{"paper_id":"d1d66764-0ac3-40b9-8baf-6aa1a3af3245","body_text":"Effect of Surgical Treatment for Deep In filtrating\nEndometriosis on Pelvic Floor Disorders:\nA Systematic Review with Meta-analysis\nEfeito do tratamento cirúrgico para endometriose\ninfiltrante profunda nas disfunções do assoalho pélvico:\nUma revisão sistemática com metanálise\nMirian Vieira Fraga 1 Cristina Laguna Benetti-Pinto 1 Daniela Angerame Yela 1\nTiciana Alves de Mira 1 Luiz Gustavo Oliveira Brito 1\n1 Department of Obstetrics and Gynecology, School of Medical\nSciences, Universidade Estadual de Campinas, Campinas, SP , Brazil\nRev Bras Ginecol Obstet 2022;44(5):503 –510.\nAddress for correspondence Luiz Gustavo Oliveira Brito, MD, PhD,\nRua Alexander Fleming, 101, Cidade Universitária, Campinas, SP ,\nBrazil (e-mail: lgobrito@unicamp.br).\nKeywords\n► systematic review\n► endometriosis\n► fecal incontinence\n► urinary incontinence\n► pelvic floor\nAbstract Objectives To evaluate the impact of surgical treatment of deep in filtrative endome-\ntriosis (DIE) on pelvic floor dysfunction (urinary incontinence [UI], pelvic organ prolapse\n[POP], fecal incontinence [FI)] or constipation, and sexual function [dyspareunia]).\nData Source The present systematic review was performed in the PubMed database.\nFor the selection of studies, articles should be published by January 5, 2021, without\nlanguage restriction.\nStudy Selection Six randomized controlled studies that evaluated surgical treatment\nfor DIE and the comparison of different surgical techniques were included.\nData Collection The studies were selected independently by title and abstract by two\nauthors. Disagreements were resolved by a third author. All included studies were also\nevaluated according to the Cochrane risk of bias tool and the quality of the evidence\nwas analyzed using the GRADE criteria. Subgroup analysis by different treatments and\nfollow-up periods was also performed.\nResults Six studies were included in the quantitative analysis. The risk of bias between\nstudies showed an uncertain risk of bias for most studies, with concealment of\nallocation being the least reported cat egory. The quality of the evidence was\nconsidered low. High heterogeneity was found between the studies. No study has\nevaluated UI or POP comparatively before and after surgery.\nConclusion Dyspareunia and FI have improved after the surgical procedure, but it was\nnot possible to demonstrate which surgical technique was related to these outcomes as\nthere was surgical heterogeneity. This diversity was found across data, with the\nrecommendation of future prospective studies addressing pelvic floor disorders with\nDIE.\nreceived\nApril 2, 2021\naccepted\nNovember 3, 2021\npublished online\nFebruary 17, 2022\nDOI https://doi.org/\n10.1055/s-0042-1742293.\nISSN 0100-7203.\n© 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights\nreserved.\nThis is an open access article published by Thieme under the terms of the\nCreative Commons Attribution License, permitting unrestricted use,\ndistribution, and reproduction so long as the original work is properly cited.\n(https://creativecommons.org/licenses/by/4.0/)\nThieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de\nJaneiro, RJ, CEP 20270-135, Brazil\nTHIEME\nReview 503\nArticle published online: 2022-02-17\n\nIntroduction\nEndometriosis affects 10% of the female population. Its main\nsymptoms are pelvic pain and infertility. For pain, women\nmay refer dysmenorrhea, chronic pelvic pain, dyschezia,\ndysuria, and dyspareunia. 1 For deep in filtrative endometri-\nosis (DIE), gastrointestinal manifestations (between 3.8 and\n37%)2 can be more intense and with major repercussions. The\nurinary tract can be involved (bladder endometriosis) in\nbetween 0.3 and 12% of the cases and may also compromise\nthe quality of life of women.\n3\nThe literature has several systematic reviews on the\nimpact of conservative and/or surgical treatment of DIE.\nHowever, pelvic floor dysfunctions before and after treat-\nment of endometriosis are not so deeply explored. When\nsurgery is performed without focusing on nerve-sparing\ntechniques or without carefully revising the anatomy, the\nrisk for urinary incontinence (UI), fecal incontinence (FI), and\nother dysfunctions are possibly increased. An observational\nstudy assessing 138 women with DIE has shown that the\npresence of endometriosis in the bladder was an indepen-\ndent predictor of low bladder compliance, whereas the\npresence of endometriosis in the parametrium was predictor\nof voiding dysfunction.\n4–6 A recent systematic review has\nfound that colorectal surgery for endometriosis has a signi fi-\ncant impact on urinary function regardless of the technique. 6\nWe can even find in the literature an association between\nbladder endometriosis and UI. 5\nHowever, we do not have data pooled and analyzed into a\nsystematic fashion, with analysis of the quality of evidence\nabout pelvic floor dysfunctions and DIE or bladder endome-\ntriosis. Given that, we sought to systematically review the\nliterature for studies that addressed pelvic floor dysfunctions\nwith DIE before and/or after treatment.\nMethods\nSearch Strategy\nThe present systematic review was performed according to\nthe preferred reporting items for systematic review and\nmeta-analysis (PRISMA) guidelines\n7 (►Fig. 1 )a n dw a sr e g i s -\ntered in the PROSPERO database (CRD42020197049).\nWe have included randomized controlled studies that\nassessed surgical treatment for DIE and have compared the\nutilized techniques. We have excluded all studies that did not\nanalyze pelvic floor dysfunctions, case reports, animal\nand/or experimental studies. The following outcomes were\nincluded: UI or FI, de fined by self-report or any measurable,\nResumo Objetivos Avaliar o impacto do tratamento cirúrgico para endometriose in filtrante\nprofunda (EIP) nas disfunções do assoalho pélvico (incontinência urinária [IU], prolapso\nde órgãos pélvicos [POP], incontinência fecal [IF] ou constipação e função sexual\n[dispareunia]).\nF o n t ed eD a d o s A presente revisão sistemática foi realizada na base de dados\nPubMed. Para a seleção dos estudos, os artigos deveriam ser publicados até 5 de\njaneiro de 2021, sem restrição de idioma.\nSeleção dos Estudos Foram incluídos seis estudos randomizados e controlados que\navaliaram o tratamento cirúrgico para EIP e a comparação de diferentes técnicas\ncirúrgicas.\nColeta de Dados Os estudos foram selecionados de forma independente por título e\nresumo por dois autores. As discordâncias foram avaliadas por um terceiro autor. Todos\nos estudos incluídos foram avaliados de acordo com a ferramenta Cochrane de risco de\nviés e a qualidade de evidência foi analisada usando os critérios GRADE. A análise de\nsubgrupo por diferentes tratamentos e períodos de acompanhamento também foi\nrealizada.\nResultados Seis estudos foram incluídos na análise quantitativa. O risco de viés\nmostrou um risco incerto de viés para a maioria dos estudos, sendo a ocultação da\nalocação a categoria menos relatada. A qualidade de evidência foi considerada baixa.\nAlta heterogeneidade foi encontrada entre os estudos. Nenhum estudo avaliou a IU ou\no POP comparativamente antes e após a cirurgia.\nConclusão A dispareunia e a IF melhoraram após o procedimento cirúrgico, mas não\nfoi possível demonstrar qual técnica cirúrgica esteve relacionada a estes desfechos,\npois houve heterogeneidade cirúrgica. Esta diversidade foi encontrada nos dados, com\na recomendação de estudos prospectivos futuros abordando distúrbios do assoalho\npélvico com EIP.\nPalavras-chave\n► revisão sistemática\n► endometriose\n► incontinência fecal\n► incontinência urinária\n► assoalho pélvico\nRev Bras Ginecol Obstet Vol. 44 No. 5/2022 © 2022. Federação Bra sileira de Ginecologia e Obste trícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al.504\n\n\nvalidated, or nonvalidated scale or questionnaire, following\nthe IUGA/ICS recommendations for pelvic floor dysfunction\nterminology; pelvic organ prolapse (POP), whether symp-\ntomatic or by physical examination, constipation, and dys-\npareunia. Quality of life questionnaires related to pelvic floor\ndysfunctions were also included.\nWe have consulted the PubMed database on 5 January,\n2021; no studies were excluded due to language restrictions.\nThe following strategy was utilized: ((((((( urinary inconti-\nnence)O R( incontinence)) OR ( fecal incontinence )) OR ( con-\nstipation)) OR ( pelvic organ prolapse )) OR ( prolapse)) OR\n(urodynamics)) OR ( pelvic floor muscle )) OR ( dyspareunia)\nAND (endometriosis ). We intended to produce a broad search\nstrategy because we hypothesized that we would have\ndifficulties to retrieve data.\nStudy Selection, Data Extraction, and Risk of Bias\nStudies were independently selected by title and abstract by\ntwo authors (Fraga M. V. and TAAM). Discordances were\nsolved by a third author (Brito L. G. O.). Data extraction was\nperformed in a previous spreadsheet pilot-tested and\nblinded for both authors. All included studies were also\nassessed according to the Cochrane risk of bias tool\n8,9 and\nthe quality of evidence was analyzed by the GRADE criteria. 9\nRisk of bias analyzes five domains (selection, attrition, re-\nport, and other biases). The GRADE criteria consider the\nstrength of other recommendations according to the pre-\nsented variables.\nData Analysis\nMeta-analysis was considered when at least two studies\ncould be pooled. Heterogeneity was classi fied according to\nthe i2 test10 and a random-effect model was applied to data\nwhen i 2 was > 50%. Continuous variables were described as\nmean difference plus standard deviation (SD). Some out-\ncomes were described as median plus interquartile ranges\n(IQRs) and their data were transformed into mean plus SD\naccording to the following formula (median ¼ mean, SD ¼\nIQR/1.35). Dichotomous variables were transformed into\nodds ratio (OR) plus 95% con fidence intervals (CIs) with\nlower and upper limits. A subgroup analysis before and after\ntreatment was performed for each treatment and pooled\ninto forest plots. No funnel plots were built to assess\npublication bias as we did not have enough studies to\nperform this analysis. Statistical analysis was revised by\nReview Manager version 5.4 (The Cochrane Collaboration,\nCopenhagen).\nResults\nStudy Selection and Characteristics\n►Fig. 1 depicts the process for data selection and extraction.\nAfter excluding duplicates, 1,301 studies were selected, and\nafter another screening, 83 studies were fully read. Finally, 6\nstudies were selected, comprising 346 women. All manu-\nscripts included women with DIE.\n11–16\nFour studies were performed in France, 11–14 one in\nPoland15 and one in Italy. 16 For assessing dyspareunia, the\nvisual analogic scale (VAS) 11–13; the numeric classi fication\nscale,15 and the multidimensional punctuation system of\nAndersch16 were used. For gastrointestinal symptoms,\nwe have found the following questionnaires: Knowles –\nEccersley – Scott (KESS) symptom questionnaire, gastroin-\ntestinal index of quality of life (GIQLI), and Wexner\nscore.\n12–14 For urinary symptoms, we have found the Urinary\nSymptom Pro file (USP). 12–14 None of the studies criteria\nassessed UI and POP comparatively before and after surgery.\nMost studies analyzed dyspareunia. 11–13,15,16 Only three\nstudies12–14 have assessed the complaints of FI.\nThe surgical techniques compared were laparoscopically\nassisted or open colorectal resection surgery 11; conservative\nsurgery (shaving or disc excision) or radical rectal surgery\n(segmental resection)\n12–14; laparoscopy treatment using\nelectroablation versus CO2 laser ablation,15 and conservative\nsurgery alone or conservative surgery and presacral\nneurectomy.\n16\nThe primary outcomes of the studies were characterized\nby the relief of dyspareunia and the evaluation of gastroin-\ntestinal symptoms (constipation and fecal loss). The other\noutcomes proposed by the review were not analyzed as they\nwere not found during data selection/extraction.\nRisk of Bias and GRADE Evaluation\nThree studies reported having performed a sample size\ncalculation.\n12,14,16 Two studies 12,13 included the intention\nto treat analysis. Three studies 14–16 presented uncertain risk\nfor randomization. For allocation bias, Daraï et al. 11 had an\nuncertain risk and Roman et al. 12 presented a low risk, while\nthe others had a high risk. One study 15 reported high risk of\nbias and two were categorized as low-risk.11,12 Regarding the\nFig. 1 Flowchart diagram of identi fied studies.\nRev Bras Ginecol Obstet Vol. 44 No. 5/2022 © 2022. Federação Bras ileira de Ginecologia e Obstetrícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al. 505\n\n\nrest of risk of bias, only Roman et al. 12 reported low risk of\nbias, whereas the others were labeled uncertain ( ►Fig. 2 ).\nAbout the quality of evidence and the strength of recom-\nmendation according to the GRADE criteria, the studies\npresented a very low quality of evidence regarding reducing\ndyspareunia (MD: 1.18; 95%CI: 1.46 –1.90; 3 studies, 167\nwomen) and gastrointestinal complaints (KESS: MD: 1.63 for\nconstipation; 95%CI: 1.82 –1.43; 3 studies, 355 women;\nWEXNER: MD 0.25 for FI; 95%CI: 0.38 –0.11; 3 studies, 355\nwomen; GIQLI: MD 26.56 of gastrointestinal quality of life;\n95% CI: 25.74 –27.38; 3 studies, 355 women).\nResults from Individual Studies\n►Chart 1 describes the general characteristics of the studies\nselected for the review.\nDyspareunia\nFive studies 11–13,15,16 evaluated dyspareunia, with only\none16 specifying having assessed dyspareunia in depth. Daraï\net al.,11 comparing laparoscopically assisted or open colorec -\ntal resection surgery techniques, found a signi ficant im-\nprovement in dyspareunia after surgery, with a median\npain of 1 (0 to 8) (p < 0.0001), but with no difference between\nthe techniques.\nRoman et al. 12 evaluated the results after conservative\nsurgery (shaving or disc excision) and radical rectal\nsurgery (segmental resection), with no difference be-\ntween groups after 24 months (median dyspareunia of\n3( 2t o3 )a n d4( 3t o6 ) ,r e s p e c t i v e l y ;p ¼ 1.00). In another\nstudy by the same group,\n13 comparing shaving, disc\nexcision or segmental resection 5 years after the surgery,\nthey demonstrated a reduction in dyspareunia, with no\nstatistically signi ficant difference between the surgical\ntechniques.\nPosadzka et al.\n15 compared electroablation versus lapa-\nroscopy CO2 laser ablation and found an improvement in\ndyspareunia at 3 months after surgery; however, at 6 months,\nthere was an increase in the symptom score within both\ngroups.\nCandiani et al.\n16 compared the surgical techniques of\nconservative surgery alone or conservative surgery with\npresacral neurectomy. The authors have found a reduction\nin moderate and severe dyspareunia and an increase in the\nnumber of asymptomatic women in both groups. However,\nthey have concluded that presacral neurectomy did not add\nsignificant improvement in the performance of conservative\nsurgery alone.\nGastrointestinal Symptoms\nOnly three studies 12–14 evaluated the complaint of FI, classi-\nfying it as an involuntary loss of gas or feces, and they are\nfrom the same group. Roman et al. 12 compared shaving/disc\nexcision versus segmental resection and, after 24 months,\nthey found an improvement in FI symptoms within both\ngroups, but with no difference between them (p ¼ 0.83). They\nalso used assessment of gastrointestinal symptoms using the\nGIQLI score (low scores are related to a worse result) and,\nafter treatment, the scores increased in both groups, but with\nno signi ficant difference between them ( p ¼ 0.64). Wexner\nscores before and after treatment behaved the same way\n(p ¼ 0.42).\nThe second study\n13 presented a longer follow-up period\n(5 years) and the authors have also noticed symptom im-\nprovement, but with no difference between groups\n(p ¼ 0.42). The presurgical evaluation using the GIQLI,\nKESS, and Wexner score questionnaires showed improve-\nment in the functional results, but with no difference be-\ntween the groups. A third study\n14 has found the same results.\nSubgroup Meta-analysis\nIn the subgroup meta-analysis, it can observed that there was\na decrease in dyspareunia after surgical intervention (MD: -\n0.82 [- 1.05 –- 0.59] ( p < 0.00001) (\n►Fig. 3 ); however, an\nimportant heterogeneity is found as each study represents\na different intervention (Chi 2:3 0 . 3 1 ;I2: 87%). The same can\nbe observed for constipation ( ►Fig. 4 ) (assessed by the Kess\nquestionnaire) ( ►Fig. 4a ) and FI (assessed by the Wexner\nscale) (►Fig. 4b ); there was an improvement for both (MD: -\n1.63 [- 1.82 –-1 . 4 3 ] ;p < 0.00001; MD: - 0.25 [- 0.38 –- 0.11];\np ¼ 0.006), with high heterogeneity (I 2:9 8a n d6 4 % ) .W ec a n\nobserve the same pattern for gastrointestinal quality of life,\nwith the improvement of the GIQLI questionnaire (MD: 26.56\n[25.74–27.28]; p ¼ 0.0003), with high heterogeneity (I\n2: 74%)\n(►Fig. 4c ).\nFig. 2 Risk of bias summary.\nRev Bras Ginecol Obstet Vol. 44 No. 5/2022 © 2022. Federação Bra sileira de Ginecologia e Obste trícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al.506\n\n\nChart 1 General characteristics of the included studies\nAuthor/ Year Sample Intervention Follow-up Assessment methods Preoperative PFDs FI UI Dyspareunia POP\nDaraï et al.\n(2010)11\nn ¼52\nLaparoscopy ( n ¼ 26)\nversus open surgery\n(n ¼ 26)\nLaparoscopy versus\nopen surgery\n1 and 6 months,\nthen every\n6 months up to 3\nyears\n1.Pain\nVAS\nThere is no report in\nthe study\nThere is no report in the\nstudy\nThere is no\nreport in the study\nWhen the overall re-\nsult was assessed,\nthere was a reduction\nin pain in both groups.\nHowever, when ana-\nlyzed separately, the\nreduction of the com-\nplaint was not\nsignificant\nThere is no report in\nthe study\nRoman et al.\n(2018)\n12\nn¼ 60\nConservative surgery\n(n ¼ 27) versus\nRadical surgery ( n ¼ 33)\nConservative surgery\nversus radical rectal\nresection\n6-month intervals\nfor 2 years\n1.Fecal Incontinence-\nGIQLI, Kess and Wex-\nner score\n2. Urinary Inconti-\nnence USP score\n3. Pain and quality of\nlife\nVAS and SF-36\nPatients presented\ngastrointestinal disor-\nders such as fecal in-\ncontinence and gas\nloss, in addition to\ndyspareunia in both\ngroups studied\nBoth groups had gastroin-\ntestinal disorders after the\n24-month evaluation, with\nno significant difference for\nthe types of surgery\nThere is no report in\nthe study\nDespite the reduction\nin VAS in the groups\nstudied, there was no\nsignificant difference\nfor the types of\nsurgery\nThere is no report in\nthe study\nRoman et al.\n(2019)\n13\nn¼ 55\nExcision ( n ¼ 27)\nversus Resection ( n ¼ 28)\nExcision versus Colo-\nrectal segmental\nresection\n5 years 1. Fecal Incontinence\nGIQLI, Kess, and Wex-\nner score\n2.Urinary Inconti-\nnence USP score\n3. Pain and quality of\nlife\nVAS and SF-36\nPatients presented\ngastrointestinal disor-\nders such as fecal in-\ncontinence and gas\nloss, in addition to\ndyspareunia in both\ngroups studied\nBoth groups had gastroin-\ntestinal disorders after a 5-\nyear assessment. Despite\nthe improvement when\ncompared with preopera-\ntive values, there was no\nsignificant difference be-\ntween the groups\nThere is no report in\nthe study\nDespite the reduction\nin VAS in the groups,\nthere was no signi fi-\ncant difference for the\ntypes of surgery\nThere is no report in\nthe study\nRoman et al.\n(2019)\n14\nn ¼ 60\nConservative surgery\n(n ¼ 27) versus segmental\nresection ( n ¼ 33)\nConservative surgery\nversus segmental\nresection\n6,12,18 and 24\nmonths\n1.Fecal Incontinence\nGIQLI, Kess and Wex-\nner score\n2.Urinary Inconti-\nnence USP score\nPatients had gastroin-\ntestinal disorders such\nas fecal incontinence\nand gas loss in both\ngroups. The groups\nwere not analyzed\nseparately regarding\nthe type of surgery\nBoth groups showed sig-\nnificant improvement after\nan evaluation when com-\npared together. When an-\nalyzed separately, there\nwas no signi ficant differ-\nence between groups\nThere is no report in\nthe study\nThere is no report in\nthe study\nThere is no report in\nthe study\nPosadzka\net al. (2015)\n15\nn¼ 48\nElectroablation\n(n ¼ 33) versus CO2 laser\nablation ( n ¼ 15)\nElectroablation of en-\ndometriosis versus\nCO2 laser ablation\n3 and 6 months 1. Pain\nNRS\nBoth groups had\ndyspareunia.\nThere is no report in the\nstudy\nThere is no report in\nthe study\nAfter an initial im-\nprovement veri fied in\n3 months, the com-\nplaint worsened sig-\nnificantly in the exam\nof 6 months for the\nCO2 laser group. For\nthe electroablation\ngroup, the complaint\nalso increased signi fi-\ncantly, 50% of the\npatients reported a\nlevel /C21 10 points after\n6 months\nThere is no report in\nthe study\nCandiani\net al. (1992)\n16\nn ¼ 71\nConservative surgery\n(n ¼ 36) versus Presacral\nneurectomy ( n ¼ 35)\nConservative surgery\nversus Presacral\nneurectomy\n12 months 1. Pain\nAndersch and Milsom\nMultidimensional\nScoring System\nBoth groups had dys-\npareunia (mild, mod-\nerate, and severe)\nThere is no report in the\nstudy\nThere is no report in\nthe study\nAlthough not signi fi-\ncant, there was a re-\nduction in complaints\nin both groups\nThere is no report in\nthe study\nAbbreviations: GIQLI, Gastrointestinal Quality of Life index; KESS, Knowles Eccersley Scott Symptom; NRS, Numerical Rating Scale; SF-36, Short Fo rm Health Survey 36; USP, Urinary Symptom Pro file; VAS, Visual\nAnalogue Scale.\nRev Bras Ginecol Obstet Vol. 44 No. 5/2022 © 2022. Federação Bras ileira de Ginecologia e Obstetrícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al. 507\n\n\nDiscussion\nAlthough the present review found studies that addressed\nthe effect of the surgical treatment of DIE on pelvic floor\ndysfunctions, the heterogeneity of the studies did not make it\npossible to gather and analyze all the data. Within the\nsubgroup analysis, it was possible to observe the bene fits\nof surgical treatment for some pelvic floor disorders (dyspar-\neunia and FI), but without superiority for a technique.\nAccording to the GRADE tool, the quality of the evidence\nwas very low for both symptoms evaluated, that is, reduction\nof dyspareunia and improvement of gastrointestinal symp-\ntoms. None of the selected studies evaluated the presence\nand/or alteration of UI and POP.\nAmong the studies that analyzed dyspareunia, although\nmost of them suggested a reduction in this symptom after\nsurgical treatment, one of them\n15 revealed a resurgence of\nthe symptom at the same level after 6 months, indicating the\nneed for long-term evaluations. Through the meta-analysis,\nit was possible to con firm the results presented individually\nby the authors; however, the high heterogeneity among\nthem is noteworthy. In the same direction, a recent system-\natic review that included only two surgical techniques\n(laparoscopic excision compared with laparoscopic ablation)\nfor endometriosis and their effects on dyspareunia showed\nthat both reduced the symptom, with no difference between\nthe two techniques.\n17\nLikewise, we can point out that studies are scarce in the\nanalysis of the dyspareunia response; they are even more\nrestricted to gastrointestinal symptoms, such as FI. Although\nwe have demonstrated, through meta-analysis, the improve-\nment of symptoms of FI, the evidence is also not robust enough\nto indicate the superiority of one technique over another, with\nimportant heterogeneity between studies. Considering non-\ncomparative studies, Erdem et al.,\n18 in a cohort study of 48\nwomen with DIE, assessed long-term functional results (post-\noperative bowel movement and FI) after rectal resection,\nshowing improvement in FI. A cohort study by Riiskjaer\net al.\n19 that evaluated 128 patients, before and after laparosco-\npic intestinal resection, also observed an improvement in the\nevacuation procedure 1 year after surgery.\nGastrointestinal symptoms usually present before surgi-\ncal intervention, according to some authors, can predict\npostoperative results, which are worse the greater the sever-\nity of symptoms, indicating that surgical removal of the\nlesions may not completely reduce the symptoms.\n20,21\nSuch data indicate that symptoms related to the pelvic floor\nshould be evaluated before the surgical procedure. Their\npresence can directly interfere with functional results after\nsurgery, requiring long-term follow-up.\nWe did not find data regarding dysfunctions related to UI\nand POP that could be included in a robust methodological\nanalysis, although the literature draws attention to the risk of\nimpaired urinary control when DIE is surgically treated.\n22\nConsidering the extent of endometriotic lesions and the\nextent of surgical procedures performed, a potential effect\non such pelvic floor dysfunctions may occur.\nConsidering that one of the most important indications\nfor the surgical treatment of DIE is the control of pain\nsymptoms, the present review has its main strength in\ndemonstrating that surgeries, regardless of the technique\nused, can reduce dyspareunia and intestinal complaints, but\nalso it has its greatest weaknesses when it demonstrates the\ngreat heterogeneity between the studies about the compar-\nator group and the different instruments used to evaluate the\nresults, as well as differences between the follow-up period\nacross studies. Thus, groups of experts must meet and\nindicate methodologies that guide the authors when plan-\nning and executing prospective controlled studies to treat\nsymptomatic women with DIE, evaluating the possible\nimplications on pelvic floor dysfunctions.\nConclusion\nDyspareunia and FI improved after the surgical procedure,\nbut it was not possible to demonstrate which surgical\ntechnique was related to these outcomes, as there was\nsurgical heterogeneity. This diversity was found in the\ndata, recommending future prospective studies addressing\nUI, POP and FI so that more robust evidence can be provided\nto health professionals about the association of DIE and\npelvic floor disorders.\nFig. 3 Subgroup analysis for dyspareunia comprising two s tudies across each group before and after surgery.\nRev Bras Ginecol Obstet Vol. 44 No. 5/2022 © 2022. Federação Bra sileira de Ginecologia e Obste trícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al.508\n\n\nFig. 4 Subgroup analysis for gastrointestinal symptoms. ( A) Subgroup analysis for gastrointestinal symptoms (KESS questionnaire) comprising\ntwo studies across each group before and after surgery. ( B) Subgroup analysis for gastrointestinal symptoms (WEXNER questionnaire)\ncomprising two studies across each group before and after surgery. ( C) Subgroup analysis for gastrointest inal symptoms (GIQLI questionnaire)\ncomprising two studies across each group before and after surgery.\nRev Bras Ginecol Obstet Vol. 44 No. 5/2022 © 2022. Federação Bras ileira de Ginecologia e Obstetrícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al. 509\n\n\nConflict of Interests\nThe authors have no con flict of interests to declare.\nReferences\n1 Falcone T, Flyckt R. Clinical management of endometriosis. Obstet\nGynecol. 2018;131(03):557 –571. 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Federação Bra sileira de Ginecologia e Obste trícia. All rights reserved.\nDeep Infiltrating Endometriosis on Pelvic Floor Disorders Fraga et al.510","source_license":"CC0","license_restricted":false}