Unilateral nerve preservation during parametrectomy is not sufficient to prevent persistent urinary retention after cytoreductive endometriosis surgery

Objectives This study sought to quantify the risks of urinary retention following different levels or degrees of nerve preservation during parametrectomies for deep endometriosis (DE).

Women undergoing laparoscopic and robotic nerve-sparing DE surgeries were studied. The cases were divided into 6 groups according to the degree of preservation of parasympathetic parametrium fibers on each side: P1 (P1 left /P1 right—Excellent preservation: presacral and pararectal fascia bilateral preservation), P2 (P1/P2 or P2/P1, P2/P2—Regular preservation: fascia violation with local fat visualization—either of both sides; and P3 (P1/P3 or P3/P1, P2/P3 or P3/P2, P3/P3)—Poor preservation: musculature and pelvic floor exposure—even if only unilateral.

Of a total of 151 women eligible for the study, 110 (72.8%) had excellent nerve preservation; 24 (15.8%) had regular nerve preservation, and 17 (11.2%) had poor-nerve preservation. The incidence of elevated PVR was higher in the P3 group. Thirty-five patients were catheterized post-operatively, more common in the P3 group. In four cases from the P3 group, prolonged intermittent self-catheterization after discharge was necessary. The calculated risk of needing intermittent catheterization in the P3 group was 23.1% up to 8 weeks and 7.7% up to 8 months post-surgery.

Parametrectomy with poor-nerve preservation can lead to urinary retention, even with excellent contralateral preservation. Similar content being viewed by others Data availability All relevant data are within the paper and its Supporting Information files. Abbreviations - ASRM: - American Society of Reproductive Medicine - DE: - Deep endometriosis - ESHRE: - European Society of Human Reproduction and Embryology - IHP: - Inferior hypogastric plexus - PVR: - Post-void residual urine - P1: - Excellent preservation - P2: - Regular preservation - P3: - Poor preservation - P1/P1: - Excellent preservation, left side and right side - P1/P2: - Left excellent preservation and regular right preservation - P2/P1: - Left regular preservation and excellent right preservation - P2/P2: - Regular preservation bilateral - P1/P3: - Excellent left preservation and poor right preservation - P3/P1: - Poor left preservation and excellent right preservation - P2/P3: - Regular left preservation and poor right preservation - P3/P2: - Poor left preservation and regular right preservation - P3/P3: - Poor preservation left and right

de Freitas Fonseca M, Aragao LC, Sessa FV, Dutra de Resende JA Jr, Crispi CP (2018) Interrelationships among endometriosis-related pain symptoms and their effects on health-related quality of life: a sectional observational study. Obstet Gynecol Sci 61(5):605–614 de Resende Júnior JAD, Crispi CP, Cardeman L, Buere RT, Fonseca MF (2018) Urodynamic observations and lower urinary tract symptoms associated with endometriosis: a prospective cross-sectional observational study assessing women with deep infiltrating disease. Int Urogynecol J 29(9):1349–1358 Abrão MS, Petraglia F, Falcone T, Keckstein J, Osuga Y, Chapron C (2015) Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management. Hum Reprod Update 21(3):329–339 Misal M, Girardo M, Wasson MN (2020) Surgical decision regret in women pursuing surgery for endometriosis or chronic pelvic pain. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2020.09.016 Mathieu d’Argent E, Cohen J, Chauffour C et al (2018) Endométriose profonde et infertilité, RPC Endométriose CNGOF-HAS [Deeply infiltrating endometriosis and infertility: CNGOF-HAS endometriosis guidelines]. Gynecol Obstet Fertil Senol 46(3):357–367 de Resende JAD, Cavalini LT, Crispi CP, Fonseca MF (2017) Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: a systematic review and meta-analysis. Neurourol Urodyn 36(1):57–61 Oliveira MA, Pereira TR, Gilbert A, Tulandi T, de Oliveira HC, De Wilde RL (2016) Bowel complications in endometriosis surgery. Best Pract Res Clin Obstet Gynaecol 35:51–62 Keckstein J, Becker CM, Canis M, Feki A, Grimbizis GF, Hummelshoj L, Nisolle M, Roman H, Saridogan E, Tanos V, Tomassetti C, Ulrich UA, Vermeulen N, De Wilde RL (2020) Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis. Hum Reprod Open. https://doi.org/10.1093/hropen/hoaa002 Rabischong B, Botchorishvili R, Bourdel N, Curinier S, Campagne-Loiseau S, Pouly JL, Canis M (2018) Nerve sparing techniques in deep endometriosis surgery to prevent urinary or digestive functional disorders: techniques and results: CNGOF-HAS endometriosis guidelines. Gynecol Obstet Fertil Senol 46(3):309–313 Barra F, Ferrero S, Zorzi C et al (2024) “From the tip to the deep of the iceberg”: parametrial involvement in endometriosis. Best Pract Res Clin Obstet Gynaecol 94:102493. https://doi.org/10.1016/j.bpobgyn.2024.102493 Ballester M, Santulli P, Bazot M, Coutant C, Rouzier R, Daraï E (2011) Preoperative evaluation of posterior deep-infiltrating endometriosis demonstrates a relationship with urinary dysfunction and parametrial involvement. J Minim Invasive Gynecol 18:36–42 Eskenazi B, Warner ML (1997) Epidemiology of endometriosis. Obstet Gynecol Clin North Am 24(2):235–258 Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K (2022) ESHRE guideline: endometriosis. Hum Reprod Open. https://doi.org/10.1093/hropen/hoac009 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61(4):344–349. https://doi.org/10.1016/j.jclinepi.2007.11.008 Agha RA, Sohrabi C, Mathew G, Franchi T, Kerwan A, O’Neill N (2020) The PROCESS 2020 guideline: updating consensus preferred reporting of case series in surgery (PROCESS) guidelines. int J Surg 84:231–235. https://doi.org/10.1016/j.ijsu.2020.11.005 Ribeiro-Julio GS, Pereira JA, Ribeiro E, Gallo CM, Favorito LA (2023) Anatomy of the lower hypogastric plexus applied to endometriosis: a narrative review. Int Braz J Urol 49(3):299–306 Tanaka Y, Kuratsune K, Otsuka A, Ishii T, Shiraishi M, Shiki Y (2024) Total laparoscopic hysterectomy with posterior cul-de-sac obliteration: step-by-step procedures based on precise anatomical landmarks. Arch Gynecol Obstet 310(3):1795–1799. https://doi.org/10.1007/s00404-024-07614-y. (Epub 2024 Jun 28) Aurore V, Röthlisberger R, Boemke N, Hlushchuk R, Bangerter H, Bergmann M, Imboden S, Mueller MD, Eppler E, Djonov V (2020) Anatomy of the female pelvic nerves: a macroscopic study of the hypogastric plexus and their relations and variations. J Anat 237(3):487–494. https://doi.org/10.1111/joa.13206. (Epub 2020 May 19) Possover M (2014) Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 101(5):1296–1297. https://doi.org/10.1016/j.fertnstert.2013.12.019 Daraï E, Ballester M, Chereau E, Coutant C, Rouzier R, Wafo E (2010) Laparoscopic versus laparotomic radical en bloc hysterectomy and colorectal resection for endometriosis. Surg Endosc 24:3060–3067 Dior UP, Reddington C, Cheng C, Levin G, Healey M (2022) Urinary function after surgery for deep endometriosis: a prospective study. J Minim Invasive Gynecol 29(2):308-316.e2. https://doi.org/10.1016/j.jmig.2021.08.024 Azaïs H, Rubod C, Ghoneim T et al (2015) Persistent urinary retention after surgery for deep infiltrating endometriosis: a multi-center series of 16 cases. Arch Gynecol Obstet 291:1333–1339. https://doi.org/10.1007/s00404-014-3588-7 Gomes FH, de Freitas Fonseca M, Favorito LA, Gasparoni MP, da Silva Filho FS, Diniz ALL, de Resende Júnior JAD (2024) Changes in lower urinary tract function after minimally invasive nerve-sparing for complete excision of endometriosis: an observational study. Neurourol Urodyn 43(4):862–873. https://doi.org/10.1002/nau.25414. (Epub 2024 Mar 18) Kanno K, Yanai S, Masuda S, Ochi Y, Sawada M, Sakate S, Andou M (2024) Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis. Arch Gynecol Obstet 310(3):1677–1685. https://doi.org/10.1007/s00404-024-07674-0. (Epub 2024 Aug 16)

The authors thank Dr. Leigh J. Passman for reviewing the English manuscript. Funding One author (MFF) is a salaried staff physician of the Fundação Instituto Oswaldo Cruz, but Fiocruz did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Our study received no funding from any company or institution for the field work and development. The other authors declare that no funds, grants, or other support were received. The publication fee was funded by a grant from the Brazilian Ministry of Education: CAPES-PROAP grant number 001/2021 VPEIC to the Post-graduate Program in Applied Research of the Fernandes Figueira National Institute of Women, Children and Adolescents. Author information Authors and Affiliations Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mauro Poggiali Gasparoni Junior. The first draft of the manuscript was written by Mauro Poggiali Gasparoni Junior; all co-authors commented on it and successive iterations. All authors read and approved the final manuscript. Gasparoni Jr MP, Fonseca MF, Resende Jr JAD: Manuscript writing/editing. Gasparoni Jr MP, Fonseca MF, Resende Jr JAD, Favorito LA: Protocol/project development. MP Gasparoni Jr, LA Favorito, AL Diniz, FH Gomes, MF Schuh: Data collection or management. MF Fonseca, LA Favorito, FS Salles: Data analysis. Corresponding author Ethics declarations Conflict of interest None declared. None of the authors have any competing interest that could be perceived to bias this work. In the same way, there was no influence of any of the financial support in the results presented. Ethical approval The study was approved according to the ethical standards of the hospital’s institutional committee on experimentation with human beings [CAAE 31050120.2.0000.5259]. The study has also been registered in the Brazil Platform, maintained by the National Research Ethics Commission for Studies with Human Subjects, a commission of the National Health Council of the federal Ministry of Health. We affirm that all methods used in this study were carried out in accordance with relevant guidelines and regulation in compliance with the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. Consent to participate Informed consent was obtained from all individual participants included in the study. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Gasparoni, M.P., de Freitas Fonseca, M., Favorito, L.A. et al. Unilateral nerve preservation during parametrectomy is not sufficient to prevent persistent urinary retention after cytoreductive endometriosis surgery. Arch Gynecol Obstet 310, 3267–3278 (2024). https://doi.org/10.1007/s00404-024-07842-2 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00404-024-07842-2