Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis

OBJECTIVE: To investigate pathophysiologic mechanisms involved in bladder retention after surgery for rectovaginal deeply infiltrating endometriosis (DIE). DESIGN: Retrospective case study. SETTING: Tertiary referral unit. PATIENT(S): All patients who presented at our center over the last 5 years with bladder retention developed after laparoscopic surgery for rectovaginal or parametric DIE. INTERVENTION(S): To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step workup including patient history, clinical neuropelveologic assessment, cystoscopy, and video-urodynamic testing with pelvic floor electromyography and rectomanometry. MAIN OUTCOME MEASURE(S): Patient Perception of Bladder Condition, International Prostate Symptom Score, and the short-form version of the Urogenital Distress Inventory questionnaires. RESULT(S): Forty-seven patients were investigated in this study. Mean (±SD) interval from the surgery was 9.5 years (±4.3; range, 7-15 years). Eighteen patients developed acute paralytic motor bladder atony and 5 acute neurogenic bladder atony. Twenty-four patients developed chronic neurogenic bladder atony. The first symptom of chronic bladder retention was reduction of urinary frequency (after 5 years on average). The most frequent complaints that made patients aware of difficulties in voiding were a weak urinary stream (appearing on average 7 years after the procedure) and the need for Valsalva or Crede maneuver (on average 9 years after the procedure). CONCLUSION(S): Segmental rectum resection with parametric resection exposes the most patients to the risk of bladder motor paralytic retention. However, the most frequent etiology seems to be chronic myogenic destruction secondary to chronic bladder overdistention. Patients after surgery for DIE require a long follow-up, with particular attention paid to postvoid residual volumes.