Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis

PURPOSE

Drug resistance and severe pelvic pain often warrant surgical intervention for treating deep endometriosis (DE); however, damage to the autonomic nervous system can occur because of anatomical considerations. We aimed to investigate the advantages of robotic technology in enabling precise dissection, even in DE.

METHODS

We retrospectively compared the surgical outcomes of robot-assisted (RA) and conventional laparoscopic (CL) nerve-sparing modified radical hysterectomies (NSmRHs) for DE.

RESULTS

Between the two groups (RA-NSmRH group, n = 50; CL-NSmRH group, n = 18), no differences were identified based on patient demographics, such as age, body mass index, previous surgery, revised American Society of Reproductive Medicine classification, Enzian classification, uterine weight, number of removed DE lesions, and concomitant procedures. All patients in both groups achieved complete removal of the DE lesions with complete bilateral pelvic autonomic nerve preservation. The mean operative time (OT) was significantly longer (130 ± 46 vs. 98 ± 22 min, p < 0.01), and estimated blood loss (EBL) was lower (35 ± 44 vs. 131 ± 49 ml, p < 0.01) in the RA-NSmRH group than in the CL-NSmRH group. The hospitalization days (4.3 ± 1.3 vs. 4.1 ± 0.2 days, p = 0.45) and perioperative complications with Clavien-Dindo classification ≥ grade III (0% vs. 0%) were not significant in both the groups. None of the patients required self-catheterization after surgery.

CONCLUSION

Compared with CL-NSmRH, RA-NSmRH was associated with longer OT and lower EBL, whereas the number of hospitalization days and complications were similar in both groups. Our results imply that nerve-sparing surgery can be safely and reproducibly performed using conventional or robotic laparoscopic modalities to treat DE.

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.

Post-orgasm pain associated with endometriosis and complete resolution of symptoms after laparoscopic en-bloc peritonectomy, a case report

INTRODUCTION AND IMPORTANCE

We report a rare case of post-orgasmic pain associated with endometriosis of the left hypogastric nerve and posterior vaginal wall. It is not a typical symptom of dyspareunia and has not been frequently associated with endometriosis in previous reports.

CASE PRESENTATION

A 36-year-old woman presented with post-orgasmic pain exclusively at orgasm, but no dyspareunia during intercourse. She also reported bladder irritation and secondary dysmenorrhea.

CLINICAL DISCUSSION

Physical examination revealed a small mass on the posterior vaginal wall and thickening of the left uterosacral ligament (USL) associated with severe pain. Pelvic magnetic resonance imaging (MRI) revealed endometrial tissue infiltration of the USL, hypogastric nerve tract, and posterior vaginal wall, consistent with endometriosis. Laparoscopic surgical excision was performed. Complete en bloc peritonectomy excision of the posterior pelvic compartment and complete removal of the lesions identified on MRI was performed. There were no postoperative complications and symptoms resolved completely. Histopathological examination revealed endometriosis.

CONCLUSION

Orgasm-associated pain is rarely associated with endometriosis of the hypogastric nerve. In most cases there is no obvious cause for this symptom in this type of dysorgasmia. The complete resolution of symptoms after removal of the endometriosis by peritonectomy of the posterior pelvic compartment and en bloc excision strongly suggests a causal relationship between endometriosis of the hypogastric nerve and the orgasmic pain and urinary symptoms observed in this case. Also, the effective surgical technique used to treat endometriosis.

"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.

Nerve-sparing surgery for deep lateral parametrial endometriosis

OBJECTIVE

Although dLPE is not overly rare, isolation of the autonomic nerves from dLPE cannot always be guaranteed. In patients with endometriosis lesions that are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except for those with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to bladder dysfunction, which seriously affects the quality of life. Therefore, the objective is to demonstrate the anatomical and technical highlights of nerve-sparing laparoscopic surgery for deep lateral parametrial endometriosis (dLPE).

DESIGN

Stepwise demonstration of this method with a narrated video footage.

SETTING

An urban general hospital.

PATIENT(S)

A 38-year-old woman, para 1, presented with a 5-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. The patient showed no neurological disorders, such as bladder dysfunction. Magnetic resonance imaging revealed right ovarian endometrioma and hydrosalpinx with dLPE reaching the lateral pelvic wall. Based on the dermatome involved, we suspected that the main lesion causing gluteal pain was located around the second and third sacral roots.

INTERVENTION(S)

Laparoscopic excision of dLPE with a pelvic autonomic nerve-sparing technique, decompression of somatic nerves and preservation of all branches of the internal iliac vessels. Assessment of preserved tissue perfusion using indocyanine green. The procedure was performed using 8 steps, as follows: step 1, adhesiolysis and adnexal surgery; step 2, complete ureterolysis; step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; step 4, dissection of the internal iliac vessels; step 5, identification and dissection of the sacral roots S2-S4 and the pelvic splanchnic nerves; step 6, complete removal of dLPE; step 7, hemostasis and assessment of tissue perfusion using indocyanine green; and step 8, application of barrier agents to prevent adhesion. Dissection of the pelvic nerves before dLPE excision revealed the relationship between the lesions and pelvic innervation, thereby reducing the risk of nerve injury, whether by minimizing the risk of neuropraxia or by allowing as many nerve fibers as possible to be spared in patients with some invasion of the pelvic nerve system. We considered even partial preservation of these nerves as beneficial to the resumption of pelvic organ functions. The step-by-step technique should help perform each stage of the surgery in a logical sequence, ensuring easy and safe completion of the procedure.

MAIN OUTCOME MEASURE(S)

Relief from severe pain, avoidance of postoperative morbidity (including intermittent self-catheterization).

RESULT(S)

The patient developed no perioperative complications, including postoperative bladder, rectal, or sexual dysfunctions. Pain was completely resolved.

CONCLUSION(S)

Nerve-sparing surgery is technically safe and feasible for selected patients with dLPE. Suitably tailored treatment should be provided for each individual based on both latest scientific evidence and life planning for the patient.

The effect of colpectomy on lower urinary tract function in transgender men

Background: In transgender men, effects of colpectomy on voiding function are unknown, except for the incidence rates of urinary tract infections and urinary retention. Aims: To provide insight into the effect of colpectomy on Lower Urinary Tract Function (LUTF) in transgender men. Methods: A retrospective chart review was conducted among transgender men who underwent colpectomy between January 2018 and October 2020. Primary outcomes were objective and subjective changes in voiding. Secondary outcomes were transurethral catheterization length and the need for clean intermittent self-catheterization (CISC). Results: Of 132 men, 89 (67%) underwent Robot-assisted Laparoscopic Colpectomy (RaLC) and 43 (33%) Vaginal Colpectomy (VC). Maximum flow rate on uroflowmetry decreased following RaLC (mean of 29.1 vs. 38.3 mL/s, p = 0.002) and VC (mean of 29.2 vs. 40.3 mL/s, p < 0.001) after a median of four months postoperatively. An increase in total International Prostate Symptom Score was seen more frequently following VC compared to RaLC. Subjective changes were indicated by 39%, more often by men who underwent VC, of which the majority improved during the first months postoperatively. Trial without catheter (TWOC) on the first postoperative day was more successful after RaLC (79/89, 89%) than VC (24/43, 56%). Secondary TWOC was successful in 22/132 (17%) patients after a median of eight days postoperatively. In 5/132 (4%) men (three VC and two RaLC), temporary CISC was necessary for a period ranging from 5 to 21 days. The last 2/132 (2%) men after RaLC were still performing CISC at end of follow-up. Eventually, 5% (two VC and four RaLC) had to refrain from genital gender-affirming surgery with urethral lengthening due to voiding dysfunction. Discussion: After colpectomy, most objective and subjective worsening in LUTF is of a temporary nature, however, 5% had to refrain from genital gender-affirming surgery with urethral lengthening due to persistent voiding dysfunction, despite the desire to void while standing.

Impact of Nerve-Sparing Postero-Lateral Parametrial Excision for Deep Infiltrating Endometriosis on Postoperative Bowel, Urinary and Sexual Function

OBJECTIVE

To evaluate the functional outcomes of nerve-sparing surgery for deep infiltrating endometriosis (DIE) with or without postero-lateral parametrectomy.

METHODS

A multicenter, observational, retrospective, cohort study was performed including all symptomatic women who underwent nerve-sparing laparoscopic excision of DIE and preoperative and postoperative assessment of functional outcomes through validated questionnaires between April 2019 and March 2020. Women with postero-lateral parametrial DIE (P-group) and women with no parametrial involvement (NP-group) were compared in term of preoperative and postoperative: functional outcomes related to pelvic organs assessed through validated questionnaires (KESS and GIQLI for bowel function, BFLUTS for urinary function, and FSFI for sexual function); pain symptoms at 3-month follow-up assessed through a 11-points Visual Analogue Scales (VAS) for dyschezia, dysmenorrhea, dyspareunia and chronic pelvic pain; surgical outcomes; rate of urinary voiding dysfunction at 3-month follow-up.

RESULTS

One-hundred patients were included: 69 in the P-group and 31 in the NP-group. Preoperative and postoperative values of questionnaires, pain symptoms and postoperative complications rates were comparable between the two groups, except for postoperative dyspareunia and sexual dysfunction, which were statistically higher in the P-group. Only patients in the P-group experienced urinary voiding dysfunction, but no statistical significance was reached (p=.173).

CONCLUSION

Postero-lateral parametrectomy for DIE appears associated to a higher risk of post-operative dyspareunia and sexual dysfunction.