{"paper_id":"2288c163-7084-415b-a044-23fd5af3c53d","body_text":"Research Article\nISSN: 2574 -1241              DOI: 10.26717/BJSTR.2023.51.008116\nFunctional Outcomes and Quality of Life After \nLaparoscopic Nerve-Sparing Radical Treatment of \nParametrial Deep Infiltrating Endometriosis\nCarlo Alboni1, Veronica Sampogna1*, Mirvana Airoud2, Stefania Malmusi2, Antonino Farulla1, \nGiuseppe Colucci 3, Ludovica Camacho Mattos 1, Annarita Pecchi 5, Giorgia Gaia 6 and Antonio La \nMarca1,4\n1Minimally Invasive and Robotic Gynecologic Surgery Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Italy\n2Gynecology and Obstetrics Unit, Sassuolo Civil Hospital, Italy\n3General Surgery Unit, Sassuolo Civil Hospital, Italy\n4Obstetrics and Gynecology Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Italy\n5Department of Radiology, Policlinico di Modena, University of Modena and Reggio Emilia, Italy\n6Department of Gynecology, ASST Santi Paolo e Carlo, University of Milan, Italy\n*Corresponding author: Veronica Sampogna, Minimally Invasive and Robotic Gynecologic Surgery Unit, Policlinico di Modena \nUniversity of Modena and Reggio Emilia, Via del Pozzo 71, 41124 Modena, Italy\nCopyright@ : Veronica Sampogna | Biomed J Sci & Tech Res | BJSTR. MS.ID.008116. 42797\nABSTRACT\nStudy objective: Complete eradication of parametrial nodules of Deep Infiltrating Endometriosis (DIE) is \nassociated with a high risk of iatrogenic nerves damage and pelvic organs dysfunction. The aim of this study \nis to evaluate the effect of laparoscopic excision of parametrial DIE on quality of life, pain symptoms and \npost- operative voiding function (bladder and rectal).\nDesign: Retrospective observational study.\nSetting: All patients undergoing laparoscopic nerve-sparing excision of parametrial DIE by a single expert \nsurgeon between January 2013 and March 2017 were included in the study.\nPatients: Fifty-one patients were included in the final analysis.\nIntervention: Quality of life (QoL) and Functional outcomes were evaluated using validated questionnaires \n(EHP-30, NBD score, ICIQ-FLUTS), administered preoperatively and after surgery. Pain scores were \ncollected using Visual Analogue Scale (VAS).\nMeasurement and Main Results:  EHP-30 scores had a significant improvement in all the domains \nanalyzed. No differences were found in terms of urinary function. The NBD score showed that intestinal \ndysfunction was. reported as very minor by 76.4%, minor by 11.8%, moderate by 5.9% and severe by \n5.95% of patients. Pain symptoms (VAS score) decreased significantly after surgery except for chronic \npelvic pain (p value < .05).\nConclusion: Laparoscopic nerve-sparing radical excision of parametrial DIE can favorably impact on \npatients QoL and reduces pain score and intestinal dysfunction.\nKeywords: Deep Endometriosis; Laparoscopy; Nerve-Sparing; Parametrial Endometriosis; QoL\nAbbreviations: DIE: Deep Infiltrating Endometriosis; VAS: Visual Analogue Scale; NBD: Neurogenic Bowel \nDysfunction; QoL: Quality of Life\nARTICLE INFO\nReceived: \n   July 06, 2023\nPublished: \n   July 13, 2023 \nCitation: Carlo Alboni, Veronica Sam -\npogna, Mirvana Airoud, Stefania Mal -\nmusi, Antonino Farulla, Giuseppe \nColucci, Ludovica Camacho Mattos, \nAnnarita Pecchi, Giorgia Gaia and An -\ntonio La Marca. Functional Outcomes \nand Quality of Life After Laparoscopic \nNerve-Sparing Radical Treatment of \nParametrial Deep Infiltrating Endome -\ntriosis. Biomed J Sci & Tech Res  51(3)-\n2023. BJSTR. MS.ID.008116.\n\nCopyright@ : Veronica Sampogna | Biomed J Sci & Tech Res | BJSTR. MS.ID.008116.\n42798\nVolume 51- Issue 3\nDOI: 10.26717/BJSTR.2023.51.008116\nIntroduction\nEndometriosis is a chronic inflammatory disease, characterized \nby ectopic proliferation of endometrial glands and stroma [1-3]. The \ndeep infiltrating endometriosis (DIE) is a specific clinical entity char-\nacterized by an extension of the disease more than 5 mm under the \nperitoneal surface, retroperitoneal fibrosis and neural tropism with \ndistortion of the regular pelvic anatomy [4]. DIE affects most fre -\nquently uterosacral ligaments (69.2%), rectovaginal septum (14.5%), \nbowel (9.9%) and bladder (4.2%) [5]. In recent years a growing atten-\ntion was pointed out on parametrial localization of DIE with studies \ninvestigating diagnosis, treatments and clinical outcomes [6-8]. The \nlateral parametrium contains the nerve branches of autonomic pelvic \norgans innervation, therefore the complete eradication of the disease \nis associated with the risk of serious impairment of rectal, bladder \nand sexual function due to the iatrogenic disruption of inferior hypo-\ngastric plexus Radical resection of the posterior parametrium, corre-\nsponding to the uterosacral ligament plus rectovaginal ligaments and \nlateral ligament of the rectum, can also result in injury to the hypo -\ngastric nerves, pelvic splanchnic nerves and to the anterior branches \nof the sacral sympathetic chains. Different authors have described \nthe nerve-sparing approach in case of DIE nodules [9-11]. In 2012, \na prospective cohort study compared the laparoscopic nerve-spar -\ning approach to the classical laparoscopic procedure demonstrating \nthe feasibility of radical removal of infiltrating endometriosis tissue \nfrom parametrial structures avoiding disruption of autonomic pelvic \norgans innervation [12]. \nThere has been a growing interest in recent years on analyzing \nQoL after laparoscopic surgery for endometriosis. However, only a \nfew studies have specifically addressed data on functional outcomes \nafter DIE excision, and, to the best of our knowledge, no one was pub-\nlished investigating patient’s QoL with specific validated question -\nnaires [13,14]. The aim of this study is to use validated questionnaires \nto evaluate patients’ response to laparoscopic nerve- sparing excision \nof parametrial DIE in terms of self-perceived well-being, pain relief \nand voiding function.\nMaterials and Methods\nThis study was approved by the local Ethics Committee (protocol \nnumber 0024582/19), and all patients expressed their informed con-\nsent to anonymous data collection. All patients that underwent lap -\naroscopic surgery for endometriosis in the period between January \n2013 and March 2017 at Obstetrics and Gynecology Division of the \nSassuolo Civil Hospital and at the Endometriosis tertiary level referral \ncenter of the University Hospital of Modena were enrolled. All sur -\ngeries were performed by the same surgeon with high expertise in \nlaparoscopic treatment of endometriosis (C.A.) Medical records from \npatients with histologically confirmed laparoscopic resection of pos -\nterior and/or lateral parametrium were collected. Exclusion criteria \nwere as follows: age < 18 years, preoperative diagnosis of neurogenic \nbladder and bowel inflammatory disease, absence of sexual activity \nand failure to complete the study questionnaires. All patients under -\nwent speculum examination, pelvic bimanual vagino-rectal evaluation \nand transvaginal ultrasound performed by an expert sonographer ex-\npert in endometriosis diagnosis. A transabdominal ultrasound scan \nof the kidneys was also routinely performed to rule out hydrouret -\neronephrosis. Eventually, they underwent pelvic magnetic resonance \nwith rectal injection of 10-50 ml of sterile gel to confirm dimension \nand depth of infiltration of the bowel lesions (if any) and to define \nthe parametrial/ureteral involvement. All patients signed a specific \ninformed consent before surgery, specifying all surgical procedures \nnecessary for their complete excision and the potential risks (vascu -\nlar, neurologic, urologic and intestinal) related to the type of surgery. \nAll patients were submitted to nerve sparing excision of DIE ac -\ncording to Negrar Method [15]. In case of bowel lesions infiltrating \nthe muscularis interna and causing a stenosis of more than 50% of \nthe lumen in patients symptomatic for bowel dysfunction, a segmen -\ntal resection with Knight-Griffen technique and end-to-end anasto -\nmosis was performed by a general surgeon. A protective ileostomy \nwas routinely done in case of ultra-low rectal segmental resection \n(resection margin < 5 cm from the dental line). The data on patient \nage, parity, body mass index, previous abdominopelvic surgery, oper-\nating time, amount of blood loss, use of hormonal therapy, length of \nhospital stay were recorded, while intraoperative, early and late post-\noperative complications were analyzed according to the Clavien-Din-\ndo classification system [16]. Pain symptoms were investigated using \nthe Visual Analogue Scale (VAS) and the different need of analgesic \ndrugs was evaluated at the preoperative visit and at the follow up \nevaluation after three months. For the comparative analysis of dys -\nmenorrhea with VAS scale, patients underwent hysterectomy and pa-\ntients with post-operative continuous hormonal therapy were exclud-\ned (22 patients). Quality of life and functional and status outcomes \nwere collected using the Italian validated version of Endometriosis \nHealth Profile-30 (EHP-30) and International Consultation on Incon -\ntinence-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) [17] \nand the Italian translation of Neurogenic Bowel Dysfunction (NBD) \n[18], administered one month before surgery and three months after \nthe intervention. \nThe EHP-30 was used to evaluate the global health profile of the \npatients [19] and consists of 30 questions about pain, control and \npowerlessness, emotional well-being, social support and self-image. \nCurrently is the only questionnaire that evaluates QoL specifically in \npatients with endometriosis. For bowel function the NBD score was \nused [20]: this questionnaire evaluates intestinal dysfunction and \nits impact on quality of life in patients with neurological lesions; it is \nbased on 10 items assessing defecation and faecal incontinence with \na score ranging from 0 (very low disfunction) to 47 (severe disfunc -\ntion). The urinary function was evaluated using ICIQ-FLUTS [21,22]. \nthis questionnaire includes 22 items relating to bladder filling, uri -\n\nCopyright@ : Veronica Sampogna | Biomed J Sci & Tech Res | BJSTR. MS.ID.008116.\nVolume 51- Issue 3\nDOI: 10.26717/BJSTR.2023.51.008116\n42799\nnation and incontinence; for each question, a score from 0 to 4 is \nassigned. Higher scores correspond to a higher level of dysfunction. \nData were expressed as mean±standard deviation or median (range) \nfor numerical variables and as numbers (percentages) for categori -\ncal variables. The Wilcoxon test was used to compare any change in \nvariables before and after the surgical treatment. P value of <0.05 de-\nnoted statistical significance. All statistical analyses were performed \nusing SPSS software (version 21, SPSS, Inc., Chicago, IL, USA).\nResults\nDuring the study period a total of 65 patients underwent \nnerve-sparing surgery for parametrial deep infiltrating endometrio -\nsis. 51 patients met the inclusion criteria and were included for the \nstudy analyses. Demographic characteristics of patients are provided \nin (Table 1). Mean age was 36.6 ± 6.2 years. Eight patients had had \nprevious surgery for endometriosis (15.6%) and 27 were nulliparous \n(53%). Operative details and procedures are summarized in (Table \n2). Dysmenorrhea was the most frequent symptom (84.3%), followed \nby dyspareunia (74.5%), ovulatory pain (70.6%), dyschezia (51%), \nchronic pelvic pain (35.3%) and stranguria (27.5%). Laparoscopic \napproach was used in all cases, no conversion to open surgery oc -\ncurred. Laparoscopic segmental bowel resection was performed in \n15 (%) patients, while discoid resection was performed in only one \n(%). Three (%) patients needed protective ileostomy for ultra-low \nrectal anastomosis. The mean operating time was 239 +/-111 min -\nutes. The mean estimated blood loss during surgery was 165 +/- 59.9 \nmL (range 50-1020 mL). The mean hospital stay was 6 days (range \n3-12 days). In 37 patients (62.7%) parametrial endometriosis was \nunilateral, in 13 patients (22% of cases) both posterior and lateral \nparametrium were involved and in 9 patients (15.3% of cases) poste-\nrior and lateral parametria were involved bilaterally. Right posterior \nparametrium was involved in 38% of cases (19/50), while the left one \nwas involved in 40% of cases (20/50). Right lateral parametrium was \ninvolved by endometriosis in 59.1% of cases (13/22), the left one was \ninvolved in 31.8% of cases (7/22), and lateral parametria were in -\nvolved bilaterally in 9.1% of cases (2/22). \nTable 1: Demographic characteristics of patients.\nAge, years 36 +/- 6.2\nWeight, kg 62.1 +/- 12.9\nBMI, Kg/m2 22.7 +/- 3.9\nNationality\n· Caucasian 90.1% (46/51)\n· North African 5.9% (3/51)\n· Asian 2% (1/51)\n· Latin American 2% (1/51)\nMarital Status\n· Married 72.5% (37/51)\n· Divorced 11.8% (6/51)\n· Nubile 13.7% (7/51)\n· Widow 2% (1/51)\nEducation\n· Secondary school 21.6% (11/51)\n· High school 56.8% (29/51)\n· Degree 21.6% (11/51)\nOccupation\n· Employed 88.2% (45/51)\n· Unemployed 9.8% (5/51)\n· Students 2% (1/51)\nMedical History\n· No prior history 33.3% (17/51)\nNote: Values are given as mean +/- standard deviation or absolute number \n(percentage).\nTable 2: Detail of operative procedures.\nOPERATIVE PROCEDURES  \nendometrioma enucleation 31/51 (60.8%)\nmonolateral adnexectomy 8/51 (15.7%)\novarian fossa peritoneum removal 25/51 (49%)\nTotal hysterectomy 5/51 (10%)\nRectosigmoid endometriosis \nremoval 31/51 (60.7%)\n-Shaving 15/51 (29.4%)\n-bowel resection 15/51 (29.4%)\n-discoid resection 1/51 (2%)\nprotective ileostomy 3/51 (5.9%)\nLateral parametrium removal 15/51 (29.4%)\nUnilateral 13/15 (86.6%)\nright 7/15 (46.6%)\nleft 6/15 (40%)\nBilateral 2/15 (13.4%)\nPosterior parametrium removal 44/51 (86.3%)\nUnilateral 36/51 (70.6%)\nright 16/44 (36.4%)\nleft 20/44 (45.4%)\nBilateral 8/51 (15.7%)\nNote: Values are given as absolute number (percentage).\nThe average size of parametrial nodules was 2 +/- 0.5 cm. No case \nof intrinsic ureteral endometriosis was found. No intraoperative com-\nplications occurred. Three postoperative complications were regis -\ntered: one hemoperitoneum (class IIIb), one rectovaginal fistula (class \nIIIb) and one case of stenosis of colorectal anastomosis requiring en-\ndoscopic balloon dilation (class IIIa). Twenty-seven patients (52.9%) \nwere undertaking hormonal therapy at the 3-month post-operative \nfollow up visit. Pain symptoms severity expressed in VAS score, except \n\nCopyright@ : Veronica Sampogna | Biomed J Sci & Tech Res | BJSTR. MS.ID.008116.\n42800\nVolume 51- Issue 3\nDOI: 10.26717/BJSTR.2023.51.008116\nCPP , were significantly decreased after the operation (p value < .05) \nas shown in (Table 3). The EHP-30 score before and after surgery are \nshown in (Table 4). Surgery improved significantly QoL in many of the \ndomains analyzed such as pain, control and powerlessness, emotional \nwell-being, social support, self-image, satisfaction of treatment, sex -\nual life. It was not possible to evaluate the “infertility” and “relation -\nship with children” modules because respectively 21 (41.2%) and 31 \n(60.8%) patients did not answer the questions. Limited to the small \nsample analyzed, however, even in these two modules a statistical -\nly significant improvement was observed. No significative disfunc -\ntion were found at post-operative ICIQ-FLUTS questionnaire. Bowel \nfunction improved after surgery in patients’ subjective perception, \nalthough the results are controversial: the NBD score showed that in-\ntestinal dysfunction in the whole group was related to constipation, \nwhile the surgery was resolutive for diarrhea. Most of the patients \nshowed mild dysfunction (76.4%), while only three patients had se -\nvere dysfunction (5.9%).\nTable 3: VAS score before and after surgery*.\nMedian + IQR \nbefore\nMedian + IQR \nafter p-value\nDysmenorrhea 8 + 5.5 2 + 5.25 0.01\nDyspareunia 6 + 3 4 + 3 0.012\nChronic pelvic \npain 0 + 3.5 0 + 0 0.823\nDyschezia 2 + 7.5 0 + 2.5 0.001\nStrangury 0 + 4 0 + 0 0.01\nNote: VAS score before and after surgery, values are given in median + \nIQR (interquartile range) *no continues hormonal therapy l contraceptives.\nTable 4: EHP-30 scores before and after surgery.\nEHP-30 questionnaire BEFORE SURGERY AFTER SURGERY P-value\nPain 47.2 (+/- 25.3) 10.1 (+/- 14.8) < .001\nControl and powerlessness 56.3 (+/- 25.7) 13.2 (+/- 15.6) < .001\nEmotion 53.4 (+/- 24) 23.3 (+/- 20.7) < .001\nSocial support 38.8 (+/- 26.5) 22.2 (+/- 21.5) < .001\nSelf-image 30.7 (+/- 23.9) 19.7 (+/- 22.5) < .001\nwork module 38.8 (+/- 28.3) 9.3 (+/- 16.7) < .001\nrelationship with children 20 (+/- 26.1) 6 (+/- 12.9) 0.002\nsexual intercourse 49.2 (+/- 27.8) 20.6 (+/- 22.6) < .001\nmedical profession 21 (+/- 26.7) 3.9 (+/- 8.7) < .001\ntreatment module 38.3 (+/- 29.1) 15.5 (+/- 21.9) < .001\ninfertility module 48.8 (+/- 27.8) 30.2 (+/- 30.0) .007\nNote: Values are given as mean +/- standard deviation or absolute number (percentage), if not otherwise expressed.\nDiscussion\nThe parametrium has been described as the supporting system \nof the uterus that anchors the organ to the lateral pelvic wall and has \nboth supply-drainage and fascial functions. More often DIE lesions \nare at the level of the posterior and lateral part of the parametrium \nassociated to retrocervical, bowel and ureteral nodules [23]. This pat-\ntern of lesions distribution can be associated with ureteral and bowel \nfunction impairment and often with chronic pelvic pain symptoms \nexpressed as dyspareunia and dyschezia [8,24]. Due to these symp -\ntoms, endometriosis may have a profound impact on quality of life \nand mental health of the patients affected. In 2004 (Abbot, et al. [25]) \ndemonstrated that surgical excision of endometriosis determines \na symptomatic improvement. significantly more than placebo. Ac -\ncording to this evidence, surgical eradication of DIE represents the \ntreatment of choice in symptomatic patients unresponsive to medical \ntreatment. The preservation of the pelvic autonomic system may be \nchallenging in case of large nodules and surgical treatment of deep \ninfiltrating endometriosis needs adequate surgical skills and exper -\ntise to minimize the risk of surgical complication; in fact only a few \nseries, with limited sample size, have demonstrated the feasibility \nof nerve-sparing surgery in case of parametrial DIE [26-28] To the \nbest of our knowledge this study is the first to analyze the impact of \nlaparoscopic nerve-sparing surgery for parametrial deep infiltrating \nendometriosis on quality of life using EHP-30 questionnaire. We ob -\nserved that this type of surgery improved quality of life of patients \nand reduced all the painful symptoms, except for chronic pelvic pain. \nThis evidence suggests that a “symptom guided approach” and a \nradical surgery are associated with better postoperative outcomes. \nThe main post-operative improvement in term of quality of life re -\nlates to domains affecting social and relationship life. This represents \nan important goal considering that the average age of the patients \nenrolled is 36 years, with a percentage of working and married wom-\nen being respectively 88.2% and 72.5%, and that 47% of them are \nengaged in the management of children. Furthermore, the eventual -\nity of surgical complications associated with this technique was low. \nPatients reported a subjective improvement in bowel function at NBD \n\nCopyright@ : Veronica Sampogna | Biomed J Sci & Tech Res | BJSTR. MS.ID.008116.\nVolume 51- Issue 3\nDOI: 10.26717/BJSTR.2023.51.008116\n42801\nquestionnaire, excepted for constipation. This evidence is in accor -\ndance with a retrospective study by (Abo, et al. [29]) on 371 women \nundergoing surgery for colorectal endometriosis. The results of the \nICIQ-FLUTS questionnaire on urinary function showed that incon -\ntinence was more frequent in patients undergoing posterior para -\nmetrial resection than those undergoing lateral or resection of both \nparametria. However, a conclusion can’t be achieved because of size \ndiscrepancy between the three groups (36/51 patients underwent \nresection of the posterior parametrium, 7/51 of the lateral parame -\ntrium and 8/51 of both parametria). The main bias of our study is \nrelated to the lack of pre-operative data on urinary function. Many \nauthors have studied the incidence of urinary symptoms in patients \nwith endometriosis (Fauconnier, et al. [24]). \nRelated specific symptoms to anatomical locations of DIE but did \nnot evaluate the correlation between urinary symptoms and posteri-\nor DIE; (Darai, et al. [30]) reported a high incidence of urinary symp-\ntoms in patients with deep infiltrating endometriosis, but without \nbeing able to correlate the presence of symptoms with well-defined \nanatomical lesions. Among the possible limitations of this study, we \nmention the small sample size, the lack of a comparison arm of pa -\ntients not receiving nerve-sparing approach and the short follow up \n[31,32]. On the other hand, our study provides the first analysis of \nthe impact of nerve-sparing surgery on quality of life, using validated \nquestionnaires and it gives good and promising results for the sys -\ntematic use of this type of approach.\nConclusion\nIn conclusion, the use of nerve sparing technique by expert sur -\ngeons warrants good results in term of improvement of QoL and pain \ncontrol and provides good functional outcomes. The development of \nsurgical skills based on anatomical knowledge can lead to a more ex -\ntensive use of the nerve-sparing technique with a persistent improve-\nment in the quality of life of the patients with parametrial localization \nof DIE.\nConflict of Interest\nAuthors have no conflict of interest and economic interest to de -\nclare. The authors declare no conflict of interest. This research re -\nceived no specific grant from any funding agency in the public, com -\nmercial, or not-for-profit sectors. The data that support the finding of \nthis study are available from the corresponding authors upon reason-\nable request.\nReferences\n1. Eskenazi B, Warner ML (1997) Epidemiology of endometriosis. Obstet Gy-\nnecol Clin North Am 24(2): 235-258.\n2. Soliman AM, Yang H, Du EX, Kelley C, Winkel C (2016) The direct and indi-\nrect costs associated with endometriosis: A systematic literature review. \nHuman Reproduction. Oxford University Press 31:  712-722. \n3. Viganò P , Parazzini F, Somigliana E, Vercellini P (2004) Endometriosis: \nEpidemiology and aetiological factors. Best Practice and Research Clinical \nObstetrics and Gynaecology. Bailliere Tindall Ltd 18: 177-200.\n4. Nisolle M, Donnez J (1997) Peritoneal endometriosis, ovarian endometri-\nosis, and adenomyotic nodules of the rectovaginal septum are three differ-\nent entities. Fertil Steril 68(4): 585-596.\n5. Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, et al. (2006) Deeply \ninfiltrating endometrioses: Pathogenetic implications of the anatomical \ndistribution. Hum Reprod 21(7): 1839-1845.\n6. Mabrouk M, Raimondo D, Arena A, Iodice R, Altieri M, et al. (2019) Para-\nmetrial Endometriosis: The Occult Condition that Makes the Hard Harder. \nJ Minim Invasive Gynecol 26(5): 871-876.\n7. Possover M (2014) Pathophysiologic explanation for bladder retention \nin patients after laparoscopic surgery for deeply infiltrating rectovaginal \nand/or parametric endometriosis. Fertil Steril 101(3): 754-758.\n8. Ballester M, Santulli P , Bazot M, Coutant C, Rouzier R, et al. (2011) Preop-\nerative Evaluation of Posterior Deep-Infiltrating Endometriosis Demon -\nstrates a Relationship with Urinary Dysfunction and Parametrial Involve-\nment. J Minim Invasive Gynecol 18(1): 36-42.\n9. Alboni C, Farulla A, Facchinetti F, Ercoli A (2021) Robot-Assisted Ner -\nve-sparing Resection of Bilateral Parametrial Deep Infiltrating Endome -\ntriosis. J Minim Invasive Gynecol 28(1): 18-19.\n10. Kavallaris A, Banz C, Chalvatzas N, Hornemann A, Luedders D, et al. (2011) \nLaparoscopic nerve-sparing surgery of deep infiltrating endometriosis: \ndescription of the technique and patients’ outcome. Arch Gynecol Obstet \n284(1): 131-135.\n11. Ceccaroni M, Pontrelli G, Scioscia M, Ruffo G, Bruni F, et al. (2010) \nNerve-Sparing Laparoscopic Radical Excision of Deep Endometriosis with \nRectal and Parametrial Resection. J Minim Invasive Gynecol 17(1): 14-5.\n12. Ceccaroni M, Clarizia R, Bruni F, D’Urso E, Gagliardi ML, et al. (2012) \nNerve-sparing laparoscopic eradication of deep endometriosis with seg -\nmental rectal and parametrial resection: The negrar method. A single-cen-\nter, prospective, clinical trial. Surg Endosc 26(7): 2029-2045.\n13. Comptour A, Lambert C, Chauvet P , Figuier C, Gremeau AS, et al. (2020) \nLong-Term Evolution of Quality of Life and Symptoms Following Surgical \nTreatment for Endometriosis: Different Trajectories for Which Patients? J \nClin Med 9(8): 2461.\n14. Rindos NB, Fulcher IR, Donnellan NM (2020) Pain and Quality of Life after \nLaparoscopic Excision of Endometriosis. J Minim Invasive Gynecol 27(7): \n1610-1617.\n15. Ceccaroni M, Roberto C, Francesco B (2016) Nerve-sparing laparoscopic \neradication of deep endometriosis with segmental rectal and parametrial \nresection: the Negrar method. A single-center, pro-spective, clinical trial. \nSurg Endosc 7: 2029-2045.\n16. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical com -\nplications: A new proposal with evaluation in a cohort of 6336 patients \nand results of a survey. Annals of Surgery. Ann Surg 240: 205-213.\n17. Tubaro A, Zattoni F, Prezioso D, Scarpa RM, Pesce F, et al. (2006) Italian \nvalidation of the International Consultation on Incontinence Question -\nnaires. BJU Int 97(1): 101-108\n18. Maiorana A, Scafidi Fonti GM, Audino P , Rosini R, Alio L, et al. (2012) The \nrole of EHP-30 as specific instrument to assess the quality of life of Italian \nwomen with endometriosis. Minerva Ginecol 64(3): 231-238.\n19. Jones G, Kennedy S, Barnard A, Wong J, Jenkinson C (2001) Development \nof an endometriosis quality-of-life instrument: The Endometriosis Health \nProfile-30. Obstet Gynecol 98(2): 258-264.\n\nCopyright@ : Veronica Sampogna | Biomed J Sci & Tech Res | BJSTR. MS.ID.008116.\n42802\nVolume 51- Issue 3\nDOI: 10.26717/BJSTR.2023.51.008116\nSubmission Link: https://biomedres.us/submit-manuscript.php\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nhttps://biomedres.us/\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nISSN: 2574-1241\nDOI: 10.26717/BJSTR.2023.51.008116\nVeronica Sampogna. Biomed J Sci & Tech Res \n20. Krogh K, Christensen P , Sabroe S, Laurberg S (2006) Neurogenic bowel \ndysfunction score. Spinal Cord 44(10): 625-631.\n21. Tubaro A, Zattoni F, Prezioso D, Scarpa RM, Pesce F, et al. (2006) Italian \nvalidation of the International Consultation on Incontinence Question -\nnaires. BJU Int 97(1): 101-108.\n22. Abrams P , Avery K, Gardener N, Donovan J (2006) The international con-\nsultation on incontinence modular questionnaire: www.iciq.net. J Urol \n175(3): 1063-1066.\n23. Raimondo D, Mabrouk M, Zannoni L, Arena A, Zanello M, et al. (2018) Se-\nvere ureteral endometriosis: frequency and risk factors. J Obstet Gynaecol \n(Lahore) 38(2): 257-260.\n24. Fauconnier A, Chapron C (2005) Endometriosis and pelvic pain: epidemi-\nological evidence of the relationship and implications. Hum Reprod Up -\ndate 11(6): 595-606.\n25. Abbott J, Hawe J, Hunter D, Holmes M, Finn P , et al. (2004) Laparoscopic \nexcision of endometriosis: A randomized, placebo-controlled trial. Fertil \nSteril 82(4): 878-884.\n26. Volpi E, Ferrero A, Sismondi P (2004) Laparoscopic identification of pelvic \nnerves in patients with deep infiltrating endometriosis. Surg Endosc Oth -\ner Interv Tech 18(7): 1109-1112.\n27. Uccella S, Gisone B, Serati M, Biasoli S, Marconi N, et al. (2018) Functional \noutcomes of nerve-sparing laparoscopic eradication of deep infiltrating \nendometriosis: a prospective analysis using validated questionnaires. \nArch Gynecol Obstet 298(3): 639-647.\n28. Landi S, Ceccaroni M, Perutelli A, Allodi C, Barbieri F, et al. (2006) Laparo-\nscopic nerve-sparing complete excision of deep endometriosis: Is it feasi-\nble? Hum Reprod 21(3): 774-781.\n29. Abo C, Moatassim S, Marty N, Saint Ghislain M, Huet E, et al. (2018) Post -\noperative complications after bowel endometriosis surgery by shaving, \ndisc excision, or segmental resection: a three-arm comparative analysis of \n364 consecutive cases. Fertil Steril 109(1): 172-178.e1.\n30. Daraï E, Dubernard G, Coutant C, Frey C, Rouzier R, et al. (2010) Random-\nized trial of laparoscopically assisted versus open colorectal resection for \nendometriosis: Morbidity, symptoms, quality of life, and fertility. Ann Surg \n251(6): 1018-1023.\n31. Turco LC, Scaldaferri F, Chiantera V, Cianci S, Ercoli A, et al. (2020) Long-\nterm evaluation of quality of life and gastrointestinal well-being after \nsegmental colo-rectal resection for deep infiltrating endometriosis (EN -\nDO-RESECT QoL). Arch Gynecol Obstet 301(1): 217-228.\n32. Parra RS, Feitosa MR, Camargo HP de, Valério FP , Zanardi JVC, et al. (2021) \nThe impact of laparoscopic surgery on the symptoms and wellbeing of pa-\ntients with deep infiltrating endometriosis and bowel involvement. J Psy-\nchosom Obstet Gynecol 42(1): 75-80.","source_license":"CC0","license_restricted":false}