Voiding dysfunction after complex deep endometriosis surgery is probably one of the less recognised complications of this type of surgery.  Certain locations of deep endometriosis (eg. Parametrium, uterosacral ligaments, sacral plexus), when excised, may be linked to higher risk of voiding dysfunction post-operatively. This may be due to inadvertent injury to the innervation of the bladder during surgical excision of endometriosis. Intermittent self-catheterisation (ISC) may be required in the immediate post-operative period, with the hope that normal voiding will resume as time goes by after surgery. Fear of causing permanent damage may limit surgical resection, with some surgeons preferring to leave some lesions intact, an approach that may be linked to higher risk of pain persistence and post-operative recurrence.

However, the question as to what extent urinary dysfunction is caused by deep endometriosis itself or surgical sequalae post excision remains to be answered. A review article quoted a wide range of pre-operative urinary dysfunction of 2-48% in patients with colorectal DE and mean de novo dysfunction of 4.8% after surgery [1]. It is likely that patients with impaired urinary function pre-operatively will benefit more from surgery, whereas those with normal function before surgery may be more at risk of post-operative deterioration [2]. When discussing urinary function after colorectal endometriosis surgery, results of studies are conflicting, with others suggesting worsening in voiding function [3,4], and others amelioration [5]. It is also likely that employing a less radical approach may protect urinary function to some extent, as bowel shaving may lead to less voiding problems compared to bowel resection [2,5]. Excluding the high-risk groups of patient requiring bowel or ureteral resection, an interesting prospective multi-centre study found deep  endometriosis excision to improve all urodynamic parameters (filling and voiding) [6].

 The importance of employing a nerve-sparing surgical approach in reducing post-operative voiding dysfunction makes sense. Being able to visualize the nerves means a higher chance of keeping them intact, however, inadvertent injury can occur during dissection. Moreover, complete nerve-sparing may not be possible, particularly in large endometriotic nodules of the parametrium. However, Soares et al. clearly demonstrated a benefit of complete nerve sparing approach in terms of urinary function [7]. Equally, ‘’the Negrar method’’ (Nerve-sparing laparoscopic eradication of deep endometriosis) led to improved bladder and sexual function post-operatively, compared to the conventional surgical approach [8].

Let us look particularly at post-operative urinary retention. The risk is estimated to reach up to 30%, with the location and extent of disease playing a crucial role: in particular, colorectal resection, especially when combined with bilateral uterosacral ligament resection, puts patients at a high-risk group [9,10]. Thankfully, in most cases, the problem is temporary and may last for a few weeks after surgery. ISC is usually employed.

  But in case that ISC is required, how likely is it to resolve and is there a way to predict the likelihood of resolution, based on certain risk factors? A recent study from Boulus et al. comes to shed light on this topic [11]. Although retrospective, this study is based on prospectively collected data from a large number of deep endometriosis patients managed in a tertiary referral centre. They looked at patients that required ISC after deep endometriosis surgery. The same patients were also given oral alfuzosin and Urostim device along with ISC. They reported a 77% spontaneous resolution rate, with half of those recovering during the first 8 weeks after surgery, whereas, in a quarter of cases, ISC was required for over a year. The presence of pre-operative bladder dysfunction was associated with a higher risk of needing prolonged ISC after surgery.

When considering the cause of urinary retention, neuropraxia (similar to nerve palsy) induced by surgery may cause temporary retention, whereas transection of the nerve fibres may lead to long term dysfunction. This may explain the results of de Resende’s study [12], that showed little difference between nerve-sparing and non nerve-sparing approaches in the short term (due to neuropraxia), in contrast with the long-term, where the risk of retention is higher in the non-nerve sparing approach.

  In conclusion, deep endometriosis itself may cause a severe deterioration in urinary function, with appropriately performed surgical excision offering a potential improvement. Accurate assessment of urinary function pre-operatively is important and, as a minimum, an accurate history should be taken, with or without urodynamic investigations to counsel patients accordingly. Certain locations of deep endometriosis (eg. Sacral plexus, parameteria) carry a higher risk of post-operative dysfunction and accurate imaging will help inform surgical decision making. Employing a nerve-sparing surgical approach, although does not guarantee complete prevention of voiding dysfunction, may significantly lower the risk, particularly in the long term. Even when post-operative urinary retention occurs requiring ISC, it is likely to resolve within 2 months after surgery.

References:

1. Bonneau C, Zilberman S, Ballester M, et al. Incidence of pre- and postoperative urinary dysfunction associated with deep infiltrating endometriosis: relevance of urodynamic tests and therapeutic implications. Minerva Ginecol. Aug 2013;65(4):385-405.
2. Uri P Dior MD MPH , Charlotte Reddington MBBS, Claudia Cheng MBBS , Gabriel Levin MD , Martin Healey MBBS MD , Urinary Function after Surgery for Deep Endometriosis: a Prospective Study, The Journal of Minimally Invasive Gynecology (2021), doi: https://doi.org/10.1016/j.jmig.2021.08.024.
3. Ballester M, Chereau E, Dubernard G, Coutant C, Bazot M, Daraï E. Urinary dysfunction after colorectal resection for endometriosis: results of a prospective randomized trial comparing laparoscopy to open surgery. Am J Obstet Gynecol. Apr 2011;204(4):303.e1-6. doi:10.1016/j.ajog.2010.11.011.
4. 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 Gynecol. 2008 Mar-Apr 2008;15(2):235-40. doi:10.1016/j.jmig.2007.10.009.
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