Urinary Function after Surgery for Deep Endometriosis: A Prospective Study

A Systematic Review of the Prevalence of Overactive Bladder in Women with Non-Urinary Tract Endometriosis and the Effect of Endometriosis Surgery on Symptoms of Overactive Bladder

INTRODUCTION AND HYPOTHESIS

Overactive bladder (OAB) is characterised by urinary urgency, with or without incontinence, often accompanied by daytime frequency and nocturia, in the absence of urinary tract infection or other identifiable causes. Population studies estimate the prevalence of OAB at 12.8% (EPIC study), increasing with age, reaching up to 43% after age 40. Endometriosis affects about 10% of women of reproductive age. Both OAB and endometriosis are chronic and negatively impact women's quality of life. They appear to share a common pathophysiology related to central sensitisation. We hypothesised that OAB and endometriosis might co-exist, and surgical excision of endometriosis could alleviate OAB symptoms. We aimed to assess the prevalence of OAB in patients with endometriosis and examine the effect of endometriosis surgery on OAB symptoms.

METHODS

A systematic search of MEDLINE, PubMed, Embase, and CINAHL-Plus identified studies reporting on endometriosis and OAB or overlapping conditions such as interstitial cystitis. Studies on bladder or ureteric endometriosis were excluded.

RESULTS

Six studies (772 participants) were included. The prevalence of OAB in endometriosis patients ranged from 9.4% (Brazil) to 32% (France). OAB diagnosis varied, with tools such as International Consultation of Incontinence Modular Questionnaire on Female Lower Urinary Tract Symptoms, Core Lower Urinary Tract Symptom Score, Bristol Female Lower Urinary Tract Symptoms, and urodynamics. Surgical outcomes were inconsistent, with no improvement in three studies, equivocal in one, and worsened in another.

CONCLUSION

Overactive bladder and non-urinary tract endometriosis may co-occur in 20.5% of patients, with surgery showing variable effects on OAB symptoms. Further standardised global research is warranted to fill in evidence gaps such as whether pre-operative desensitisation could improve surgical and quality-of-life outcomes.

Lower Urinary Tract Dysfunction Among Patients Undergoing Surgery for Deep Infiltrating Endometriosis: A Prospective Cohort Study

Background/Objectives: Postsurgical lower urinary tract dysfunction (LUTD) is a common problem following deep infiltrating endometriosis (DIE) resection. The condition may be caused either by surgically induced damage to the bladder innervation or by pre-existing endometriosis-associated nerve damage. The aim of this study is to evaluate the efficacy of preoperative and postoperative multichannel urodynamic testing (UD) in identifying pre-existing or surgically induced LUTD among patients with DIE. Methods: Women with suspected DIE and planned surgical resection of DIE at the Department of Obstetrics and Gynecology at the University Hospital of Bern from September 2015 to October 2022 were invited to participate in this prospective cohort study. UD was performed before and 6 weeks after surgery. The primary outcome was the maximum flow rate (uroflow), an indicator of LUTD. Secondary outcomes were further urodynamic observations of cystometry and pressure flow studies, lower urinary tract symptoms (LUTS) as assessed by the International Prostate Symptom Score (IPSS), and pain as assessed by the visual analog scale (VAS). Results: A total of 51 patients requiring surgery for DIE were enrolled in this study. All patients underwent surgical excision of the DIE. The cohort demonstrated a uroflow of 22.1 mL/s prior to surgery, which decreased postoperatively to 21.5 mL/s (p = 0.56, 95%CI -1.5-2.71). The mean bladder contractility index (BCI) exhibited a notable decline from 130.4 preoperatively to 116.6 postoperatively (p = 0.046, 95%CI 0.23-27.27). Significant improvements were observed in the prevalence of dysmenorrhea, abdominal pain, dyspareunia, and dyschezia following surgical intervention (p = <0.001). The IPSS score was within the lower moderate range both pre- and postoperatively (mean 8.37 vs. 8.51, p = 0.893, 95%CI -2.35-2.05). Subgroup analysis identified previous endometriosis surgery as a significant preoperative risk factor for elevated post-void residual (43.6 mL, p = 0.026, 95%CI 13.89-73.37). The postoperative post-void residual increased among participants with DIE on the rectum to 54.39 mL (p = 0.078, 95%CI 24.06-84.71). Participants who underwent hysterectomy exhibited a significantly decreased uroflow (16.4 mL/s, p = 0.014, 95%CI 12-20) and BCI (75.1, p = 0.036, 95%CI 34.9-115.38). Conclusions: Nerve-respecting laparoscopy for DIE may alter bladder function. UD is not advisable before surgery, but the measurement may detect patients with LUTD.

Unilateral nerve preservation during parametrectomy is not sufficient to prevent persistent urinary retention after cytoreductive endometriosis surgery

OBJECTIVES

This study sought to quantify the risks of urinary retention following different levels or degrees of nerve preservation during parametrectomies for deep endometriosis (DE).

METHODS

Women undergoing laparoscopic and robotic nerve-sparing DE surgeries were studied. The cases were divided into 6 groups according to the degree of preservation of parasympathetic parametrium fibers on each side: P1 (P1 left /P1 right-Excellent preservation: presacral and pararectal fascia bilateral preservation), P2 (P1/P2 or P2/P1, P2/P2-Regular preservation: fascia violation with local fat visualization-either of both sides; and P3 (P1/P3 or P3/P1, P2/P3 or P3/P2, P3/P3)-Poor preservation: musculature and pelvic floor exposure-even if only unilateral.

RESULTS

Of a total of 151 women eligible for the study, 110 (72.8%) had excellent nerve preservation; 24 (15.8%) had regular nerve preservation, and 17 (11.2%) had poor-nerve preservation. The incidence of elevated PVR was higher in the P3 group. Thirty-five patients were catheterized post-operatively, more common in the P3 group. In four cases from the P3 group, prolonged intermittent self-catheterization after discharge was necessary. The calculated risk of needing intermittent catheterization in the P3 group was 23.1% up to 8 weeks and 7.7% up to 8 months post-surgery.

CONCLUSION

Parametrectomy with poor-nerve preservation can lead to urinary retention, even with excellent contralateral preservation.

Comparing the treatment of endometriosis-related pain by excision of endometriosis or hysterectomy: A multicentre prospective cohort study

OBJECTIVE

To compare the effectiveness of endometriosis excision alone to excision plus hysterectomy, with and without bilateral oophorectomy, for endometriosis-related symptoms.

DESIGN

Multicentre prospective cohort.

SETTING

Eighty-six specialist endometriosis centres.

POPULATION

Women undergoing rectovaginal endometriosis surgery between 2009 and 2021.

METHODS

We performed multivariable regression with random effects for patient and centre, controlling for age, BMI, smoking, laparoscopic versus open approach and type of bowel surgery performed, with sensitivity analysis for loss to follow-up.

MAIN OUTCOME MEASURES

Pain scores, bowel symptoms and quality-of-life measures.

RESULTS

Compared to endometriosis excision alone, women undergoing hysterectomy with conservation of ovaries had greater improvement in non-cyclical pain (MD: 1.41/10, 95% CI: 1.03-1.78, p < 0.001), dyspareunia (MD: 1.12/10, 95% CI: 0.71-1.53, p < 0.001), back pain (MD: 1.29/10, 95% CI: 0.92-1.67, p < 0.001) and quality-of-life scores (MD: 8.77/100, 95% CI: 5.79-11.75, p < 0.001) at 24 months post-operatively. Women undergoing hysterectomy with bilateral oophorectomy also had greater improvement in non-cyclical pelvic pain (MD: 2.22/10, 95% CI: 1.80-2.63, p < 0.001), dyspareunia (MD: 1.05/10, 95% CI: 0.59-1.52, p < 0.001), back pain (MD: 1.18/10, 95% CI: 0.77-1.59, p < 0.001) and quality of life (MD: 12.41/100, 95% CI: 9.07-15.74, p < 0.001) at 24 months compared to endometriosis excision alone. Compared to hysterectomy with ovarian conservation, hysterectomy with bilateral oophorectomy was associated with greater improvement in non-cyclical pelvic pain (MD: 0.81/10, 95% CI: 0.32-1.30, p = 0.001) at 24 months and quality of life (MD: 3.74/100, 95% CI: 0.56-6.92, p = 0.021) at 12 months, although this result was sensitive to loss to follow-up.

CONCLUSIONS

Patients who undergo endometriosis excision plus hysterectomy experience greater improvement in pain and quality of life compared to those who have endometriosis excision alone. There are additional benefits of bilateral oophorectomy with hysterectomy, although its value is less clear due to loss of follow-up.

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.

A Prospective Study of Bladder Function Following Endometriosis Surgery With Up to Eight years Follow-up

STUDY OBJECTIVE

To assess long-term urinary function for women having laparoscopic surgery for endometriosis.

DESIGN

Institutional Review Board-approved nested cohort study within a larger randomized controlled trial assessing urinary function following any benign laparoscopy for gynecological presentations.

SETTING

Two tertiary-level university-affiliated hospitals.

PATIENTS

Women with histologically confirmed endometriosis within the randomized controlled trial between April 2012 and November 2019, where baseline urinary function was determined.

INTERVENTIONS

Women with histologically confirmed endometriosis were contacted between February and October 2020, and urinary function was re-assessed.

MEASUREMENTS AND MAIN RESULTS

Urinary function was assessed using validated questionnaires across the domains of filling, voiding, incontinence, and quality of life determined distant from surgery. Higher scores correlated with a greater severity of symptoms. From 518/711 (72.9%) women with histologically confirmed endometriosis, 289/518 (55.8%) consented to the nested study. At a mean of 50 months (range 12-103 months) post-operatively, 35 participants (12.1%) had sought treatment for bladder symptoms, and 81 participants (28.0%) reported at least one urinary tract infection since their index surgery. There was a significant worsening of symptoms for filling, voiding, incontinence, and quality of life pre-operative to post-operatively (2.27 vs 3.32, 0.93 vs 2.02, 1.06 vs 2.32, 0.83 vs 2.13 respectively, p <.001). There was no statistically significant difference in urinary questionnaire scores in participants with and without uterovesical endometriosis. There was no statistically significant difference in any parameter when comparing any revised American Society of Reproductive Medicine (rASM) stage of endometriosis. Participants who had post-operative urinary retention reported a higher mean voiding score than those who did not (3.24 vs 1.94, p = .017), while participants with post-operative urinary tract infection reported a higher mean frequency score than those who did not (5.17 vs 3.24, p = .016).

CONCLUSION

This study suggests a decline in urinary function over time following laparoscopic surgery for endometriosis that is not dependent on the severity or location of the disease.