Systematic nerve sparing during surgery for deep-infiltrating posterior endometriosis improves immediate postoperative urinary outcomes.

STUDY OBJECTIVE Evaluate the feasibility and risk/benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves (IHNs) and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) based on complication rates and postoperative bladder morbidity. DESIGN Observational before (2012-2014) and after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. SETTING Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. PATIENTS This study includes patients undergoing laparoscopic surgery for DIE (Pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament (USL) resection) with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. Exclusion criteria include prior history of surgery for DIE or colorectal DIE excision, unilateral USL resection and bladder endometriotic lesions. INTERVENTIONS For patients in group 1 (2012-2014, n=56), partial dissection of the pelvic nerves was carried out, only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerve. Patients in group 2 (2015-2017, n=65) systematically underwent nerve sparing during DIE surgery, with dissection of the IHNs and pelvic splanchnic nerves. MEASUREMENTS AND MAIN RESULTS Both groups were comparable in terms of patient age, parity, body mass index and previous abdominal surgery. Operating time was similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71min in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in patients in group 1 (p<0.01), with 7 (12.9%) patients requiring self-catherization in this group compared to no patients (0%) in group 2. Duration of self-catherization for the 7 patients in group 1 was 28, 21, 3, 60, 21,1 (stopped by the patient) and 28 days respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared to 1/33 in group 2 (p=-0.031). CONCLUSION Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection during surgery for posterior DIE, improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.