Clinical opinion
Urinary Complications After Surgery for Posterior Deep Infiltrating Endometriosis are Related to the Extent of Dissection and to Uterosacral Ligaments Resection

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Abstract

Surgery for deep infiltrating endometriosis can relieve symptoms and improve quality of life. However, few data are available on complications, especially urinary disorders. The aim of this longitudinal study (Canadian Task Force classification II-3) was to evaluate urinary complications of laparoscopic surgery for deep infiltrating endometriosis in 86 patients. The main locations of endometriosis were colorectum (58 patients), uterosacral ligaments (21 patients), and rectovaginal septum (7 patients). Patients requiring surgical resection for posterior deep pelvic endometriosis completed before and after surgery the Bristol Female Lower Urinary Tract Symptom Questionnaire. After surgery, almost all the patients reported significant urinary complications, consisting of hesitancy (p = .02), strain to start (p = .04), stopping flow (p = .01), incomplete emptying (p = .008), and reduced stream (p = .02). Most symptoms were observed postoperatively in the colorectum group. De novo hesitancy (p = .02), stopping flow (p = .02), and incomplete emptying (p = .004) occurred more frequently after colorectal resection than after resection of other locations. The risk of de novo urinary symptoms did not depend on uterosacral ligament resection, except for incomplete emptying (p = .003) when bilateral resection was performed. Extensive dissection in the colorectum group, when combined with uterosacral ligament resection, was associated with significant urinary complications. Urinary complications mainly occurred after segmental colorectal endometriosis resection combined with bilateral uterosacral ligament resection. Surgery designed to spare the pelvic autonomic nerves could reduce the incidence of urinary complications.

Section snippets

Patients

From April 2001 through April 2004, 90 women with DIE were referred to our gynecology department.

Before surgery, all women underwent both transvaginal sonography and magnetic resonance imaging to confirm the topography of endometriosis. All the patients received gonadotropin-releasing hormone analogs for 3 months before surgery. The main location of endometriosis was the colorectum in 58 patients (67.4%) (colorectum group) (data previously published [7]), uterosacral ligaments in 21 patients

Surgical Findings

Of the 86 patients, 79 (91.9%) underwent surgical resection of endometriotic lesions by laparoscopy, exclusively. Seven patients (8.1%) (all in the colorectum group) required conversion to open surgery. The reasons for laparoconversion were severe adhesions related to endometriosis in 4 cases, incomplete circular stapled anastomosis at the end of the laparoscopic procedure in 1 case, ureteral involvement by endometriosis requiring segmental ureterectomy with reimplantation into the bladder in 1

Discussion

This study confirms the high incidence of de novo urinary symptoms after surgery for posterior DIE. De novo urinary symptoms were more frequent after colorectal resection than after resection of other sites. The extent of resection appeared the main determinant of urinary complications.

The overall incidence of de novo urinary symptoms was 30% in this study. This high incidence may be explained by systematic preoperative and postoperative evaluations of urinary symptoms with a validated

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