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%).