Urogynecological Outcomes After Minimally Invasive Surgery for Deep Endometriosis: A Systematic Review

Giuseppe Mascellino,1 Antonio Simone Laganà,1 Marco Anatrà,2 Pietro Serra,1 Giada Mesiano,3 Matteo Terrinoni,4,5 Vincenzo Mascellino,6 Simone Ferrero,2 Maurizio Serati,3 Maurizio Leone,2 Fabio Barra2,7 1Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital - Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; 2Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; 3Department of Obstetrics and Gynecology, Del Ponte Hospital, University of Insubria, Varese, Italy; 4Department of Medicine and Surgery, University of Perugia, Perugia, Italy; 5Department of Obstetrics and Gynecology, “Alto Tevere” Hospital - Città di Castello, Perugia, Italy; 6Department of Obstetrics and Gynecology, “Fogliani” Hospital - Milazzo, Messina, Italy; 7Department of Health Sciences (DISSAL), University of Genoa, Genoa, ItalyCorrespondence: Fabio Barra, Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genoa, 16132, Italy, Tel +01139 334 9437959, Email [email protected]: Deep endometriosis (DE) frequently affects pelvic organs and may impair urinary function through both direct involvement and surgical nerve disruption. Minimally invasive excision is the standard treatment for symptomatic DE, but its impact on lower urinary tract symptoms (LUTS) remains uncertain. We conducted a systematic review according to PRISMA 2020 guidelines to evaluate postoperative urogynecological outcomes following laparoscopic or robotic surgery for DE (PROSPERO ID: CRD420251113885). PubMed, Scopus, and the Cochrane Library were searched for studies published over the last 25 years. Eligible studies included women undergoing minimally invasive surgery for DE with postoperative urinary outcomes assessed by validated questionnaires or urodynamic testing. Methodological quality was appraised using the Newcastle–Ottawa Scale. Out of 175 records, 9 studies involving 20– 289 participants met the inclusion criteria. Six studies reported significant postoperative improvements, particularly in urgency, frequency, and dysuria, with benefits most evident in women presenting with moderate-to-severe preoperative LUTS. Improvements were observed in both subjective assessments, by using standardized questionnaires such as the International Consultation on Incontinence Questionnaire (ICIQ), Urinary Symptom Profile (USP), International Prostate Symptom Score (IPSS), and Visual Analogue Scale (VAS), and, in some cases, objective measures such as bladder capacity and uroflowmetry. Conversely, three studies documented no significant change or worsening of urinary function, predominantly in women with minimal baseline dysfunction or extensive parametrial and sacral nerve involvement. In these series, postoperative deterioration included increased voiding difficulties and worsening symptom scores. Across studies, outcome definitions, assessment tools, surgical techniques, and follow-up intervals varied substantially, introducing significant heterogeneity that prevented a formal meta-analysis from being performed. Overall, minimally invasive surgery for DE may yield meaningful symptomatic relief in selected patients, particularly when nerve-sparing techniques are applied. However, functional deterioration remains a relevant risk, especially among those with minimal baseline LUTS. Future research should prioritize prospective trials with standardized outcome measures, longer follow-up, and stratification by preoperative symptom burden to optimize patient selection and refine surgical approaches.Keywords: deep endometriosis, urinary symptoms, nerve-sparing surgery, minimally invasive surgery, urinary function