[Urinary functional disorders bound to deep endometriosis and to its treatment: review of the literature]

Voiding dysfunction after surgery for colorectal deep infiltrating endometriosis: an updated systematic review and meta-analysis

To define the risk factors of post-operative voiding dysfunction according to the type of surgical procedure performed. A systematic review through PubMed, the Cochrane Library, and Web of Science databases was performed. The Medical Subject Headings terms aimed for English articles about colorectal endometriosis surgery and voiding dysfunction published until December 26, 2022 were used. The primary outcome was the occurrence of post-operative voiding dysfunction. Secondary outcome was the presence of a persistent voiding dysfunction at 1 month. MeSH terms included ''deep endometriosis'', ''surgery'', or ''voiding dysfunction''. Two reviewers (AM, PE) assessed the quality of each article independently. A Study Quality Assessment Tool was used to provide rating of the quality of the included studies. 22 studies were included in the final analysis. Rectal shaving was associated with less voiding dysfunction than segmental resection (OR 0.33; 95%CI [0.20: 0.54]; I2 = 0%; p < 10-3). No difference was found between rectal shaving and discoid excision (OR 0.44; 95%CI [0.07: 2.84]; I2 = 55%; p = 0.39), nor between discoid excision and segmental resection (OR 0.44; 95%CI [0.18: 1.09]; I2 = 49%; p = 0.08). Conservative surgery (i.e., shaving and discoid) was associated with less voiding dysfunction than radical surgery (i.e., segmental resection) (OR 0.37; 95%CI [0.25: 0.55]; I2 = 0%; p < 10-3). Regarding persistent voiding dysfunction, rectal shaving and discoid excision were less associated with voiding dysfunction than segmental resection (respectively, OR 0.30; 95%CI [0.14: 0.66]; I2 = 0%; p = 0.003 and OR 0.13; 95%CI [0.03: 0.57]; I2 = 0%; p = 0.007). Conservative bowel procedures are associated with lower rates of persistent post-operative voiding dysfunction and should be considered first when possible.Trial registration: Our meta-analysis was registered under the PROSPERO number: CRD42023395356.

Dismissal informs the priorities of endometriosis patients in New Zealand

Introduction

Endometriosis is a common condition with average delays to diagnosis in New Zealand of almost 9 years.

Methods

In total, 50 endometriosis patients participated in anonymous, asynchronous, online group discussions about their priorities, and their experiences with the development of symptoms, seeking a diagnosis, and receiving appropriate treatment.

Results

Higher subsidy of care was the top change endometriosis patients wanted, followed by more research funding. When asked to choose whether research should be focused on improving diagnosis or improving treatment methods, the results were evenly split. Within this cohort, patients highlighted that they did not know the difference between normal menstrual discomfort and pathological endometriotic pain. If, upon seeking help, medical practitioners classified their symptoms as "normal," these dismissals could instill doubt in patients, which made it more difficult for them to continue to seek a diagnosis and effective treatments. Patients who did not express dismissal had a significantly shorter delay from symptom onset to diagnosis of 4.6 ± 3.4 years vs. 9.0 ± 5.2 years.

Conclusion

Doubt is a frequent experience for endometriosis patients in New Zealand, which was reinforced by some medical practitioners who were dismissive of their pain and thus prolonged the patient's delay to diagnosis.

Clinical outcomes following surgical management of deep infiltrating endometriosis

The main aim of the study was to evaluate severe post-operative complications following deep endometriosis surgery in a tertiary referral centre. This is a retrospective cohort study that included women who had surgery for deep infiltrating endometriosis between 1st January 2013 and 31st December 2019. Endometriosis was diagnosed based on clinical, imaging and histological parameters. We evaluated the rates of post-operative complications, potential risk factors for such complications and postoperative pregnancy rates. A total of 165 patients were included in the final analysis. The median follow-up was 63 (25-106) months. Thirty-seven patients (22.42%) had hysterectomy, 60 (36.81%) had ureterolysis and 44 (26.67%) had colorectal surgery. The overall and severe rates of post-operative complications were 16.20% (n = 23) and 2.42% (n = 4) respectively. Of the variables assessed, operative time and age were the only statistically significant risk factor for complications on multivariate analysis. Among women operated on for infertility, 34.5% (n = 20/58) got pregnant following surgery with 30% of these spontaneously. This study demonstrates acceptable overall and severe post-operative complications and pregnancy rates after deep endometriosis surgery. This information should help clinicians when counselling women to enable them making an informed choice about their management.

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.

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.

Endometriosis of the vesico-vaginal septum: a rare and unusual localization (case report)

BACKGROUND

We report a rare and unusual case of endometriosis in the vesico-vaginal septum. The location of this disease at this site is so uncommon that the literature about is very rare.

CASE PRESENTATION

A 41-year-old female was presented with urinary symptoms. There was history of caesarean section. Physical examination revealed an anterior vaginal wall mass. Pelvic MRI showed an inter vesico-vaginal mass, suggesting a leiomyoma. Surgical excision was performed by the vaginal route. There were no postoperative complications. Histopathology examination showed focal endometriosis.

CONCLUSION

Endometriosis of the anterior compartment remains relatively rare; its localization to the vesico-vaginal septum (VVS) is very rare. With the occurrence of nonspecific cyclic urinary signs in women during periods of genital activity, endometriosis should be mentioned, especially in the presence of an antecedent of pelvic surgery.

Voiding Dysfunction after Colorectal Surgery for Endometriosis: A Systematic Review and Meta-analysis

OBJECTIVE

Surgical management of deep endometriosis is associated with a high incidence of lower urinary tract dysfunction. The aim of the current systematic review and meta-analysis was to assess the rates of voiding dysfunction according to colorectal shaving, discoid excision, and segmental resection for deep endometriosis.

DATA SOURCES

We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. Medical Subject Headings terms for colorectal endometriosis and voiding dysfunction were combined and restricted to the French and English languages. The final search was performed on August 28, 2019. The outcome measured was the occurrence of postoperative voiding dysfunction.

METHODS OF STUDY SELECTION

Study Quality Assessment Tools were used to assess the quality of included studies. Studies rated as good and fair were included. Two reviewers independently assessed the quality of each included study, discrepancies were discussed; if consensus was not reached, a third reviewer was consulted.

TABULATION, INTEGRATION AND RESULTS

Out of 201 relevant published reports, 51 studies were ultimately reviewed systematically and 13 were included in the meta-analysis. Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection (Odds ratio [OR] 0.34; 95% confidence intervals [CI], 0.18-0.63; I² = 0%; p <.001) or discoid excision (OR 0.22; 95% CI, 0.09-0.51; I² = 0%; p  <.001). No significant difference was noted when comparing discoid excision and segmental colorectal resection (OR 0.74; 95% CI, 0.32-1.69; I² = 29%; p = .47). Similarly, rectal shaving was associated with a lower risk of self-catheterization >1 month than segmental colorectal resection (OR 0.3; 95% CI, 0.14-0.66; I² = 0%; p = .003). This outcome was no longer significant when comparing discoid excision and segmental colorectal resection (OR 0.72; 95% CI, 0.4-1.31; I² = 63%; p = .28).

CONCLUSION

Colorectal surgery for endometriosis has a significant impact on urinary function regardless of the technique. However, rectal shaving causes less postoperative voiding dysfunction than discoid excision or segmental resection.

Predictive approach in managing voiding dysfunction after surgery for deep endometriosis: a personalized nomogram

INTRODUCTION AND HYPOTHESIS

The aim was to develop a nomogram based on clinical and surgical factors to predict the likelihood of voiding dysfunction after surgery for deep endometriosis.

METHODS

This was a retrospective study of 789 patients (training set) who underwent surgery for deep endometriosis with colorectal involvement from January 2005 through December 2017 at Tenon University Hospital. A multivariate logistic regression analysis of selected risk factors was performed to construct a nomogram to predict postoperative voiding dysfunction. The nomogram was externally validated in 333 patients (validation set) from Rouen University Hospital.

RESULTS

Postoperative voiding dysfunction occurred in 23% of the patients (180/789) in the training set. Age, colorectal involvement/management, colpectomy and parametrectomy were the main factors associated with an increased risk of voiding dysfunction and were included in the nomogram. The predictive model had an internal concordance index of 0.79 (95% CI: 0.77-0.81) after the 200 repetitions of bootstrap sample corrections and showed good calibration. The ROC area related to the nomogram for external validation was 0.74 (95% CI: 0.72-0.76).

CONCLUSIONS

The nomogram we present here, based on four clinical and imaging characteristics, could be useful in predicting postoperative voiding dysfunction for women undergoing surgery for deep endometriosis. Patients could thus be better informed about this postoperative risk and the surgical strategy adapted according to individual risk. The accuracy of the tool was validated externally but additional validation is required.

Discoid resection for colorectal endometriosis: results from a prospective cohort from two French tertiary referral centres

AIM

Using a prospective database of discoid resection performed in two tertiary referral centres, the aim of this study is to assess the feasibility, short-term complication rates and clinical outcomes, including voiding dysfunction, of the procedure.

METHOD

A retrospective analysis of a prospective cohort database was conducted from February 2010 to October 2017 in two tertiary referral centres. One hundred and forty-eight consecutive patients scheduled for colorectal endometriosis by discoid resection were enrolled. The median follow-up was 21 months. All the women underwent complete preoperative assessment (MRI, transvaginal ultrasonography and rectal echo-endoscopy) before the removal of colorectal endometriosis. Postoperative complications were classified according to the Clavien-Dindo classification system as minor (grades I and II) or major (grades IIIA, IIIB and IV). Cases of voiding dysfunction were also noted.

RESULTS

The procedure was abandoned in seven patients. In 91 (64.5%) of the remaining 141 patients, the diameter of discoid resection removed was ≥ 30 mm. Surgery was performed by laparoscopy in 137/141 cases (92.7%). Grade I-III complications were observed in 37 patients (26.2%) with 11 grade IIIb (7.8%). Postoperative voiding dysfunction occurred in 16 patients (11.3%), 11 of whom required self-catheterization for < 1 month. In a multivariate analysis including age, body mass index, lesion size and history of previous surgery for endometriosis, a history of previous surgery was independently correlated to complication outcome (P = 0.043).

CONCLUSIONS

This analysis suggests that discoid resection is associated with good short-term results for women with colorectal endometriosis in a tertiary referral centre as it is associated with a low rate of postoperative complications.

Feasibility, Complications, and Recurrence after Discoid Resection for Colorectal Endometriosis: A Series of 93 Cases

Laparoscopic discoid colorectal resection is a surgical option for bowel endometriosis, 1 of the most severe forms of endometriosis. However, no study has clearly analyzed the feasibility or the complication and recurrence rates of the procedure in a homogeneous population with specific criteria for discoid resection. The aims of this study were to evaluate the rate of conversion to segmental resection, the need for double discoid resection, and the complication and recurrence rates. We conducted a prospective study of 93 consecutive patients who underwent discoid resection in Tenon University Hospital, Paris, France. The median follow-up was 20 months. We included patients with colorectal endometriosis (≤3 cm long and <90° of bowel circumference) experiencing failure of medical treatment or associated infertility. All the patients underwent a discoid colorectal resection using a transanal circular stapler. The primary end point was the rate of conversion to segmental resection (3.2%). The secondary end point was the rate of double discoid resection (6.5%). The overall complication rate was 24%, and the severe complication rate (i.e., Clavien-Dindo IIIB) was 3% (n = 4). Postoperative voiding dysfunction requiring bladder self-catheterization was observed in 16% (n = 15). The mean duration of bladder self-catherization was 30 days (range, 15-90) including 11 cases (74%) lasting less than 30 days and 4 cases lasting more than 30 days. No patients required bladder self-catheterization over 3 months. No difference in the complication rate or in voiding dysfunction was observed between double and single discoid resection. The low rate of conversion to radical resection confirms the satisfactory preoperative evaluation of bowel endometriosis. Few publications report the rate of conversion to radical surgery. This raises the crucial issue of the right indications for discoid resection. The present study confirms that discoid resection is probably the best option for small lesions because of its high feasibility and low complication rate. Further studies are required to evaluate the technique for larger colorectal endometriotic lesions.

[Detrusor sphincter disorders associated with deep endometriosis: Systematic review of the literature]

CONTEXT

Detrusor sphincter disorders impact quality of life in case of deep endometriosis. Surgery, which is one of the main treatments, is responsible of detrusor sphincter disorders. Since then, it is essential to look for those disorders and find the right medical care.

OBJECTIVE

To specify the detrusor sphincter disorders, its links with anatomical localisation of deep endometriosis and its prognosis after surgery.

METHODS

A literature review was carried out via PubMed^® with the followings keywords: "deep endometriosis", "urinary disorders", "voiding dysfunction" and "urinary dysfunction". Prospective and retrospective studies as well as previous reviews were analyzed.

RESULTS

Concerning bladder deep endometriosis, detrusor sphincter disorders are observed in more than 50%. Resection of the lesions allows a clear improvement or even a disappearance of the disorders. Concerning the deep endometriosis of the posterior part of the pelvis, disorders are highlighted even if women do not complain of urinary trouble. Detrusor sphincter disorders are observed in 2 to 50% and women with colorectal localisation have the highest rate. Resection of the lesions improves the symptoms described preoperatively but also provides de novo disorders of up to 47.5%. In terms of prevention, the nerve sparing surgery respects the pelvic nerve plexus, and reduces post-operative morbidity to less than 1%.

CONCLUSIONS

Detrusor sphincter disorders associated with deep endometriosis have a prognosis if their management is adapted. Well-conducted interviews and standardized questionnaires is necessary to diagnosis them. Urodynamic test may be discussed in case of bladder endometriosis, including for urinary asymptomatic patients. The management of the detrusor sphincter disorders requires a complete resection of the nodules of deep endometriosis. In the case of posterior endometriosis, a dissection must be performed respecting the retroperitoneal vegetative nerves.

Protocol of randomized controlled trial of potentized estrogen in homeopathic treatment of chronic pelvic pain associated with endometriosis

BACKGROUND

Endometriosis is a chronic inflammatory disease that causes difficult-to-treat pelvic pain. Thus being, many patients seek help in complementary and alternative medicine, including homeopathy. The effectiveness of homeopathic treatment for endometriosis is controversial due to the lack of evidences in the literature. The aim of the present randomized controlled trial is to assess the efficacy of potentized estrogen compared to placebo in the treatment of chronic pelvic pain associated with endometriosis.

METHODS/DESIGN

The present is a randomized, double-blind, placebo-controlled trial of a homeopathic medicine individualized according to program 'New Homeopathic Medicines: use of modern drugs according to the principle of similitude' (http://newhomeopathicmedicines.com). Women with endometriosis, chronic pelvic pain and a set of signs and symptoms similar to the adverse events caused by estrogen were recruited at the Endometriosis Unit of Division of Clinical Gynecology, Clinical Hospital, School of Medicine, University of São Paulo (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HCFMUSP). The participants were selected based on the analysis of their medical records and the application of self-report structured questionnaires. A total of 50 women meeting the eligibility criteria will be randomly allocated to receive potentized estrogen or placebo. The primary clinical outcome measure will be severity of chronic pelvic pain. Statistical analysis will be performed on the intention-to-treat and per-protocol approaches comparing the effect of the homeopathic medicine versus placebo after 24 weeks of intervention.

DISCUSSION

The present study was approved by the research ethics committee of HCFMUSP and the results are expected in 2016.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: https://clinicaltrials.gov/ct2/show/NCT02427386.

Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: A systematic review and meta-analysis

AIMS

Recently, nerve-sparing (NS) techniques have been incorporated in surgeries for deep infiltrating endometriosis (DIE) to prevent urinary complications. Our aim was to perform a systematic review and meta-analysis to assess the risk of urinary retention after NS surgery for DIE compared with classical (non-NS) techniques.

METHODS

Following the MOOSE guidelines for systematic reviews of observational studies, data were collected from published research articles that compared NS techniques with non-NS techniques in DIE surgery, with regard to post-operative urinary complications.

INCLUSION CRITERIA

randomized clinical trials, intervention or observational (cohort and case-control) studies assessing women who underwent surgery for painful DIE.

EXCLUSION CRITERIA

cancer surgery and women submitted to bladder or ureteral resections. The respective relative risks (RR) and 95% confidence intervals (CI) were extracted and a forest plot was generated to show individual and combined estimates.

RESULTS

Preliminarily, 1,270 potentially relevant studies were identified from which four studies were selected. A meta-analysis was performed to assess the risk of urinary retention at discharge and 90 days after surgery. We found a common RR of 0.19 [95%CI: 0.03-1.17; (I² = 50.20%; P = 0.09)] for need of self-catheterization at discharge in the NS group in relation to the conventional technique. Based on two studies, common RR for persistent urinary retention (after 90 days) was 0.16 [95%CI: 0.03-0.84].

CONCLUSIONS

Our results suggest significant advantages of the NS technique when considering the RR of persistent urinary retention. Controlled studies evaluating the best approach to manage the urinary tract after complex surgery for DIE are needed. Neurourol. Urodynam. 36:57-61, 2017. © 2015 Wiley Periodicals, Inc.

Endometriosis and Vesico-Sphincteral Disorders

Objectives

The aim of this mini review is to determine the relationship between endometriosis and urinary tract symptoms and to investigate the consequences of surgical treatment of mild to severe endometriosis, especially deep lesions, on the vesico-sphincteral function (lower urinary tract function).

Materials and methods

We performed a literature review by searching the MEDLINE database for articles published between 2000 and 2014, limiting the searches to the words: urinary tract, vesico-sphincteral, dysfunction, endometriosis, symptoms, and surgery.

Results

The incidence of vesico-sphincteral symptoms in endometriosis varies from 3.4 up to 15.4%. The frequency of such symptoms seems to be under estimated because of a lack of specific questionnaire including urinary symptoms. Urodynamic evaluation could help to detect unsuspected abnormalities. It seems that endometriosis surgery (particularly deep infiltrating lesions) is a purveyor of de novo urinary dysfunction, with an incidence varying from 6.8 up to 17.5%. Nerve sparing processes such as neuro-navigators or neuro-stimulators seem to be promising techniques to avoid postoperative urinary tract dysfunction.

Conclusion

A precise anamnesis and the use of specific validated questionnaires (IPSS and BFLUTS) improve the screening of vesico-sphincteral symptoms in case of endometriosis. No recommendation can be found in the literature about the place of urodynamic evaluation. Most publications lack of proof and therefore do not allow making recommendations about optimal treatment of endometriotic lesions to avoid urinary tract disorders.