Does deep endometriosis surgery impact bladder function?

A study in the Journal of Minimally Invasive Gynecology concluded that, in select pateints with deep infiltrating endometriosis (DIE) whom do not require bowel or ureteral resection, bladder function significantly improves after surgery, both during filling and in voiding urodynamic phases.

The study also found that postoperatively, patients with DIE have delayed awareness of bladder filling, along with a higher bladder capacity and maximal flow.

Postoperative urodynamic results were validated by improved scores on bladder questionnaires.

The prospective, multicenter observational study was conducted at the Medical University of Vienna in Austria and Insubria University of Varese in Italy from 2014 to 2018.

The study comprised 32 patients, with a mean age of 35.8 years and a body mass index of 22. All patients had a diagnosis of DIE that required surgery.

The endometriosis lesions penetrated the retroperitoneal space to a depth of 22 mm, whereas the average size of the endometriosis nodule excised was 38 mm.

In 22% of cases, endometriosis infiltrated the rectum; in 19% of cases, endometriosis involved the ureter. No study patient underwent hysterectomy.

Prior to and 3 months after surgery, women were evaluated by urodynamic studies, the International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ-UI SF) and the International Consultation on Incontinence Questionnaire Overactive Bladder Module (ICIQ-OAB).

The main outcome was the impact of deep endometriosis surgery on urodynamic parameters.

All cystomanometric parameters showed an improvement postoperatively compared to presurgery; in particular, the first desire to void and bladder capacity, both of which increased significantly from 120 mL to 204 mL (P < 0.001) and from 358 mL to 409 mL (P = 0.011), respectively.

Maximal voiding flow also improved significantly postoperatively: from 19 mL/s to 25 mL/s (P = 0.026).

Both the ICIQ-UI SF and the ICIQ-OAB questionnaire showed significant postop improvements: 2.5 vs 0 (on an overall score of 0 to 21) (P = 0.0005) and 4.3 vs. 1.2 (on an overall score of 0 to 16) (P < 0.001), respectively.

“DIE surgery with meticulous dissection and careful attention to neurologic anatomy resulted in improved urinary function postoperatively,” wrote the authors, noting that the surgery did not appear to be the cause of postop urinary symptoms, “but rather [seemed] to have beneficial effects on the bladder function.”

The authors advocate an attentive preoperative evaluation because their study data strongly indicates that surgery, if performed by experienced clinicians, unmasks a subclinical pre-existing detrusor pathology as opposed to being the cause of neural impairment.

The authors concluded that the diligent dissection of the anatomic spaces and the careful DIE surgical resection performed on the study’s cohort of patients were partially responsible for the impressive results, because there was avoidance of iatrogenic damage to the pelvic autonomic innervation. The sympathetic and parasympathetic routes were also preserved.

Bladder function is highly relevant to the preoperative counseling of a patient with DIE, according to the authors, during which time the clinician is able to provide correct and comprehensive information, better temper the patient’s expectations, and avoid potential legal claims over postoperative complications.

A larger and long-term follow-up study is recommended to confirm findings.

Reference

  1. Laterza RM, Uccella S, Serati M, et a. Is the deep endometriosis or the surgery the cause of postoperative bladder dysfunction? J Minim Invasive Gynecol. Printed online January 2, 2022. doi:org/10/1016/j.jmig.2021.12.017