Predictive approach in managing voiding dysfunction after surgery for deep endometriosis: a personalized nomogram

Introduction and hypothesis The aim was to develop a nomogram based on clinical and surgical factors to predict the likelihood of voiding dysfunction after surgery for deep endometriosis.

This was a retrospective study of 789 patients (training set) who underwent surgery for deep endometriosis with colorectal involvement from January 2005 through December 2017 at Tenon University Hospital. A multivariate logistic regression analysis of selected risk factors was performed to construct a nomogram to predict postoperative voiding dysfunction. The nomogram was externally validated in 333 patients (validation set) from Rouen University Hospital.

Postoperative voiding dysfunction occurred in 23% of the patients (180/789) in the training set. Age, colorectal involvement/management, colpectomy and parametrectomy were the main factors associated with an increased risk of voiding dysfunction and were included in the nomogram. The predictive model had an internal concordance index of 0.79 (95% CI: 0.77–0.81) after the 200 repetitions of bootstrap sample corrections and showed good calibration. The ROC area related to the nomogram for external validation was 0.74 (95% CI: 0.72–0.76).

The nomogram we present here, based on four clinical and imaging characteristics, could be useful in predicting postoperative voiding dysfunction for women undergoing surgery for deep endometriosis. Patients could thus be better informed about this postoperative risk and the surgical strategy adapted according to individual risk. The accuracy of the tool was validated externally but additional validation is required. Similar content being viewed by others

Clement PB. The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol. 2007;14:241–60. Weed JC, Ray JE. Endometriosis of the bowel. Obstet Gynecol. 1987;69:727–30. Dubernard G, Rouzier R, David-Montefiore E, Bazot M, Darai E. Use of the SF-36 questionnaire to predict quality-of-life improvement after laparoscopic colorectal resection for endometriosis. Hum Reprod Oxf Engl. 2008;23:846–51. Comptour A, et al. Patient quality of life and symptoms following surgical treatment for endometriosis. J Minim Invasive Gynecol. 2018. https://doi.org/10.1016/j.jmig.2018.08.005. Byrne D, et al. Laparoscopic excision of deep rectovaginal endometriosis in BSGE endometriosis centres: a multicentre prospective cohort study. BMJ Open. 2018;8:e018924. Roman H, et al. High postoperative fertility rate following surgical management of colorectal endometriosis. Hum Reprod Oxf Engl. 2018;33:1669–76. Campin L, et al. Urinary functional disorders bound to deep endometriosis and to its treatment: review of the literature. J Gynecol Obstet Biol Reprod (Paris). 2014;43:431–42. Kondo W, et al. Complications after surgery for deeply infiltrating pelvic endometriosis. BJOG Int J Obstet Gynaecol. 2011;118:292–8. Ballester M, et al. Urinary dysfunction after colorectal resection for endometriosis: results of a prospective randomized trial comparing laparoscopy to open surgery. Am J Obstet Gynecol. 2011;204:303.e1–6. Possover M. Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril. 2014;101:754–8. Clavien PA, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96. Wagenmakers E-J, Farrell S. AIC model selection using Akaike weights. Psychon Bull Rev. 2004;11:192–6. Harrell FEJ, Lee KL, Mark DB. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15:361–87. Steyerberg EW, Eijkemans MJ, Harrell FEJ, Habbema JD. Prognostic modelling with logistic regression analysis: a comparison of selection and estimation methods in small data sets. Stat Med. 2000;19:1059–79. Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29–36. Coutant C, et al. Comparison of models to predict nonsentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: a prospective multicenter study. J Clin Oncol Off J Am Soc Clin Oncol. 2009;27:2800–8. Miller ME, Hui SL, Tierney WM. Validation techniques for logistic regression models. Stat Med. 1991;10:1213–26. Schisterman EF, Perkins NJ, Liu A, Bondell H. Optimal cut-point and its corresponding Youden index to discriminate individuals using pooled blood samples. Epidemiol Camb Mass. 2005;16:73–81. de Resende Júnior, J. A. D., Crispi, C. P., Cardeman, L., Buere, R. T. & Fonseca, MF de. Urodynamic observations and lower urinary tract symptoms associated with endometriosis: a prospective cross-sectional observational study assessing women with deep. Ballester M, et al. Evaluation of urinary dysfunction by urodynamic tests, electromyography and quality of life questionnaire before and after surgery for deep infiltrating endometriosis. Eur J Obstet Gynecol Reprod Biol. 2014;179:135–40. Roman H, et al. Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol. 2016;215:762.e1–9. Fedele L, et al. Long-term follow-up after conservative surgery for bladder endometriosis. Fertil Steril. 2005;83:1729–33. Donnez J, Nisolle M, Casanas-Roux F, Bassil S, Anaf V. Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients. Hum Reprod Oxf Engl. 1995;10:630–5. Jayot A, Nyangoh Timoh K, Bendifallah S, Ballester M, Darai E. Comparison of Laparoscopic Discoid Resection and Segmental Resection for Colorectal Endometriosis Using a Propensity Score Matching Analysis. J Minim Invasive Gynecol. 25:440–6. Abo C, 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;109:172–178.e1. Dubernard, G., Rouzier, R., David-Montefiore, E., Bazot, M. & Daraï, E. Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gy Bonneau C, et al. Incidence of pre- and postoperative urinary dysfunction associated with deep infiltrating endometriosis: relevance of urodynamic tests and therapeutic implications. Minerva Ginecol. 2013;65:385–405. Che 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;175:87–91. de Resende JAD, Cavalini LT, Crispi CP, de Freitas Fonseca M. Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: a systematic review and meta-analysis. Neurourol Urodyn. 2017;36:57–61. Author information Authors and Affiliations Contributions Dr. Vesale: Protocol/project development, data collection or management, data analysis, manuscript writing/editing. Pr. Roman: Data collection or management, manuscript writing/editing. Dr. Abo: Data collection or management, manuscript writing/editing. Dr. Benoit: Data analysis, manuscript writing/editing. Dr. Tuech: Data analysis, manuscript writing/editing. Pr. Darai: Protocol/project development, manuscript writing/editing. Dr. Bendifallah: Protocol/project development, data collection or management, manuscript writing/editing. Corresponding author Ethics declarations Conflicts of interest None. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material ESM 1 (download DOC ) (DOC 26 kb) ESM 2 (download DOC ) (DOC 79 kb) Rights and permissions About this article Cite this article Vesale, E., Roman, H., Abo, C. et al. Predictive approach in managing voiding dysfunction after surgery for deep endometriosis: a personalized nomogram. Int Urogynecol J 32, 1205–1212 (2021). https://doi.org/10.1007/s00192-020-04428-9 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s00192-020-04428-9