exclusively laparoscopic route (controls). Rates of preoperative cyclical voiding difficulty and sensation of incomplete bladder emptying were comparable between the two groups. Preoperative urodynamic assessment was carried out in 18% of cases and 38% of controls, with abnormal results in 27.3% and 11.1% of cases and controls respectively. Early postoperative voiding difficulty (post-void residual>100mL) occurred in 14.7% and 24.3% of cases and controls respectively. There was a significant reduction in risk of intermittent self-catheterisation of 13% at time of discharge in the study cases. Three months postoperatively, one case and 6 controls had persistent voiding dysfunction requiring prolonged self-catheterisation.

CONCLUSION

The combined vaginal-laparoscopic approach for large rectovaginal endometriotic nodules could reduce the risk of postoperative bladder dysfunction, when compared to an exclusively laparoscopic approach, most likely due to a reduced risk of damage to the pelvic splanchnic nerves at the paravaginal level.

Endometriosis infiltrating the pelvic floor muscles with histopathological correlation-A case report

We report the case of a 29-year-old woman with deep infiltrating endometriosis who underwent robotic nerve-sparing surgery for resection of all visible lesions infiltrating pelvic and extrapelvic sites. Painful symptoms included severe dysmenorrhea, menstrual dyschezia and stranguria, with no improvement in response to hormonal treatment. The location on physical examination of a painful retrocervical nodule was identified by magnetic resonance imaging to be infiltrating the right parametrium/paracervix. During surgery, this nodule was recognized as an important retrocervical/rectovaginal lesion infiltrating the pelvic floor (i.e. levator ani and coccygeus), and was histopathologically confirmed as endometriosis infiltrating the skeletal pelvic floor muscles. A Pubmed search of the MEDLINE database in March (2019) found no publication reporting histopathologic confirmation of endometriosis infiltrating the pelvic floor muscles.

Pelvic floor dysfunction at transperineal ultrasound and voiding alteration in women with posterior deep endometriosis

INTRODUCTION AND HYPOTHESIS

Posterior deep infiltrating endometriosis (DIE) has been associated with pelvic floor muscle (PFM) alteration and voiding dysfunction (VD). The aim of this study is to evaluate the correlation between the presence of VD and altered PFM morphometry, objectively evaluated using 3D/4D transperineal ultrasound at rest and during dynamic maneuvers, in patients with posterior DIE.

METHODS

A prospective study was conducted on 108 symptomatic women scheduled for surgical removal of posterior DIE. The study population was divided in two groups according to presence or absence of VD on the Bristol Female Lower Urinary Tract Symptoms (BFLUTS). A 3D/4D transperineal ultrasound was performed to compare the following PFM morphometric parameters: levator hiatus area (LHA), antero-posterior (AP) and left-right (LR) diameters and levator ani muscle (LAM) coactivation. LAM coactivation was defined as the paradoxical contraction of the pelvic floor muscle during the Valsalva maneuver causing a smaller LHA than in the resting state.

RESULTS

Forty-eight (45.2%) women presented VD, while 60 (54.8%) women did not report any voiding complaints. Baseline characteristics did not significantly differ between the two groups. We did not find any significant statistical differences in PFM parameters between the two groups, except for a higher rate of levator ani muscle coactivation in women with VD compared with women without VD [64.6% (31/48) versus 31.7% (19/60), respectively; p = < 0.001].

CONCLUSIONS

In women affected by posterior DIE, LAM coactivation at 3D/4D transperineal ultrasound seems to be more frequent in patients with than without VD.