A narrative review of functional outcomes following nerve-sparing surgery for deeply infiltrating endometriosis

Sacral Neuromodulation for defecation disorders after non oncologic pelvic surgery

PURPOSE

Defecation disorders (DD) can sometimes affect the outcomes of pelvic or colorectal surgery. The aim of the present study is to evaluate the role of sacral neuromodulation for the treatment of constipation and other evacuation disorders after surgery.

METHODS

A retrospective analysis in all the consecutive patients that underwent sacral nerve modulation (SNM) for DD arisen or worsened after pelvic or colorectal surgery was performed from January 2010 to December 2020. DD were defined starting from Rome IV Criteria, and according to manometric results, all patients were further divided into the two subgroups: inadequate defecatory propulsion and dyssynergic defecation. Cleveland Clinic Constipations Score (CCCS) and SF-36 have been evaluated in the time.

RESULTS

Thirty-seven patients have been included in the study. Twenty-seven out of thirty-seven (73.3%) patients had experienced sufficient benefits to implant the definitive device, and 22 patients (59.4% of tested and 81.5% of permanently implanted) still had the device functioning after a mean follow-up of 6.3 years. The most represented manometric pattern was inadequate propulsive function (59% of patients). CCCS at preoperative assessment for all patients was 17.5 with a reduction to 10.4 at the first year of follow-up (p < 0.001).

CONCLUSION

SNM appears to be a feasible, safe, and well-tolerated procedure with durable benefit in the long-term treatment of defecatory dysfunction after pelvic or colorectal surgery for benign diseases.

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.