Resection of Bilateral Endometriosis of the Uterosacral Ligaments Resolves Voiding Dysfunction: A Case Report

A 28‐year‐old nulliparous woman presented with severe urinary retention requiring clean intermittent self‐catheterization three to four times daily. Patient history revealed neither prior pelvic nor abdominal operations, nor any neurological or other known diseases. Infectious causes were ruled out with negative microbiological tests, and neurological etiologies were excluded by the urodynamic examination performed by the urologist.

Viktória Szántó: conceptualization, project administration, validation, visualization, writing – original draft. Balázs Kenyeres: data curation, investigation, methodology, validation, writing – original draft. Miklós Koppán: conceptualization, formal analysis, resources, supervision, visualization, writing – review and editing.

The patient underwent urodynamic testing, where we adhered to the recommendations of International Continence Society (ICS) good urodynamic practice and terminology [ 7 , 8 ]. Uroflowmetry and post‐void residual (PVR) measurement following filling cystometry and pressure‐flow study were carried out with the use of fluid‐filled external transducers and catheter system (8Ch, multichannel). Uroflowmetry revealed significant voiding dysfunction (intermittent urine flow, decreased Q max, and voided volume values as well as high post‐voidal residual volume) and also analyzed by the Liverpool nomogram [ 9 ] (Figure  1 , Table  1 ). Preoperative uroflowmetry result. The horizontal axis represents time measured in seconds (s). The vertical axis represents urinary flow rate ( Q ura) measured in mL/s. Uroflowmetry and urodynamic examination results before and after laparoscopic surgery. Filling cystometry showed signs of reduced bladder sensation (normal desire to void at 400 mL) along with preserved bladder compliance. During the pressure‐flow study, the patient was unable to initiate micturition, although abdominal straining and detrusor contraction were registered. The cause of voiding dysfunction was deemed to be pelvic floor dysfunction (dysfunctional voiding) rather than detrusor underactivity. Alpha blocker, muscle relaxant therapy, and pelvic floor relaxation training were introduced, achieving poor short‐term response. Transvaginal ultrasound examination showed hypoechogenic alterations on both uterosacral ligaments in the vicinity of their cervical attachment sites. These areas appeared to be painful while scanning with the probe. MRI examination confirmed the previous finding of transvaginal ultrasound with regard to bilateral alteration of the uterosacral ligaments characteristic of endometriosis.

We performed laparoscopic surgery using a high‐definition 6K visualization system (EndoVims Prestige System with 43″ IPS widescreen) to facilitate a precise, macroscopic dissection for nerve preservation. The total surgical time was approximately 60 min, with a blood loss of less than 5 mL. During the operation, bilateral endometriotic lesions of the uterosacral ligaments were confirmed (Figure  2 , Video  1 ). After visualization of the ureter, the lesions were excised in toto through delicate dissection that ensured the preservation of the pelvic splanchnic nerves (Figure  3 , Video  1 ). A small superficial endometriotic lesion of the bladder peritoneum was also found and removed. Laparoscopic removal of the endometriotic lesions of the uterosacral ligaments. Figure shows excision of the nodule from the cervical end of the left uterosacral ligament. In the right upper corner of the image, the uterine cervix is visible. Delicate dissection and preservation of pelvic splanchnic nerves and visible superficial endometriotic nodules of the right uterosacral ligament. Video content can be viewed at https://onlinelibrary.wiley.com/doi/10.1002/ccr3.70929 . Delicate dissection and preservation of pelvic splanchnic nerves. Parasympathetic nerve filaments of the right uterosacral ligament are exposed after resection of endometriotic nodules. The proximity of pelvic autonomic nerves to the lesion site is clearly visible. The postoperative period was uneventful. Patient was discharged the day following surgery without the need of intermittent self‐catheterization and complaint‐free. Urodynamic testing was carried out 3 months after surgery.

After surgery, we observed marked improvement in the patient's voiding functions. The mean volume of PVR significantly decreased; therefore, daily usage of intermittent self‐catheterization was ceased. Uroflowmetry and urodynamic testing 3 months after surgery demonstrated an improvement in voiding parameters with an increased Q max value as compared to that obtained preoperatively (Figure  4 , Table  1 ). On the other hand, with regard to reduced bladder sensation with a normal desire to void, compliance, inability to void with the intravesical catheter inside, and maximal detrusor pressure, similar results were recorded. Histology confirmed endometriosis. Postoperative uroflowmetry result. The horizontal axis represents time measured in seconds (s). The vertical axis represents urinary flow rate ( Q ura) measured in mL/s.

The objective of this case report was to demonstrate the effect of laparoscopic removal of uterosacral endometriosis in a patient suffering from serious preoperative urinary retention mandating clean intermittent self‐catheterization. Uterosacral ligament endometriosis might be clinically complex and surgically challenging. Based on pelvic anatomy, it is obvious that certain locations of an inflammatory disease, such as endometriosis, can affect the function of pelvic autonomic nerves. Moreover, as the disease progresses, these nerves can be damaged, causing non‐restorable lack of function. The proximity of endometriotic nodules in the uterosacral ligament and the underlying pelvic autonomic nerve filaments clearly explains not only the danger that surgery in this anatomical region might pose to bladder function, but also the danger that disease progression bears. Beyond anatomical and functional damage to these nerve fibers, further deterioration of urinary function might be attributed to chronic pelvic pain and increased pelvic muscle floor tonicity caused by endometriosis. Removal of endometriotic lesions of the uterosacral ligament, along with the preservation of autonomic nerve fibers, might therefore improve the overall urinary functions, as demonstrated in our case, where considerably better postoperative voiding parameters, residual volume, symptoms, and quality of life could be recorded. As seen in our case, endometriotic lesions did not deeply penetrate the uterosacral ligaments. On one hand, this allows nerve‐sparing surgery to be easily performed. On the other hand, this highlights the importance of early detection and surgical excision of the disease before it could cause irreversible damage or markedly increase the risk of damage caused by surgery itself. The difference between postoperative urodynamic and uroflowmetry results needs explanation: The patient had both pre‐ and postoperative distended bladder with a reduced sensitivity and typical signs of functional obstruction (pelvic floor—sphincter relaxation disorder, dysfunctional urination) and detrusor underfunction (contractions maintained with insufficient strength for inadequate duration). A possible explanation could be the patient's chronic pelvic pain syndrome originating from endometriosis of the uterosacral ligaments [ 10 , 11 ]. Based on that, peripheral and central sensitization, and pelvic‐organ crosstalk could be initiated [ 12 ]. As a consequence, pelvic floor dysfunction, such as pelvic floor muscles and sphincter relaxation disorder, overactive or increased tone of the pelvic floor may develop. In such cases, the detrusor can be inhibited through the activation of the guarding reflex. After eliminating the primary noxa by surgery, the physiotherapeutic rehabilitation could continue. Consequently, the sphincter relaxation and the detrusor contractility disorder can start to resolve. Since this is a long‐lasting process, the real effectiveness of physiotherapy can be measured after at least half a year. Catheterization itself, used during invasive urodynamic examination, as well as triggered urge symptoms caused by the catheter being a corpus alienum, can still provoke a relaxation disorder, while urination without the foreign body (during uroflowmetry) is less affected. That is why postoperative results might significantly be better. When performing an extensive literature search on PubMed using keywords “preoperative voiding dysfunction” and “endometriosis”, the vast majority of results only deal with postoperative voiding dysfunction and the preventive measures to avoid them. Therefore, the importance of our finding relies on the lack of literature data on possible improvement of pre‐surgery voiding dysfunction following endometriosis resection. In 2013, Bonneau et al. highlighted the need for more effort to be made to detect preoperative urinary dysfunction in endometriosis patients [ 13 ]. However, marked progress in the field has not been documented to date, whether surgery could be aimed directly at improving urinary functions. A prospective cross‐sectional observational study evaluated women with deep infiltrating endometriosis with preoperative evaluation of urodynamics and detailed assessment of lower urinary tract symptoms. This study clearly demonstrated different types of lower urinary tract dysfunctions depending on lesion location; endometriosis involving the bladder was found to disturb storage function, while endometriosis in the parametrium appeared to disturb the voiding phase [ 14 ]. Moreover, other papers demonstrated that the application of the nerve‐sparing technique during surgery for posterior compartment endometriosis improves immediate postoperative urinary outcomes and reduces the need for self‐catheterization [ 15 ]. Also, a recent study clearly states that the development of a predictive model and implementation of controlled studies including comprehensive preoperative and postoperative functional assessments of voiding dysfunction are needed to assist patient counseling and surgical planning [ 4 ]. These are in line with our results, especially if we consider the location of the parasympathetic autonomic nerves responsible for detrusor contraction in the bladder. Since the pelvic splanchnic nerves run along the anteromedial side of the ischial spine, and the paracolpium includes at least some parts of the pelvic autonomic nerve plexus [ 16 ], it is easy to understand why cyclic inflammation and edema in the uterosacral ligament disturb autonomic function carried by pelvic splanchnic nerves. Thus, if a patient presents with cyclic bladder dysfunction synchronous with her menstruation, it is reasonable to suppose that posterior compartment endometriosis involving the uterosacral ligaments and/or pelvic side wall is to be accounted for her symptoms. When the diameter of the lesion is > 3 cm in the posterior compartment, a higher risk of postoperative voiding dysfunction is to be expected after surgery [ 17 ]. Thus, it is obvious that delay in the diagnosis increases the likelihood of non‐restorable bladder dysfunction either by the disease itself or by more radical surgery attempting to cure a more advanced stage of the disease. This case report has several limitations. First, as a single case report, the findings may not apply to all patients. Second, while the patient has remained consistently complain‐free for 3 years since the surgery and all follow‐up ultrasound examinations have shown no signs of recurrent endometriosis, this is not a part of a larger, long‐term observational study. Proper knowledge of the topographic anatomy and awareness of potential symptoms correlating with lesion location is crucial for early detection of endometriosis in the uterosacral ligaments, posing a risk of harmful damage to pelvic autonomic functions to the patient if not treated in time. Guidance by anatomical landmarks is essential to avoid intraoperative nerve injuries and postoperative bladder and bowel dysfunction. Therefore, precise preoperative assessment, laparoscopic removal of lesions, and appropriate follow‐up are essential for patients suffering from urinary retention with the presence of posterior compartment endometriosis. Based on the above, multidisciplinary awareness between gynecologists and urologists is essential for recognizing that patients might benefit from early surgical intervention in cases where endometriosis involves the uterosacral ligaments and is suspected of causing voiding dysfunction. The establishment of a multicenter registry or observational series is needed to further assess the efficacy of surgical intervention in these patients and to assist with patient counseling and surgical planning.

Authors hereby confirm that written informed consent has been obtained from the involved patient, and she has given approval and permission for this material to be published.

The incidence of lower urinary tract symptoms in endometriosis is relatively low, as compared to other gynecological and digestive manifestations, and it varies from 3.4% up to 15.4% [ 1 ]. Although such symptoms might be present in patients before any kind of surgery, they are often masked by pelvic pain [ 2 ]. Following posterior compartment endometriosis surgery, patients frequently report an improvement in urinary function, even though their previous complaints were not recognized as one to be linked to endometriosis. Lower urinary tract symptoms are frequently caused by damage to the pelvic autonomic nerves either by direct infiltration of them or by surgical trauma [ 3 , 4 , 5 ]. Sensory disturbances and voiding dysfunction might impact quality of life and could lead to long‐term urinary complications. Thus, it is of clinical significance to diagnose early and treat properly these conditions. Patients with deep endometriosis of the posterior pelvic compartment might present various lower urinary tract symptoms, including urinary retention, without any prior pelvic surgery in their medical history. These symptoms, including urinary retention, pollakiuria or urge incontinence, urinary urgency, and decreased bladder sensitivity, imply an infiltration of the pelvic autonomic nerves by endometriosis lesions, in combination with inflammatory phenomena. Patients with posterior compartment endometriosis frequently complain about altered urinary function. Although there are numerous publications dealing with de novo urinary dysfunction after endometriosis surgery, significantly less scientific information is available on the effect of endometriosis surgery specifically tailored to improve preoperative voiding dysfunction. Although there are numerous publications dealing with de novo urinary dysfunction after endometriosis surgery, significantly less scientific information is available on the effect of endometriosis surgery specifically tailored to improve preoperative voiding dysfunction. Thus, the objective of this case report was to demonstrate the effect of laparoscopic endometriosis surgery in a 28‐year‐old nulliparous woman with severe urinary retention requiring clean intermittent self‐catheterization three to four times daily. Intrapelvic part of the autonomic nervous system responsible for maintaining physiological autonomic functions of pelvic viscera is composed of two major parts. The hypogastric nerves derive from the superior hypogastric plexus and carry sympathetic signals to the internal urethral and anal sphincters as well as to the pelvic visceral proprioception. The pelvic splanchnic nerves arise from S2 to S4 and carry nociceptive and parasympathetic signals to the bladder, rectum, and the sigmoid and left colons [ 6 ]. These two nerves merge to form the inferior hypogastric plexus in the pararectal fossae. Thus, it is not surprising that endometriotic lesions in close proximity to these nerve filaments, i.e., those affecting the uterosacral ligaments and/or the pararectal fossae, might cause disturbance of pelvic autonomic visceral functions. However, there are only scattered data on the management of disease‐related voiding dysfunction in patients prior to any surgery. In this paper we present a case when bilateral uterosacral endometriosis was found to be the underlying reason for bladder dysfunction necessitating self‐catheterization, and was treated successfully by laparoscopic resection of the lesions.

The authors declare no conflicts of interest.