Results
From January 2016 to April 2019, 52 patients met inclusion criteria and
were included in our retrospective study. Their data were prospectively
recorded in the CIRENDO database. Forty-two patients were managed in
Rouen from January 2016 to June 2018, 1 patient in Aarhus in October
2017 and 9 patients underwent surgery in Bordeaux, from September 2018
to April 2019.
Table 1 presents patient characteristics. 38.5% of patients had past
history of surgery for endometriosis, using an open abdominal approach
in a quarter of cases and including major procedures such as colorectal
resections or nephrectomy. A majority of patients (80.8%) were
nullipara, 65.4% of women expressed pregnancy intention before surgery,
and in 50% infertility was affirmed. Symptoms presumed to be related to
sacral roots or sciatic nerve involvement were various and included
somatic pain, paraesthesia, motor weakness, bladder dysfunction and
severe constipation. Twenty-seven patients (51.9%) had at least one
symptom suggesting bladder dysfunction (USP score >=1, at
least “abdominal contraction required” OR “weak urine flow” OR
“urination difficult to start or to finish”), in 13 patients (25%)
bladder voiding alteration was significant with USP score
>=3 (at least “abdominal contraction required” AND “weak
urine flow” AND “urination difficult to start or to finish”), while
in 1 patient (1.9%) urination had become impossible and bladder voiding
was exclusively performed using self-catheterisation (USP=9).
Table 2 presents intraoperative findings, surgical procedures and
postoperative complications. A majority of patients presented with large
nodule of the parametrium (94.2%), providing an explanation for the
high rate of concomitant digestive tract infiltration, particularly of
the rectum (84.6%), the frequency of large vaginal infiltrations
(80.8% of patients had vaginal nodules over 3 cm in width) and frequent
lesions localised in the urinary tract (46.2%). Surprisingly, ovaries
and fallopian tubes were rarely involved. A third of patients had an
AFSr score <=15, and only one third of patients underwent a
procedure for ovarian endometrioma. Conversely, procedures on the
digestive tract were carried out in 82.7% of patients, half of whom had
a preventive stoma.
In 9 patients out of 10, sacral root and splanchnic nerve involvement
could be removed by sacral root and sciatic nerve dissection, with large
endometriosis nodule involvement leading to the sacrifice of inferior
hypogastric plexus. In 3 cases, nerves were shaved using cold scissors
and excision was performed inside the epineurium. In one patient,
endometriosis appeared to infiltrate the interior of the nerve and
complete excision led to a 5 mm wide hollow area inside the nerve.
Postoperative outcomes were however uneventful.
Four intraoperative complications (7.7%) were recorded, related to
severe haemorrhage due to hypogastric vein injuries. In 2 cases, the
vein was ligated laparoscopically. For the other 2 patients whose past
history of colorectal resection for endometriosis resulted in
postoperative extensive fibrosis, haemorrhage could not be managed
laparoscopically and conversion to open surgery was required.
The high rate of rectovaginal fistula was related to a high frequency of
excision of mid or low rectum (80.8%) associated with colpectomy
(84.6%). Bladder dysfunction over 3 weeks was recorded in 27% of
patients, however only 5.8% of them still required self-catheterisation
12 months after surgery and one of them benefited from neuromodulation
of sacral roots. Conversely, 6 patients (11.5%) presented with
postoperative transitory urinary stress incontinence.
Table 3 presents data recorded 1 year postoperatively. An overall
improvement in somatic pain and motor disorders was affirmed by 47
patients (90.4%) and confirmed by the significant increase in SF-36
values assessed 1 year after surgery. An overall improvement in terms of
digestive function was shown by better gastrointestinal score values.
Conversely, there was a tendency towards an overall impairment of
bladder function. While surgical procedures performed on nerves were
followed by a tendency towards a reduction in the rate of patients
experiencing paraesthesia and motor weakness in the legs, some patients
presented new complaints such as hypoesthesia, hyperesthesia or
allodynia.
Twenty-two patients (44.2%) attempted to conceive during postoperative
follow up of 23 +/-8.7 months. The cumulative pregnancy rate was 77.2%
(17 patients) following natural conception in 47% (8 patients) and ART
management in 53% (9 patients) of cases. Fourteen women delivered
(60.9%), and 3 pregnancies were ongoing at the time of manuscript
submission (13%). At the time of manuscript submission, two patients
were benefiting from ongoing ART management (8.7%) while 4 other
patients had deferred pregnancy attempts following unsuccessful ART
management (17.4%).