Impact on Quality of Life of Laparoscopic Nerve-sparing Radical Treatment of Parametrial Deep Infiltrating Endometriosis (Postoperative Pain Assessment and Functional Outcomes)

Impact on Quality of Life of Laparoscopic Nerve-sparing Radical Treatment of Parametrial Deep Infiltrating Endometriosis (Postoperative Pain Assessment and Functional Outcomes) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact on Quality of Life of Laparoscopic Nerve-sparing Radical Treatment of Parametrial Deep Infiltrating Endometriosis (Postoperative Pain Assessment and Functional Outcomes) Carlo Alboni, Veronica Sampogna, Mirvana Airoud, Stefania Malmusi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1021436/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Complete eradication of parametrial nodules of Deep Infiltrating Endometriosis (DIE) is associated with a high risk of iatrogenic nerves damage and pelvic organs dysfunction. The aim of this study is to evaluate via validated questionnaires the effect of laparoscopic excision of parametrial DIE on quality of life as first outcome and on pain symptoms and post- operative voiding function (bladder and rectal) as secondary outcome. Study design: All patients undergoing laparoscopic excision of posterior or lateral parametrial DIE by a single expert surgeon between January 2013 and March 2017 were included in the study. A nerve-sparing approach was adopted in all patients. Quality of life (QoL) and Functional outcomes were evaluated using validated questionnaires (EHP-30 for the health profile, NBD score for intestinal function, ICIQ-FLUTS for urinary function), administered preoperatively and after surgery. Pain scores were collected before and after surgery using Visual Analogue Scale (VAS). Results: During the study period a total of fifty-nine patients met the inclusion criteria. Fifty-one patients agreed to fill out questionnaires for post-operative outcomes. EHP-30 scores had a significant improvement in all the domains analyzed even in the relationship with children and fertility module despite to the small number of patients answering those questions. No differences were found in terms of urinary function between pre and post-operative questionnaires (ICIQ-FLUTS). Bowel function improved in patients’ subjective perception. The NBD score showed that intestinal dysfunction related only to constipation and was reported as very minor by 76.4% of patients, minor by 11.8%, moderate by 5.9% by and severe by 5.95% of patients. Pain symptoms (VAS score) decreased significantly after surgery with the exception of chronic pelvic pain. (p value < 0,05). Conclusions: Laparoscopic nerve-sparing radical excision of parametrial DIE is safe and effective when performed by an expert surgical equipe. This approach can favorably impact on patients QoL. Moreover, it has proved to result in pain score and voiding function improvements. Obstetrics & Gynecology Parametrial endometriosis laparoscopy deep endometriosis outcomes nerve-sparing quality of life Figures Figure 1 Figure 2 1. Introduction Endometriosis is a chronic inflammatory disease, characterized by ectopic proliferation of endometrial glands and stroma. It is estimated that it can affect up to 2-10 % of reproductive age women, 20-50% of infertile women and 30-80% of women with chronic pelvic pain. (1)(2)(3)(4)(5) In its deeply infiltrating form (DIE) the disease affects up to 34% of women with pelvic endometriosis. The DIE is a specific clinical entity characterized by an extension of the disease more than 5 mm under the peritoneal surface, retroperitoneal fibrosis and neural tropism with distortion of the regular pelvic anatomy. (6)(7)(8)(9) DIE affects most frequently uterosacral ligaments (69.2%), rectovaginal septum (14.5%), bowel (9.9%) and bladder (4.2%). (10) In a retrospective study, Fauconnier et al. (11) demonstrate that different types of chronic pelvic pain are related to the anatomic location of DIE. In recent years a growing attention was pointed out on parametrial localization of deep infiltrating nodules with studies investigating diagnosis, treatment and clinical outcomes. (12)(13)(14)(15) The parametrium has been described as the supporting system of the uterus that anchors the organ to the lateral pelvic wall and has both supply-drainage and fascial functions (16). All the three components (anterior, posterior, lateral) in which the parametrium is normally classified can be infiltrated by DIE. More often DIE lesions are at the level of the posterior and lateral part of the parametrium associated to retrocervical, bowel and ureteral nodules(17)(18). This pattern of lesions distribution can be associated with ureteral and bowel function impairment and often with chronic pelvic pain symptoms expressed as dyspareunia and dyschezia (14)(11). Due to these symptoms, endometriosis may have a profound impact on quality of life and mental health of the patients affected. In 2004 Abbot et al. (19) demonstrated that surgical excision of endometriosis determines a symptomatic improvement significantly more than placebo. The lateral parametrium has a ventral component called pars vasculosa and a dorsal part defined as pars nervosa because it contains the nerve branches of autonomic pelvic organs innervation, therefore the complete eradication of the disease is associated with the risk of serious impairment of rectal, bladder and sexual function due to the iatrogenic disruption of inferior hypogastric plexus. Different authors have described the nerve-sparing approach in case of DIE nodules (20)(21)(22). In 2012, a prospective cohort study compared the laparoscopic nerve-sparing approach to the classical laparoscopic procedure demonstrating the feasibility of radical removal of fibrotic infiltrating endometriosis tissue from parametrial structures avoiding disruption of autonomic pelvic organs innervation.(23) There has been a growing interest in recent years on analyzing QoL after laparoscopic surgery for endometriosis. However, despite the large amount of literature on surgical techniques and diagnostic assessment of parametrial endometriosis, only a few studies have specifically addressed data on functional outcomes, and, to the best of our knowledge, no one was published investigating patient’s QoL with validated questionnaires. (24) (25) The aim of this study is to use validated questionnaires to evaluate patients’ response to laparoscopic nerve-sparing excision of parametrial DIE in terms of self-perceived well-being, pain relief and voiding function. 2. Materials And Methods This study was approved by the local Ethics Committee (protocol number 0024582/19), and all patients expressed their informed consent to anonymous data collection. All patients that underwent laparoscopic surgery for endometriosis in the period between January 2013 and March 2017 at Obstetrics and Gynecology Division of the Sassuolo Civil Hospital and at the Endometriosis tertiary level referral center of the University Hospital of Modena were enrolled. All surgeries were performed by the same surgeon with high expertise in laparoscopic treatment of endometriosis (C.A.) and patients with histologically confirmed laparoscopic resection of posterior and lateral parametrium were selected. Exclusion criteria were age < 18, preoperative diagnosis of neurogenic bladder and bowel inflammatory disease and absence of sexual activity. All patients underwent speculum examination, pelvic bimanual vagino-rectal evaluation and transvaginal ultrasound performed by an expert sonographer expert in endometriosis diagnosis. A transabdominal ultrasound scan of the kidneys was also routinely performed to rule out hydroureteronephrosis (an indirect marker for parametrial nodules). (19) Eventually, they underwent pelvic magnetic resonance with rectal injection of 10-50 ml of sterile gel to confirm dimension and depth of infiltration of the bowel lesions (if any) and to define the parametrial/ureteral involvement. All patients signed a specific informed consent before surgery, specifying the preoperatively diagnosed localization of lesions, all surgical procedures necessary for their complete excision and the potential risks (vascular, neurologic, urologic and intestinal) related to the type of surgery. Patients were hospitalized the same day of the intervention. A nerve-sparing laparoscopic surgical technique was implemented for all the surgeries (23). In case of bowel lesions infiltrating the muscularis interna and causing a stenosis of more than 50% of the lumen in patients symptomatic for bowel dysfunction, a segmental resection with Knight-Griffen technique and end-to-end anastomosis was performed by an equipe of general surgeons.(27) A protective ileostomy was routinely done in case of ultra-low rectal segmental resection (resection margin < 5 cm from the dental line). Antibiotics were administered for 48 hours postoperatively. The data on patient age, parity, body mass index, previous abdominopelvic surgery, operating time, amount of blood loss, use of hormonal therapy, length of hospital stay were recorded, while intraoperative, early and late postoperative complications were analysed according to the Clavien-Dindo classification system.(28) Pain symptoms were investigated using the visual analogue scale (VAS) and the different need of analgesic drugs was evaluated at the preoperative visit (range 10-45 day before surgery) and at the follow up evaluation after three months. For the comparative analysis of dysmenorrhea with VAS scale, patients underwent hysterectomy and patients with post-operative continuous hormonal therapy were excluded. Quality of life and functional and status outcomes were collected using the italian validated version of three questionnaires (29), administered in paper form, one month before surgery and three months after the intervention. The Endometriosis Health Profile-30 Questionnaire (EHP-30) was used to evaluate the global health profile of the patients (30)(31)(32) as primary outcome of our study. The EHP-30 consists of 30 questions about pain, control and powerlessness, emotional well-being, social support and self-image. Currently is the only questionnaire that evaluates QoL specifically in patients with endometriosis. For bowel function the Neurogenic Bowel Dysfunction (NBD) score was used (33), whereas the urinary function was evaluated using the International Consultation on Incontinence-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) (34,35). 2.1 Statistical analysis Data were expressed as mean±standard deviation for numerical variables and as numbers (percentages) for categorical variables. The Wilcoxon test was used to compare changes in variables between before and after the surgical treatment. P value of <0.05 denoted statistical significance. All statistical analyses were performed using SPSS software (version 21, SPSS, Inc., Chicago, IL, USA). 3. Results During the study period a total of sixty-five patients underwent nerve-sparing surgery for parametrial deep infiltrating endometriosis. Fifty-nine patients met the inclusion criteria and were included and fifty-one of these agreed to fill out questionnaires for postoperative outcomes evaluation. Median age was 36 ± 6.2 years. The majority of these patients were married or a common-law wife (72.5%) and employed (88.2%) at the time of surgery. Demographic characteristics of patients are provided in Table 1. Eight patients had had previous surgery for endometriosis (15.6%) and twenty-seven were nulliparous (53%). Diagnosis of parametrial endometriosis was confirmed by histological examination in all patients included. Laparoscopic approach was used in all cases, no conversion to open surgery occurred. Laparoscopic segmental bowel resection was performed in fifteen patients, while discoid resection was performed in only one. Three patients needed protective ileostomy for ultra-low rectal anastomosis. Operative details and procedures are summarized in Table 3 . The mean operating time was 239 +/- 111 minutes, the mean estimated blood loss during surgery was 165 +|- 59.9 mL (range 50-1020 mL) and the mean hospital stay was 6 days (range 3-12 days). The average length of the removed intestinal segments was 12.5 cm (+/- 5,7). In thirty-seven patients (62,7%) parametrial endometriosis was unilateral, in 22% of cases both posterior and lateral parametrium were involved and in 15.3% of cases posterior and lateral parametria were involved bilaterally. Right posterior parametrium was involved in 38% of cases (19/50), while the left one was involved in 40% of cases (20/50). Right lateral parametrium was involved by endometriosis in 59.1% of cases (13/22), the left one was involved in 31.8% of cases (7/22), and lateral parametria were involved bilaterally in 9.1% of cases (2/22). The average size of parametrial nodules was 2 +/- 0.5 cm. No cases of intrinsic ureteral endometriosis were found. Endometriosis of the anterior compartment was detected in 41.2% of patients with three cases of DIE of the bladder (5.9%). Others DIE localizations are shown in Table 2 . Posterior compartment was most frequently involved by DIE than the anterior with the presence of nodules of the rectosigmoid colon in 69.5 % of the cases. Ovarian endometriosis was detected in 74.5% of patients. Pre-operative pain symptoms, evaluated with VAS score, are reported on Table 5. Dysmenorrhea was the most frequent symptom (84.3%), followed by dyspareunia (74.5%), ovulatory pain (70,6%), dyschezia (51%), chronic pelvic pain (35.3%) and stranguria (27.5%). Intraoperative complications occurred in five patients. Four patients had monolateral hypogastric nerve involvement and in two of the four patients neuroablation was necessary due to the need for radical resection of nodules. In one patient sigmoid lesion occurred during the shaving procedure and required the intervention of the general surgeon for the suture. A total of three postoperative complications were registered: one hemoperitoneum (class IIIb) that required a second surgery, one rectovaginal fistula requiring three operations for complete resolution (class IIIb) and we had one case of stenosis of colorectal anastomosis requiring endoscopic balloon dilation (class IIIa).(36) Twenty-seven patients (52.9%) were undertaking estroprogestins at the post-operative follow up visit (3 months). Pain symptoms (expressed in VAS score) were significantly decreased after the operation (p value < 0,05) as shown in figure 1 . Post-operative use of analgesic drugs also decreased from 37.5% (19/51) to 5.9% (3/51). The EHP-30 score variation is shown in Table 4 . The comparison of pre-operative and post-operative scores showed that surgery improved significantly QoL in many of the domains analyzed such as pain, control and powerlessness, emotional well-being, social support, self-image, satisfaction of treatment, sexual life. It was not possible to evaluate the “infertility” and “relationship with children” modules because respectively 21 (41.2%) and 31 (60.8%) patients did not answer the questions respectively. Limited to the small sample analyzed, however, even in these two modules a statistically significant improvement was observed. No differences were found in terms of urinary function between pre and post-operative questionnaires (ICIQ-FLUTS). The correlation between resected parametrium and urinary symptoms was examined: of the seven patients undergoing lateral parametrium resection, four had no symptoms (57.1%), three had mild difficulties in bladder filling (33.3%) and one complained of mild incontinence; of the thirty-six patients undergoing posterior parametrium resection, twentyfour (66.7%) had no symptoms, while twelve (33.3%) complained of mild incontinence. Six of the eight patients undergoing resection of both parametria developed difficulties in bladder filling, one was asymptomatic and one developed mild incontinence. Bowel function has improved in patients' subjective perception, although the results are controversial: while the surgery was resolutive for diarrhea and alternating alvus, there was no improvement in constipation. In fact the NBD score showed that intestinal dysfunction in the whole group was related to constipation. Most of the patients showed mild dysfunction (76.4%), while only three patients had severe dysfunction (5.9%). NBD scores of patients undergoing recto-sigmoid shaving was compared with that of patients undergoing bowel resection: data are shown in figure 2 . 4. Discussion Surgical eradication of DIE represents the treatment of choice in symptomatic patients unresponsive to medical treatment. The preservation of the pelvic autonomic system may be challenging in case of large nodules and surgical treatment of deep infiltrating endometriosis needs adequate surgical skills and expertise to minimize the risk of surgical complication; in fact only a few series, with limited sample size, have demonstrated the feasibility of nerve-sparing surgery in case of parametrial DIE (37)(38–41) Many studies showed that laparoscopic excision of endometriosis is associated with improvement in pelvic pain, but only few of this provides data on QoL using validated questionnaires. (25)(42)(43)(44) To the best of our knowledge this study is the first to analyzed the impact of nerve-sparing laparoscopic surgery for parametrial deep infiltrating endometriosis on quality of life with EHP-30 questionnaire. Preservation of pelvic innervation system entails better functional outcomes. Patients reported a subjective improvement in bowel function, excepted for constipation. This evidence is in accordance with a retrospective study by Abo et al. (45) on 371 women undergoing surgery for colorectal endometriosis and divided into three arms depending on the surgical technique used (segmental resection, discoid resection or shaving). Authors did not observe postoperative improvement in constipation in all three groups but an improvement in diarrhea only. The results of the ICIQ-FLUTS questionnaire on urinary function show that incontinence was more frequent in patients undergoing posterior parametrial resection than those undergoing lateral or resection of both parametria. However, a final conclusion can’t be achieved because of size discrepancy between the three groups (36/51 patients underwent resection of the posterior parametrium, 7/51 of the lateral parametrium and 8/51 of both parametria). The main bias of our study is related to the lack of pre-operative data on urinary function due to the preponderance of intestinal symptoms. Many authors have studied the incidence of urinary symptoms in patients with endometriosis. Fauconnier et al.(11) related specific symptoms to anatomical locations of DIE, but did not evaluate the correlation between urinary symptoms and posterior DIE; Darai et al.(46) reported an high incidence of urinary symptoms in patients with deep infiltrating endometriosis, but without being able to correlate the presence of symptoms with well-defined anatomical lesions. The EHP-30 score shows that nerve-sparing surgery improves quality of life of patients and reduces all the painful symptoms, except for chronic pelvic pain. This evidence suggests that a “symptom guided approach” and a radical surgery are associated with better postoperative outcomes. The main post-operative improvement in term of quality of life relates to domains affecting social and relationship life. This represents an important goal considering that the average age of the patients enrolled is 36 years, with a percentage of working and married women being respectively 88.2% and 72.5%, and that 47% of them are engaged in the management of children. Furthermore, the eventuality of surgical complications associated with this technique was low. Among the possible limitations of this study, we mention the small sample size, the lack of a comparison arm of patients not receiving nerve-sparing approach and the short follow up. On the other hand our study provides the first analysis of the impact of nerve-sparing surgery on quality of life, using validated questionnaires and it gives good and promising results for the systematic use of this type of approach. 5. Conclusion In conclusion, the use of nerve sparing technique by expert surgeons warrants good results in term of improvement of QoL and pain control and provides good functional outcomes. The development of surgical skills based on anatomical knowledge can lead to a more extensive use of the nerve-sparing technique with a persistent improvement in the quality of life of the patients with parametrial localization of DIE. Declarations AUTHOR CONTRIBUTION C. Alboni : protocol development V. Sampogna: manuscript writing M. Airoud: data management S. Malmusi: data collection G. Colucci: data collection A. Farulla: data analysis L. Camacho Mattos: manuscript editing A. Pecchi: data collection A. 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Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: Morbidity, symptoms, quality of life, and fertility. Ann Surg. 2010 Jun;251(6):1018–23. Tables Table 1. Demographic characteristics of patients. Values are given in mean +/- standard deviation. AGE 36 +/- 6,2 WEIGHT 62.1 Kg +/- 12,9 BMI 22.7 Kg/m 2 +/- 3,9 NATIONALITY • Italian 76.5% • Foreign 23.5% MARITAL STATUS • Married 72.5% • Divorced 11.8% • Nubile 13.7% • Widow 2% EDUCATION • Secondary school 21.6% • High-school 56.8% • Degree 21.6% OCCUPATION • Employed 88.2% • Unemployed 9.8% • Students 2% MEDICAL HISTORY • No prior history 33.3% (17/51) • Hypothyroidism 19.6% (10/51) • Mood disorder 15.6% (8/51) • Allergic asthma 11.7% (6/51) • Migraines with aura 3.9% (2/51) • Chronic Hypertension 3.9% (2/51) • Epilepsy 2% (1/51) • Myasthenia gravis 2% (1/51) • Ulcerative colitis 2% (1/51) Table 2. Localization of deep infiltrating endometriosis nodules LOCALIZATION OF DIE % Uterosacral ligaments 91.5% (54/59) Rectum, rectosigmoid junction and sigmoid 69.5% (41/59) Retrocervical area 32.2% (19/59) Bladder 8.5% (5/59) Endometrioma 74.5% (44/59) Table 3. Detail of operative procedures OPERATIVE PROCEDURES cyst enucleation 60.8% monolateral adnexectomy 15.7% removal of peritoneum of ovarian fossa 49% Total hysterectomy 10% Parametrectomy 100% Shaving of rectum and sigmoid 29.4% bowel resection 29.4% discoid resection 2% protective stomy 5.9% Table 4. EHP-30 scores before and after surgery EHP-30 questionnaire BEFORE SURGERY (mean +/- SD) AFTER SURGERY (mean +/- SD) p Value - Pain 47.2 (+/- 25.3) 10.1 (+/- 14.8) < .00001 control and powerlessness 56.3 (+/- 25.7) 13.2 (+/- 15.6) < .00001 - Emotion 53.4 (+/- 24) 23.3 (+/- 20.7) < .00001 - Social support 38.8 (+/- 26.5) 22.2 (+/- 21.5) < .00001 - Self image 30.7 (+/- 23.9) 19.7 (+/- 22.5) < .00001 - work module 38.8 (+/- 28.3) 9.3 (+/- 16.7) < .00001 relationship with children 20 (+/- 26.1) 6 (+/- 12.9) 0.0022 sexual intercourse 49.2 (+/- 27.8) 20.6 (+/- 22.6) < .00001 medical profession 21 (+/- 26.7) 3.9 (+/- 8.7) < .00001 treatment module 38.3 (+/- 29.1) 15.5 (+/- 21.9) < .00001 infertility module 48.8 (+/- 27.8) 30.2 (+/- 30.0) 0.0065 Table 5 is not available with this version. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1021436","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":73359825,"identity":"0a492f8a-3aec-496f-a328-5ae5806890f5","order_by":0,"name":"Carlo Alboni","email":"","orcid":"","institution":"Policlinico di Modena; University of Modena and Reggio Emilia","correspondingAuthor":false,"prefix":"","firstName":"Carlo","middleName":"","lastName":"Alboni","suffix":""},{"id":73359826,"identity":"f6db56fb-6304-4e70-a6d9-4329fde530aa","order_by":1,"name":"Veronica Sampogna","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYNACA2QOewNIxIIULTwHQCISpFgpkQAmcZt/vPfh44ICO3kG/sNPNxdU1Obxz3x+dcOPAgkG/vbuBKxazhw3Np5hkGzYIJFmdnvGmePFErdzym72AB0mcebsBmxaJGeksUnzGBxgbJBgMLvN23YsseF2TtoNHqAWA4lc7FrmPwNrsW/gP/4NrGX+zTNpN//g0cIvwQbWktjAkAOypSZxww32Y7fx2cLPk8ZszGOQnNwmkVMG9MuBxI1ncthuyxhI8ODyCxv7McbHPH/sbPv5j2+7XVBRlzjv+PFnN9/8sZHjb+/FqgWhF4iZGRgOAykecMzy4FUOA0AtdUCK/QFRqkfBKBgFo2DEAACm22Dl5p+DJQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-5481-0955","institution":"Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena: Azienda Ospedaliero-Universitaria di Modena","correspondingAuthor":true,"prefix":"","firstName":"Veronica","middleName":"","lastName":"Sampogna","suffix":""},{"id":73359827,"identity":"56014216-e42c-4bf6-9e54-054d410cc61f","order_by":2,"name":"Mirvana Airoud","email":"","orcid":"","institution":"Gynecology and Obstetrics Unit, Sassuolo Civil Hospital, via ruini 2, 41049 Sassuolo (MO), Italy","correspondingAuthor":false,"prefix":"","firstName":"Mirvana","middleName":"","lastName":"Airoud","suffix":""},{"id":73359828,"identity":"38ce49a7-40e7-4344-ab86-d5f0936d8b33","order_by":3,"name":"Stefania Malmusi","email":"","orcid":"","institution":"Gynecology and Obstetrics Unit, Sassuolo Civil Hospital, via ruini 2, 41049 Sassuolo (MO), Italy","correspondingAuthor":false,"prefix":"","firstName":"Stefania","middleName":"","lastName":"Malmusi","suffix":""},{"id":73359829,"identity":"f7a327b5-5015-43d7-b09f-a21bb55a0696","order_by":4,"name":"Antonino Farulla","email":"","orcid":"https://orcid.org/0000-0002-1129-1232","institution":"Policlinico di Modena; University of Modena and Reggio Emilia","correspondingAuthor":false,"prefix":"","firstName":"Antonino","middleName":"","lastName":"Farulla","suffix":""},{"id":73359830,"identity":"72e147a2-13e6-4220-9fcb-7be5f3d4d05a","order_by":5,"name":"Giuseppe Colucci","email":"","orcid":"","institution":"General Surgery Unit, Sassuolo Civil Hospital","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"","lastName":"Colucci","suffix":""},{"id":73359831,"identity":"05042b91-5a2f-4e26-9da5-1d88e3a31737","order_by":6,"name":"Ludovica Camacho Mattos","email":"","orcid":"","institution":"Policlinico di Modena; University of Modena and Reggio Emilia","correspondingAuthor":false,"prefix":"","firstName":"Ludovica","middleName":"Camacho","lastName":"Mattos","suffix":""},{"id":73359832,"identity":"f9a20133-d809-4af9-b3f7-cb2832576bc1","order_by":7,"name":"Annarita Pecchi","email":"","orcid":"https://orcid.org/0000-0001-8142-3256","institution":"Policlinico di Modena; University of Modena and Reggio Emilia","correspondingAuthor":false,"prefix":"","firstName":"Annarita","middleName":"","lastName":"Pecchi","suffix":""},{"id":73359833,"identity":"a9628e33-0bbb-4a10-a0e3-d57ddfdb3f12","order_by":8,"name":"Antonio La Marca","email":"","orcid":"","institution":"Policlinico di Modena; University of Modena and Reggio Emilia","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"La","lastName":"Marca","suffix":""}],"badges":[],"createdAt":"2021-10-26 18:56:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1021436/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1021436/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":16957032,"identity":"33af4df4-4a22-49ee-912c-d269eed1652a","added_by":"auto","created_at":"2022-01-03 23:16:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50208,"visible":true,"origin":"","legend":"\u003cp\u003eVAS score before and after surgery, values are given in mean +/- standard deviation. *no oral contraceptives\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1021436/v1/b3c4ada1362b60bd6c073038.jpg"},{"id":16957045,"identity":"aa1c5339-be66-48bb-9069-860e84f5b248","added_by":"auto","created_at":"2022-01-03 23:19:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":54117,"visible":true,"origin":"","legend":"\u003cp\u003ecomparison of NBD scores between patients undergoing shaving and patients undergoing segmental resection.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1021436/v1/2a0fb69f1c093340a6e90373.jpg"},{"id":19029898,"identity":"6d56933e-47d7-4085-8dcf-712cba38232d","added_by":"auto","created_at":"2022-03-09 15:56:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":350487,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1021436/v1/0463f2a0-3682-492f-b5e9-f8a422fb243c.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eImpact on Quality of Life of Laparoscopic Nerve-sparing Radical Treatment of Parametrial Deep Infiltrating Endometriosis (Postoperative Pain Assessment and Functional Outcomes)\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEndometriosis is a chronic inflammatory disease, characterized by ectopic proliferation of endometrial glands and stroma. It is estimated that it can affect up to 2-10 % of reproductive age women, 20-50% of infertile women and 30-80% of women with chronic pelvic pain. (1)(2)(3)(4)(5)\u003c/p\u003e\n\u003cp\u003eIn its deeply infiltrating form (DIE) the disease affects up to 34% of women with pelvic endometriosis. The DIE is a specific clinical entity characterized by an extension of the disease more than 5 mm under the peritoneal surface, retroperitoneal fibrosis and neural tropism with distortion of the regular pelvic anatomy. (6)(7)(8)(9) DIE affects most frequently uterosacral ligaments (69.2%), rectovaginal septum (14.5%), bowel (9.9%) and bladder (4.2%). (10)\u003c/p\u003e\n\u003cp\u003eIn a retrospective study, Fauconnier et al. (11) demonstrate that different types of chronic pelvic pain are related to the anatomic location of DIE. In recent years a growing attention was pointed out on parametrial localization of deep infiltrating nodules with studies investigating diagnosis, treatment and clinical outcomes. (12)(13)(14)(15)\u003c/p\u003e\n\u003cp\u003eThe parametrium has been described as the supporting system of the uterus that anchors the organ to the lateral pelvic wall and has both supply-drainage and fascial functions (16). All the three components (anterior, posterior, lateral) in which the parametrium is normally classified can be infiltrated by DIE. More often DIE lesions are at the level of the posterior and lateral part of the parametrium associated to retrocervical, bowel and ureteral nodules(17)(18). This pattern of lesions distribution can be associated with ureteral and bowel function impairment and often with chronic pelvic pain symptoms expressed as dyspareunia and dyschezia (14)(11). Due to these symptoms, endometriosis may have a profound impact on quality of life and mental health of the patients affected. In 2004 Abbot et al. (19) demonstrated that surgical excision of endometriosis determines a symptomatic improvement significantly more than placebo.\u003c/p\u003e\n\u003cp\u003eThe lateral parametrium has a ventral component called \u003cem\u003epars vasculosa\u003c/em\u003e and a dorsal part defined as \u003cem\u003epars nervosa\u003c/em\u003e because it contains the nerve branches of autonomic pelvic organs innervation, therefore the complete eradication of the disease is associated with the risk of serious impairment of rectal, bladder and sexual function due to the iatrogenic disruption of inferior hypogastric plexus.\u003c/p\u003e\n\u003cp\u003eDifferent authors have described the nerve-sparing approach in case of DIE nodules (20)(21)(22). In 2012, a prospective cohort study compared the laparoscopic nerve-sparing approach to the classical laparoscopic procedure demonstrating the feasibility of radical removal of fibrotic infiltrating endometriosis tissue from parametrial structures avoiding disruption of autonomic pelvic organs innervation.(23)\u003c/p\u003e\n\u003cp\u003eThere has been a growing interest in recent years on analyzing QoL after laparoscopic surgery for endometriosis. However, despite the large amount of literature on surgical techniques and diagnostic assessment of parametrial endometriosis, only a few studies have specifically addressed data on functional outcomes, and, to the best of our knowledge, no one was published investigating patient\u0026rsquo;s QoL with validated questionnaires. (24) (25)\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to use validated questionnaires to evaluate patients\u0026rsquo; response to laparoscopic nerve-sparing excision of parametrial DIE in terms of self-perceived well-being, pain relief and voiding function.\u003c/p\u003e"},{"header":"2.\tMaterials And Methods","content":"\u003cp\u003eThis study was approved by the local Ethics Committee (protocol number 0024582/19), and all patients expressed their informed consent to anonymous data collection. All patients that underwent laparoscopic surgery for endometriosis in the period between January 2013 and March 2017 at Obstetrics and Gynecology Division of the Sassuolo Civil Hospital and at the Endometriosis tertiary level referral center of the University Hospital of Modena were enrolled. All surgeries were performed by the same surgeon with high expertise in laparoscopic treatment of endometriosis (C.A.) and patients with histologically confirmed laparoscopic resection of posterior and lateral parametrium were selected. Exclusion criteria were age \u0026lt; 18, preoperative diagnosis of neurogenic bladder and bowel inflammatory disease and absence of sexual activity.\u003c/p\u003e\n\u003cp\u003eAll patients underwent speculum examination, pelvic bimanual vagino-rectal evaluation and transvaginal ultrasound performed by an expert sonographer expert in endometriosis diagnosis. A transabdominal ultrasound scan of the kidneys was also routinely performed to rule out hydroureteronephrosis (an indirect marker for parametrial nodules). (19)\u003c/p\u003e\n\u003cp\u003eEventually, they underwent pelvic magnetic resonance with rectal injection of 10-50 ml of sterile gel to confirm dimension and depth of infiltration of the bowel lesions (if any) and to define the parametrial/ureteral involvement.\u003c/p\u003e\n\u003cp\u003eAll patients signed a specific informed consent before surgery, specifying the preoperatively diagnosed localization of lesions, all surgical procedures necessary for their complete excision and the potential risks (vascular, neurologic, urologic and intestinal) related to the type of surgery.\u003c/p\u003e\n\u003cp\u003ePatients were hospitalized the same day of the intervention. A nerve-sparing laparoscopic surgical technique was implemented for all the surgeries (23).\u003c/p\u003e\n\u003cp\u003eIn case of bowel lesions infiltrating the muscularis interna and causing a stenosis of more than 50% of the lumen in patients symptomatic for bowel dysfunction, a segmental resection with Knight-Griffen technique and end-to-end anastomosis was performed by an equipe of general surgeons.(27) A protective ileostomy was routinely done in case of ultra-low rectal segmental resection (resection margin \u0026lt; 5 cm from the dental line). Antibiotics were administered for 48 hours postoperatively. The data on patient age, parity, body mass index, previous abdominopelvic surgery, operating time, amount of blood loss, use of hormonal therapy, length of hospital stay were recorded, while intraoperative, early and late postoperative complications were analysed according to the Clavien-Dindo classification system.(28) Pain symptoms were investigated using the visual analogue scale (VAS) and the different need of analgesic drugs was evaluated at the preoperative visit (range 10-45 day before surgery) and at the follow up evaluation after three months. For the comparative analysis of dysmenorrhea with VAS scale, patients underwent hysterectomy and patients with post-operative continuous hormonal therapy were excluded.\u003c/p\u003e\n\u003cp\u003eQuality of life and functional and status outcomes were collected using the italian validated version of three questionnaires (29), administered in paper form, one month before surgery and three months after the intervention. The Endometriosis Health Profile-30 Questionnaire (EHP-30) was used to evaluate the global health profile of the patients (30)(31)(32) as primary outcome of our study. The EHP-30 consists of 30 questions about pain, control and powerlessness, emotional well-being, social support and self-image. Currently is the only questionnaire that evaluates QoL specifically in patients with endometriosis. For bowel function the Neurogenic Bowel Dysfunction (NBD) score was used (33), whereas the urinary function was evaluated using the International Consultation on Incontinence-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) (34,35).\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec2\"\u003e\n \u003ch2\u003e2.1 Statistical analysis\u003c/h2\u003e\n \u003cp\u003eData were expressed as mean\u0026plusmn;standard deviation for numerical variables and as numbers (percentages) for categorical variables. The Wilcoxon test was used to compare changes in variables between before and after the surgical treatment. P value of \u0026lt;0.05 denoted statistical significance. All statistical analyses were performed using SPSS software (version 21, SPSS, Inc., Chicago, IL, USA).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3.\tResults","content":"\u003cp\u003eDuring the study period a total of sixty-five patients underwent nerve-sparing surgery for parametrial deep infiltrating endometriosis. Fifty-nine patients met the inclusion criteria and were included and fifty-one of these agreed to fill out questionnaires for postoperative outcomes evaluation.\u003c/p\u003e\n\u003cp\u003eMedian age was 36 \u0026plusmn; 6.2 years. The majority of these patients were married or a common-law wife (72.5%) and employed (88.2%) at the time of surgery. Demographic characteristics of patients are provided in Table 1.\u003c/p\u003e\n\u003cp\u003eEight patients had had previous surgery for endometriosis (15.6%) and twenty-seven were nulliparous (53%).\u003c/p\u003e\n\u003cp\u003eDiagnosis of parametrial endometriosis was confirmed by histological examination in all patients included. Laparoscopic approach was used in all cases, no conversion to open surgery occurred. Laparoscopic segmental bowel resection was performed in fifteen patients, while discoid resection was performed in only one. Three patients needed protective ileostomy for ultra-low rectal anastomosis. Operative details and procedures are summarized in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean operating time was 239 +/- 111 minutes, the mean estimated blood loss during surgery was 165 +|- 59.9 mL (range 50-1020 mL) and the mean hospital stay was 6 days (range 3-12 days). The average length of the removed intestinal segments was 12.5 cm (+/- 5,7).\u003c/p\u003e\n\u003cp\u003eIn thirty-seven patients (62,7%) parametrial endometriosis was unilateral, in 22% of cases both posterior and lateral parametrium were involved and in 15.3% of cases posterior and lateral parametria were involved bilaterally.\u003c/p\u003e\n\u003cp\u003eRight posterior parametrium was involved in 38% of cases (19/50), while the left one was involved in 40% of cases (20/50). Right lateral parametrium was involved by endometriosis in 59.1% of cases (13/22), the left one was involved in 31.8% of cases (7/22), and lateral parametria were involved bilaterally in 9.1% of cases (2/22). The average size of parametrial nodules was 2 +/- 0.5 cm. No cases of intrinsic ureteral endometriosis were found.\u003c/p\u003e\n\u003cp\u003eEndometriosis of the anterior compartment was detected in 41.2% of patients with three cases of DIE of the bladder (5.9%). Others DIE localizations are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Posterior compartment was most frequently involved by DIE than the anterior with the presence of nodules of the rectosigmoid colon in 69.5 % of the cases. Ovarian endometriosis was detected in 74.5% of patients. Pre-operative pain symptoms, evaluated with VAS score, are reported on Table 5. Dysmenorrhea was the most frequent symptom (84.3%), followed by dyspareunia (74.5%), ovulatory pain (70,6%), dyschezia (51%), chronic pelvic pain (35.3%) and stranguria (27.5%).\u003c/p\u003e\n\u003cp\u003eIntraoperative complications occurred in five patients. Four patients had monolateral hypogastric nerve involvement and in two of the four patients neuroablation was necessary due to the need for radical resection of nodules. In one patient sigmoid lesion occurred during the shaving procedure and required the intervention of the general surgeon for the suture. A total of three postoperative complications were registered: one hemoperitoneum (class IIIb) that required a second surgery, one rectovaginal fistula requiring three operations for complete resolution (class IIIb) and we had one case of stenosis of colorectal anastomosis requiring endoscopic balloon dilation (class IIIa).(36)\u003c/p\u003e\n\u003cp\u003eTwenty-seven patients (52.9%) were undertaking estroprogestins at the post-operative follow up visit (3 months).\u003c/p\u003e\n\u003cp\u003ePain symptoms (expressed in VAS score) were significantly decreased after the operation (p value \u0026lt; 0,05) as shown in figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Post-operative use of analgesic drugs also decreased from 37.5% (19/51) to 5.9% (3/51).\u003c/p\u003e\n\u003cp\u003eThe EHP-30 score variation is shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. The comparison of pre-operative and post-operative scores showed that surgery improved significantly QoL in many of the domains analyzed such as pain, control and powerlessness, emotional well-being, social support, self-image, satisfaction of treatment, sexual life. It was not possible to evaluate the \u0026ldquo;infertility\u0026rdquo; and \u0026ldquo;relationship with children\u0026rdquo; modules because respectively 21 (41.2%) and 31 (60.8%) patients did not answer the questions respectively. Limited to the small sample analyzed, however, even in these two modules a statistically significant improvement was observed.\u003c/p\u003e\n\u003cp\u003eNo differences were found in terms of urinary function between pre and post-operative questionnaires (ICIQ-FLUTS). The correlation between resected parametrium and urinary symptoms was examined: of the seven patients undergoing lateral parametrium resection, four had no symptoms (57.1%), three had mild difficulties in bladder filling (33.3%) and one complained of mild incontinence; of the thirty-six patients undergoing posterior parametrium resection, twentyfour (66.7%) had no symptoms, while twelve (33.3%) complained of mild incontinence. Six of the eight patients undergoing resection of both parametria developed difficulties in bladder filling, one was asymptomatic and one developed mild incontinence.\u003c/p\u003e\n\u003cp\u003eBowel function has improved in patients' subjective perception, although the results are controversial: while the surgery was resolutive for diarrhea and alternating alvus, there was no improvement in constipation. In fact the NBD score showed that intestinal dysfunction in the whole group was related to constipation. Most of the patients showed mild dysfunction (76.4%), while only three patients had severe dysfunction (5.9%).\u003c/p\u003e\n\u003cp\u003eNBD scores of patients undergoing recto-sigmoid shaving was compared with that of patients undergoing bowel resection: data are shown in figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e"},{"header":"4.\tDiscussion","content":"\u003cp\u003eSurgical eradication of DIE represents the treatment of choice in symptomatic patients unresponsive to medical treatment. The preservation of the pelvic autonomic system may be challenging in case of large nodules and surgical treatment of deep infiltrating endometriosis needs adequate surgical skills and expertise to minimize the risk of surgical complication; in fact only a few series, with limited sample size, have demonstrated the feasibility of nerve-sparing surgery in case of parametrial DIE (37)(38\u0026ndash;41)\u003c/p\u003e\n\u003cp\u003eMany studies showed that laparoscopic excision of endometriosis is associated with improvement in pelvic pain, but only few of this provides data on QoL using validated questionnaires. (25)(42)(43)(44) To the best of our knowledge this study is the first to analyzed the impact of nerve-sparing laparoscopic surgery for parametrial deep infiltrating endometriosis on quality of life with EHP-30 questionnaire.\u003c/p\u003e\n\u003cp\u003ePreservation of pelvic innervation system entails better functional outcomes.\u003c/p\u003e\n\u003cp\u003ePatients reported a subjective improvement in bowel function, excepted for constipation. This evidence is in accordance with a retrospective study by Abo et al. (45) on 371 women undergoing surgery for colorectal endometriosis and divided into three arms depending on the surgical technique used (segmental resection, discoid resection or shaving). Authors did not observe postoperative improvement in constipation in all three groups but an improvement in diarrhea only.\u003c/p\u003e\n\u003cp\u003eThe results of the ICIQ-FLUTS questionnaire on urinary function show that incontinence was more frequent in patients undergoing posterior parametrial resection than those undergoing lateral or resection of both parametria. However, a final conclusion can\u0026rsquo;t be achieved because of size discrepancy between the three groups (36/51 patients underwent resection of the posterior parametrium, 7/51 of the lateral parametrium and 8/51 of both parametria). The main bias of our study is related to the lack of pre-operative data on urinary function due to the preponderance of intestinal symptoms. Many authors have studied the incidence of urinary symptoms in patients with endometriosis. Fauconnier et al.(11) related specific symptoms to anatomical locations of DIE, but did not evaluate the correlation between urinary symptoms and posterior DIE; Darai et al.(46) reported an high incidence of urinary symptoms in patients with deep infiltrating endometriosis, but without being able to correlate the presence of symptoms with well-defined anatomical lesions.\u003c/p\u003e\n\u003cp\u003eThe EHP-30 score shows that nerve-sparing surgery improves quality of life of patients and reduces all the painful symptoms, except for chronic pelvic pain. This evidence suggests that a \u0026ldquo;symptom guided approach\u0026rdquo; and a radical surgery are associated with better postoperative outcomes. The main post-operative improvement in term of quality of life relates to domains affecting social and relationship life. This represents an important goal considering that the average age of the patients enrolled is 36 years, with a percentage of working and married women being respectively 88.2% and 72.5%, and that 47% of them are engaged in the management of children. Furthermore, the eventuality of surgical complications associated with this technique was low.\u003c/p\u003e\n\u003cp\u003eAmong the possible limitations of this study, we mention the small sample size, the lack of a comparison arm of patients not receiving nerve-sparing approach and the short follow up.\u003c/p\u003e\n\u003cp\u003eOn the other hand our study provides the first analysis of the impact of nerve-sparing surgery on quality of life, using validated questionnaires and it gives good and promising results for the systematic use of this type of approach.\u003c/p\u003e"},{"header":"5.\tConclusion","content":"\u003cp\u003eIn conclusion, the use of nerve sparing technique by expert surgeons warrants good results in term of improvement of QoL and pain control and provides good functional outcomes. The development of surgical skills based on anatomical knowledge can lead to a more extensive use of the nerve-sparing technique with a persistent improvement in the quality of life of the patients with parametrial localization of DIE.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC. Alboni : protocol development\u003c/p\u003e\n\u003cp\u003eV. Sampogna: manuscript writing\u003c/p\u003e\n\u003cp\u003eM. Airoud: data management\u003c/p\u003e\n\u003cp\u003eS. Malmusi: data collection\u003c/p\u003e\n\u003cp\u003eG. Colucci: data collection\u003c/p\u003e\n\u003cp\u003eA. Farulla: data analysis\u003c/p\u003e\n\u003cp\u003eL. Camacho Mattos: manuscript editing\u003c/p\u003e\n\u003cp\u003eA. Pecchi: data collection\u003c/p\u003e\n\u003cp\u003eA. La Marca: project development\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am. 1997;24(2):235\u0026ndash;58.\u003c/li\u003e\n \u003cli\u003eSoliman AM, Yang H, Du EX, Kelley C, Winkel C. The direct and indirect costs associated with endometriosis: A systematic literature review. Vol. 31, Human Reproduction. Oxford University Press; 2016. p. 712\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eVigan\u0026ograve; P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: Epidemiology and aetiological factors. Vol. 18, Best Practice and Research: Clinical Obstetrics and Gynaecology. Bailliere Tindall Ltd; 2004. p. 177\u0026ndash;200.\u003c/li\u003e\n \u003cli\u003eMissmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Marshall LM, Hunter DJ. Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric, and lifestyle factors. Am J Epidemiol. 2004 Oct 15;160(8):784\u0026ndash;96.\u003c/li\u003e\n \u003cli\u003eLouis GMB, Peterson CM, Chen Z, Hediger ML, Croughan MS, Sundaram R, et al. Perfluorochemicals and endometriosis: The ENDO study. Epidemiology. 2012 Nov;23(6):799\u0026ndash;805.\u003c/li\u003e\n \u003cli\u003eKoninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril. 1991;55(4):759\u0026ndash;65.\u003c/li\u003e\n \u003cli\u003eNisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril. 1997;68(4):585\u0026ndash;96.\u003c/li\u003e\n \u003cli\u003eCornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR. Deeply infiltrating pelvic endometriosis: histology and clinical significance. Fertil Steril. 1990;53(6):978\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eAnaf V, Simon P, Fayt I, Noel JC. Smooth muscles are frequent components of endometriotic lesions. Hum Reprod. 2000;15(4):767\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eChapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, et al. Deeply infiltrating endometriosis: Pathogenetic implications of the anatomical distribution. Hum Reprod. 2006;21(7):1839\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eFauconnier A, Chapron C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update. 2005 Nov 1;11(6):595\u0026ndash;606.\u003c/li\u003e\n \u003cli\u003eMabrouk M, Raimondo D, Arena A, Iodice R, Altieri M, Sutherland N, et al. Parametrial Endometriosis: The Occult Condition that Makes the Hard Harder. J Minim Invasive Gynecol. 2019 Jul 1;26(5):871\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003ePossover M. Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril. 2014;101(3):754\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eBallester M, Santulli P, Bazot M, Coutant C, Rouzier R, Dara\u0026iuml; E. Preoperative Evaluation of Posterior Deep-Infiltrating Endometriosis Demonstrates a Relationship with Urinary Dysfunction and Parametrial Involvement. J Minim Invasive Gynecol. 2011 Jan;18(1):36\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eBallester M, Santulli P, Bazot M, Coutant C, Rouzier R, Dara\u0026iuml; E. Preoperative Evaluation of Posterior Deep-Infiltrating Endometriosis Demonstrates a Relationship with Urinary Dysfunction and Parametrial Involvement. J Minim Invasive Gynecol. 2011 Jan;18(1):36\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eYabuki Y, Asamoto A, Hoshiba T, Nishimoto H, Nishikawa Y, Nakajima T. Radical hysterectomy: An anatomic evaluation of parametrial dissection. Gynecol Oncol. 2000;77(1):155\u0026ndash;63.\u003c/li\u003e\n \u003cli\u003eRuffo G, Stepniewska A, Crippa S, Serboli G, Zardini C, Steinkasserer M, et al. Laparoscopic ileocecal resection for bowel endometriosis. Surg Endosc. 2011;25(4):1257\u0026ndash;62.\u003c/li\u003e\n \u003cli\u003eRaimondo D, Mabrouk M, Zannoni L, Arena A, Zanello M, Benfenati A, et al. Severe ureteral endometriosis: frequency and risk factors. J Obstet Gynaecol (Lahore). 2018 Feb 17;38(2):257\u0026ndash;60.\u003c/li\u003e\n \u003cli\u003eAbbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: A randomized, placebo-controlled trial. Fertil Steril. 2004 Oct;82(4):878\u0026ndash;84.\u003c/li\u003e\n \u003cli\u003eVolpi E, Ferrero A, Sismondi P. Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surg Endosc. 2004 Jul 27;18(7):1109\u0026ndash;12.\u003c/li\u003e\n \u003cli\u003eKavallaris A, Banz C, Chalvatzas N, Hornemann A, Luedders D, Diedrich K, et al. Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients\u0026rsquo; outcome. Arch Gynecol Obstet. 2011 Jul 1;284(1):131\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eCeccaroni M, Pontrelli G, Scioscia M, Ruffo G, Bruni F, Minelli L. Nerve-Sparing Laparoscopic Radical Excision of Deep Endometriosis with Rectal and Parametrial Resection. J Minim Invasive Gynecol. 2010 Jan;17(1):14\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eCeccaroni M, Clarizia R, Bruni F, D\u0026rsquo;Urso E, Gagliardi ML, Roviglione G, et al. Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: The negrar method. A single-center, prospective, clinical trial. Surg Endosc. 2012;26(7):2029\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eComptour A, Lambert C, Chauvet P, Figuier C, Gremeau A-S, Canis M, et al. Long-Term Evolution of Quality of Life and Symptoms Following Surgical Treatment for Endometriosis: Different Trajectories for Which Patients? J Clin Med. 2020 Jul 31;9(8):2461.\u003c/li\u003e\n \u003cli\u003eRindos NB, Fulcher IR, Donnellan NM. Pain and Quality of Life after Laparoscopic Excision of Endometriosis. J Minim Invasive Gynecol. 2020 Nov 1;27(7):1610-1617.e1.\u003c/li\u003e\n \u003cli\u003eAdamson GD, Pasta DJ. Surgical treatment of endometriosis-associated infertility: Meta-analysis compared with survival analysis. Am J Obstet Gynecol. 1994;171(6):1488\u0026ndash;505.\u003c/li\u003e\n \u003cli\u003eDean Griffen F, Knight CD, Knight CD. Results of the double stapling procedure in pelvic surgery. World J Surg. 1992 Sep;16(5):866\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Vol. 240, Annals of Surgery. Ann Surg; 2004. p. 205\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003eMaiorana A, Scafidi Fonti GM, Audino P, Rosini R, Alio L, Oliveri AM, et al. The role of EHP-30 as specific instrument to assess the quality of life of Italian women with endometriosis. Minerva Ginecol. 2012 Jun;64(3):231\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eJones G, Jenkinson C, Taylor N, Mills A, Kennedy S. Measuring quality of life in women with endometriosis: Tests of data quality, score reliability, response rate and scaling assumptions of the Endometriosis Health Profile Questionnaire. Hum Reprod. 2006;21(10):2686\u0026ndash;93.\u003c/li\u003e\n \u003cli\u003eJones G, Kennedy S, Barnard A, Wong J, Jenkinson C. Development of an endometriosis quality-of-life instrument: The Endometriosis Health Profile-30. Obstet Gynecol. 2001;98(2):258\u0026ndash;64.\u003c/li\u003e\n \u003cli\u003eVercellini P, Frattaruolo MP, Somigliana E, Jones GL, Consonni D, Alberico D, et al. Surgical versus low-dose progestin treatment for endometriosis-associated severe deep dyspareunia II: Effect on sexual functioning, psychological status and health-related quality of life. Hum Reprod. 2013;28(5):1221\u0026ndash;30.\u003c/li\u003e\n \u003cli\u003eKrogh K, Christensen P, Sabroe S, Laurberg S. Neurogenic bowel dysfunction score. Spinal Cord. 2006 Oct 13;44(10):625\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eTubaro A, Zattoni F, Prezioso D, Scarpa RM, Pesce F, Rizzi CA, et al. Italian validation of the International Consultation on Incontinence Questionnaires. BJU Int. 2006 Jan;97(1):101\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eAbrams P, Avery K, Gardener N, Donovan J. The international consultation on incontinence modular questionnaire: www.iciq.net. J Urol. 2006 Mar;175(3):1063\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eBiraima M, Adamina M, Jost R, Breitenstein S, Soll C. Long-term results of endoscopic balloon dilation for treatment of colorectal anastomotic stenosis. Surg Endosc. 2016 Oct 1;30(10):4432\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eVolpi E, Ferrero A, Sismondi P. Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surg Endosc Other Interv Tech. 2004;18(7):1109\u0026ndash;12.\u003c/li\u003e\n \u003cli\u003eUccella S, Gisone B, Serati M, Biasoli S, Marconi N, Angeretti G, et al. Functional outcomes of nerve-sparing laparoscopic eradication of deep infiltrating endometriosis: a prospective analysis using validated questionnaires. Arch Gynecol Obstet. 2018 Sep 1;298(3):639\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eChe X, Huang X, Zhang J, Xu H, Zhang X. Is nerve-sparing surgery suitable for deeply infiltrating endometriosis? Eur J Obstet Gynecol Reprod Biol. 2014;175(1):87\u0026ndash;91.\u003c/li\u003e\n \u003cli\u003eMorelli L, Perutelli A, Palmeri M, Guadagni S, Mariniello MD, Di Franco G, et al. Robot-assisted surgery for the radical treatment of deep infiltrating endometriosis with colorectal involvement: short- and mid-term surgical and functional outcomes. Int J Colorectal Dis. 2016 Mar 1;31(3):643\u0026ndash;52.\u003c/li\u003e\n \u003cli\u003eLandi S, Ceccaroni M, Perutelli A, Allodi C, Barbieri F, Fiaccavento A, et al. Laparoscopic nerve-sparing complete excision of deep endometriosis: Is it feasible? Hum Reprod. 2006;21(3):774\u0026ndash;81.\u003c/li\u003e\n \u003cli\u003eTurco LC, Scaldaferri F, Chiantera V, Cianci S, Ercoli A, Fagotti A, et al. Long-term evaluation of quality of life and gastrointestinal well-being after segmental colo-rectal resection for deep infiltrating endometriosis (ENDO-RESECT QoL). Arch Gynecol Obstet. 2020 Jan 1;301(1):217\u0026ndash;28.\u003c/li\u003e\n \u003cli\u003eKlapczynski C, Derbal S, Braund S, Coget J, Forestier D, Seyer-Hansen M, et al. Evaluation of functional outcomes after disc excision of deep endometriosis involving low and mid rectum using standardized questionnaires: a series of 80 patients. Colorectal Dis. 2021 Apr;23(4):944\u0026ndash;54.\u003c/li\u003e\n \u003cli\u003eParra RS, Feitosa MR, Camargo HP de, Val\u0026eacute;rio FP, Zanardi JVC, Rocha JJR da, et al. The impact of laparoscopic surgery on the symptoms and wellbeing of patients with deep infiltrating endometriosis and bowel involvement. J Psychosom Obstet Gynecol. 2021;42(1):75\u0026ndash;80.\u003c/li\u003e\n \u003cli\u003eAbo C, Moatassim S, Marty N, Saint Ghislain M, Huet E, Bridoux V, et al. Postoperative complications after bowel endometriosis surgery by shaving, disc excision, or segmental resection: a three-arm comparative analysis of 364 consecutive cases. Fertil Steril. 2018 Jan 1;109(1):172-178.e1.\u003c/li\u003e\n \u003cli\u003eDara\u0026iuml; E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M. Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: Morbidity, symptoms, quality of life, and fertility. Ann Surg. 2010 Jun;251(6):1018\u0026ndash;23.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic characteristics of patients. Values are given in mean +/- standard deviation.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 +/- 6,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWEIGHT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62.1 Kg +/- 12,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.7 Kg/m \u003csup\u003e2\u0026nbsp;\u003c/sup\u003e+/- 3,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNATIONALITY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Italian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Foreign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMARITAL STATUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Divorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Nubile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Widow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEDUCATION\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;High-school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOCCUPATION\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Unemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMEDICAL HISTORY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;No prior history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.3% (17/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Hypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.6% (10/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Mood disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.6% (8/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Allergic asthma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.7% (6/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Migraines with aura\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9% (2/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Chronic Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9% (2/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Epilepsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2% (1/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Myasthenia gravis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2% (1/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;\u0026nbsp;Ulcerative colitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2% (1/51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Localization of deep infiltrating endometriosis nodules\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLOCALIZATION OF DIE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUterosacral ligaments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e91.5% (54/59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRectum, rectosigmoid junction and sigmoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.5% (41/59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRetrocervical area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.2% (19/59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.5% (5/59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndometrioma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e74.5% (44/59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Detail of operative procedures\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOPERATIVE PROCEDURES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecyst enucleation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003emonolateral adnexectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eremoval of peritoneum of ovarian fossa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal hysterectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParametrectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShaving of rectum and sigmoid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebowel resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ediscoid resection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eprotective stomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eEHP-30 scores before and after surgery\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEHP-30 questionnaire\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBEFORE SURGERY\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(mean +/- SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAFTER SURGERY\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(mean +/- SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.2 (+/- 25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.1 (+/- 14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003econtrol and powerlessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.3 (+/- 25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.2 (+/- 15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Emotion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.4 (+/- 24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23.3 (+/- 20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Social support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.8 \u0026nbsp;(+/- 26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.2 (+/- 21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Self image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.7 (+/- 23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.7 (+/- 22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;work module\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.8 (+/- 28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.3 (+/- 16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003erelationship with children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 (+/- 26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (+/- 12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esexual intercourse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.2 (+/- 27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.6 (+/- 22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003emedical profession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (+/- 26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9 (+/- 8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003etreatment module\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.3 (+/- 29.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.5 (+/- 21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003einfertility module\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48.8 (+/- 27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.2 (+/- 30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Parametrial endometriosis, laparoscopy, deep endometriosis, outcomes, nerve-sparing, quality of life","lastPublishedDoi":"10.21203/rs.3.rs-1021436/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1021436/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Complete eradication of parametrial nodules of Deep Infiltrating Endometriosis (DIE) is associated with a high risk of iatrogenic nerves damage and pelvic organs dysfunction. The aim of this study is to evaluate via validated questionnaires the effect of laparoscopic excision of parametrial DIE on quality of life as first outcome and on pain symptoms and post- operative voiding function (bladder and rectal) as secondary outcome.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy design: \u003c/strong\u003e\u0026nbsp;All patients undergoing laparoscopic excision of posterior or lateral parametrial DIE by a single expert surgeon between January 2013 and March 2017 were included in the study. A nerve-sparing approach was adopted in all patients.\u0026nbsp;Quality of life (QoL) and Functional outcomes were evaluated using validated questionnaires (EHP-30 for the health profile, NBD score for intestinal function, ICIQ-FLUTS for urinary function), administered preoperatively and after surgery. Pain scores were collected before and after surgery using Visual Analogue Scale (VAS).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e During the study period a total of fifty-nine patients met the inclusion criteria. Fifty-one patients agreed to fill out questionnaires for post-operative outcomes. EHP-30 scores had a significant improvement in all the domains analyzed even in the relationship with children and fertility module despite to the small number of patients answering those questions. No differences were found in terms of urinary function between pre and post-operative questionnaires (ICIQ-FLUTS). Bowel function improved in patients’ subjective perception. The NBD score showed that intestinal dysfunction related only to constipation and was reported as very minor by 76.4% of patients, minor by 11.8%, moderate by 5.9% by and severe by 5.95% of patients. Pain symptoms (VAS score) decreased significantly after surgery with the exception of chronic pelvic pain. (p value \u0026lt; 0,05).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eLaparoscopic nerve-sparing radical excision of parametrial DIE is safe and effective when performed by an expert surgical equipe. This approach can favorably impact on patients QoL. Moreover, it has proved to result in pain score and voiding function improvements.\u003c/p\u003e","manuscriptTitle":"Impact on Quality of Life of Laparoscopic Nerve-sparing Radical Treatment of Parametrial Deep Infiltrating Endometriosis (Postoperative Pain Assessment and Functional Outcomes)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-01-03 23:16:53","doi":"10.21203/rs.3.rs-1021436/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4a79dae7-3eb8-4423-baf2-14edb6e22d32","owner":[],"postedDate":"January 3rd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":9476219,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2022-03-09T15:55:58+00:00","versionOfRecord":[],"versionCreatedAt":"2022-01-03 23:16:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1021436","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1021436","identity":"rs-1021436","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}