Oral Presentation AGES XXVIII Annual Scientific Meeting 2018

Is Laparoscopic Nerve Sparing Surgery for Deep Infiltrating Endometriosis Essential to minimise lower urinary tract and bowel dysfunction? (5530)

Kiran Vanza 1 , Bradley deVries 2 , Shing Wong 3 , Surya Krishnan 4
  1. Obstetrics and Gynaecology, WSLHD, Blacktown, NSW, Australia
  2. Women's and Babies, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
  3. Colorectal Surgeon, Royal Hospital for Women, Royal Prince Alfred Hospital and Prince of Wales Private Hospitals, Randwick, Camperdown, NSW, Australia
  4. Royal Hospital for Women and Royal Prince Alfred Gynaecology Endoscopy Departments, Royal Hospital for Women and Royal Prince Alfred Hospitals, Randwick and Camperdown, NSW, Australia

Is Laparoscopic Nerve Sparing Surgery for Deep Infiltrating Endometriosis Essential to minimise lower urinary tract and bowel dysfunction?

 

Radical surgery for deep infiltrating endometriosis (DIE) has long lasting effects on bladder and bowel function and subsequent quality of life. Over the past fifteen years, increasing emphasis has been placed on neuropelveology with the aim of minimising post-operative pelvic floor dysfunction1,3. This is certainly feasible in reducing surgery related bladder morbidity however; minimising bowel dysfunction may be more complex1,2,3. Functional impairment may predate surgery and may not be restored by nerve preservation.

 

Aim

To compare bladder and bowel dysfunction following excision of DIE using nerve sparing techniques compared to cases where endometriosis excision was from other sites in the pelvis or where nerve sparing strategies could not be implemented due to margin of disease involvement and energy modalities used.

 

Method

A retrospective cohort study was performed. Participants who had excisional surgery for DIE over the previous 8 years were included. Pelvic floor function was assessed through a validated questionnaire comprising of questions under four domains: urinary voiding dysfunction, difficulty with stool evacuation, urinary stress and urinary urge incontinence.

 

Results

Of the 208 questionnaires sent, there was a completion rate of 34% (66 questionnaires) and 15 were return to sender. 40 respondents had excision of DIE using nerve-sparing technique. The mean age of the nerve-sparing group was 41 years compared to 37 years in the control group. Parity was evenly matched in both groups.

 

Results under the four domains were analysed using Wilcox Rank sum test. Voiding dysfunction, evacuation of stool and urinary urgency showed no significant difference between women where nerve-sparing surgery was performed (p=0.30, 0.57, 0.59, respectively). Univariate analyses and logistical regression demonstrated no significant difference in urinary stress incontinence.

 

Women undergoing nerve-sparing surgery reported a significantly increased rate of urinary symptoms following index surgery (Wilcox Rank sum test z statistic = 2.37, p=0.018). The same was demonstrated in bowel symptoms (Wilcox Rank sum test z statistic = 3.06, p=0.002). This, however was only demonstrated in the short term and there was no significant difference in long term symptoms.

 

Conclusion

Our study demonstrates that despite employing nerve-sparing techniques for excision of DIE, there was no significant different in bladder or bowel dysfunction. Further research into the impact of preexisting nerve impairment and a comparison of different energy modalities used may be useful to increase our understanding in this area.

  1. 1. Possover M, Quakermack J, Chiantera V. The LANN technique to reduce postoperative functional morbidity in laparoscopic radical surgery. Journal of the America College of Surgeons 2005 December: 201(6): 913-917
  2. 2. Kavallaris A, Banz C, Chalvatzas N, Homemann A, Luedders D, Diedrich K, Bohlmann M. Laparoscopic nerve-sparing surgery for deep infiltrating endometriosis: description of the technique and patients’ outcome. Archives in Gynecology and Obstetrics 2011 July: 284(1): 131-135
  3. 3. Lemos N, Souza C, Marques RM, Kamergorodsky G, Schor E, Girao MJ. Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve- sparing surgery by direct visualization of autonomic nerve bundles. Fertility and Sterility 2015 November: 104(5): e 11-2
  • Have you presented oral, video or DCS at an AGES meeting before?: No
  • Are you a trainee and if so at what level?: 5
  • Are you a subspecialists or AGES member?: Yes