Postoperative outcomes after surgery for deep endometriosis of sacral plexus

Postoperative outcomes after surgery for deep endometriosis of sacral plexus

Laparoscopic management of deep endometriosis involving the sacral roots and the sciatic nerve improves patient symptoms and overall quality of life, according to a retrospective case series.

The study in the Journal of Minimally Invasive Gynecology also concluded that although pain reduction may be rapid following surgery, other sensory or motor complaints might persist for months to years.

The study assessed 1-year postoperative outcomes in patients managed for big endometriosis nodules involving the sacral plexus, which control bowel and bladder function, motility and sensitivity of perineum, buttock and inferior leg,” said principal investigator Horace Roman, MD, PhD, an endometriosis surgeon at the Endometriosis Center of the Clinic Tivoli-Ducos in Bordeaux, France.

The study comprised 52 women managed by Dr. Roman in three nearby referral centers, for deep endometriosis involving the sacral roots and the sciatic nerve from October 2016 to April 2019.

Deep endometriosis involved the sacral roots in 94.2% of cases and the sciatic nerve in the remaining 5.8% of cases. Sciatic pain (buttock or leg) was observed in 82.7% of cases, pudendal neuralgia in 21.2% and leg motor weakness in 27% of cases.

For surgical procedures of the pelvis nerves, Dr. Roman performed complete releasing and decompression in 48 patients (92.3%), excision of epineurium by shaving in three patients (5.8%) and intraneural excision in one patient (1.9%).

The digestive tract was involved in 82.7% of overall cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of cases.

Self-catheterization was required in 27% of cases at 3 weeks after surgery and in 5.8% of cases at 1 year.

One-year follow up also showed significant improvement in quality of life using the 36-Item Short Form Survey (SF-36) and standardized gastrointestinal scores.

De novo hypoesthesia, hyperaesthesia or allodynia were recorded in 17.2% of cases.

After a mean follow up of 2 years, the cumulative pregnancy rate was 77.2%, with natural conception in 47% of these cases.

We were satisfied to observe a major improvement of patients’ overall quality of life and pain, as well as favorable fertility outcomes,” Dr. Roman told Contemporary OB/GYN. “However, we were surprised to discover that the impact of these large lesions was not confined to the sacral plexus, but also affected the low rectum, the vagina, the bladder and ureters in a majority of cases.”

These findings resulted in a complex surgical procedure, “where the dissection of pelvic nerves represented only one step of the surgery, and sometimes not the most challenging step,” Dr. Roman said. In addition, major unfavorable postoperative outcomes were related to both nerve dysfunction and complications related to other pelvic organs, particularly to low rectal fistulae.

Our study provides a good oversight on preoperative baseline complaints in patients with deep endometriosis involving the sacral plexus, as well as on standardized surgical procedures performed in these patients,” Dr. Roman said. “The study also estimated the probability of postoperative clinical improvement, plus the risk of major complications following this particular type of complex surgery.”

The data should be part of the information that patients receive preoperatively and will help with informed choice, according to Dr. Roman.

Furthermore, the study provides the basis to create a standardized step-by-step approach to deep endometriosis involving the sacral plexus, “which are reproducible and feasible in experienced hands, and prevents intraoperative complications,” Dr. Roman said.

Dr. Roman hopes the study will be followed by larger multicenter trials of experienced surgical teams from various countries to provide more detailed data on the reproducibility of complex surgeries worldwide and the risk of rare intraoperative or postoperative complications and their successful management.

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Surgery improves pregnancy odds for women with colorectal endometriosis

Surgery improves pregnancy odds for women with colorectal endometriosis

By I Soussis MD

Secondary analysis of results from a French trial investigating the effects of surgical management of colorectal endometriosis found that the intervention effectively improved postoperative fertility rates, including the ability to conceive naturally. 

The study is one of the first to evaluate the impact of first-line surgery on pregnancy rates in this population.

First-line assisted reproductive technology (ART) is the recommended strategy for improving pregnancy rates in women with endometriosis, but is a subject of controversy in the gynecological community due to a lack of high-quality data comparing it to surgical management. 

In addition, the European Society of Human Reproduction and Embryology (ESHRE) has reported that there was no evidence that surgical management of deep endometriosis would improve pregnancy rates prior to ART.

The study population consisted of 55 women from the ENDORE (Functional Outcomes of Surgical Management of Deep Endometriosis Infiltrating the Rectum) randomized trial conducted between March 2011 and August 2013 who wished to conceive. 

ENDORE was an unblinded, parallel-arms, controlled trial designed to determine if conservative rectal surgery was superior to segmental resection in women with colorectal endometriosis.

All of the women had deep endometriosis reaching into the rectum up to 15 cm from the anus with lesions measuring more than 20 mm in length. The endometrial lesions at minimum involved the muscular layer in depth and up to half of the rectal circumference. Twenty-five subjects underwent a conservative surgical procedure (shaving or disc excision) and 30 had radical rectal surgery (segmental resection). The surgeries were all performed by the same gynecologist. Subjects were followed for 50 to 79 months.

Of 36 patients who wanted to become pregnant after surgery, 23 (63%) had tried unsuccessfully prior to surgery for more than a year (the infertile group). After surgery, 29 patients became pregnant (81%), and some had more than one pregnancy, for a total of 37 pregnancies. Odds of postoperative conception improved over time.


Probability of Pregnancy After Surgery

At 12 months At 24 months At 36 months At 48 months
33.4% (95% CI: 20.6-51.3%) 60.6% (95% CI: 44.8-76.8%) 77% (95% CI: 61.5-89.6%) 86.8% (95% CI: 72.8-95.8%)

Overall, 17 women became pregnant naturally and 12 used ART (in vitro fertilization, intrauterine insemination, or oocyte donation). Looking specifically at the 23 infertile women, three-quarters (17) were able to conceive, and half of the pregnancies occurred naturally.

In total, 24 of the 37 pregnancies occurred as a result of natural conception, and subjects who were advised by their physicians to try to conceive naturally got pregnant significantly earlier than subjects who were referred for ART (P= 0.008).

Although the study had a small sample size, was subject to possible ascertainment bias  and preoperative and postoperative fertility assessments were not performed for all women, the trial was prospective with long-term follow up. 

It showed that fertility and the ability to conceive naturally can be restored by first-line surgery in women who are infertile due to colorectal endometriosis, perhaps in part due to the ability of women with endometriosis-related severe dyspareunia to engage in regular sexual intercourse postoperatively.

The authors stopped short of recommending that surgery for infertility be recommended over ART until more studies are performed. They suggested that in the interim “Physicians should ultimately offer patients a balanced perspective of the potential benefits and potential harms of alternative options.”

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