Voiding dysfunction after colorectal surgery for endometriosis

Colorectal surgery for deep endometriosis significantly impacts urinary function, although rectal shaving causes less postoperative voiding dysfunction (PVD) than either discoid excision or segmental resection, according to a systematic review and meta-analysis in the Journal of Minimally Invasive Gynecology.

The estimated overall rate of voiding dysfunction was 7.6%, specifically 2.4% after rectal shaving, 7.5% after discoid excision, and 10.1% after segmental colorectal resection.¹

Self-catheterization for over 1 month occurred in 13.6% of surgical cases, mainly after segmental colorectal resection.

The authors, most of whom were from France, identified studies from PubMed, Clinical Trials.gov, Embase, Cochrane Library and Web of Science databases, restricted to the French and English languages, for the frequency of PVD from colorectal surgery for endometriosis, with the final search conducted in August 2019.

A total of 13 studies rated good or fair and reporting at least two of the three types of colorectal surgery were included in the meta-analysis, comprising 1,694 patients (643 rectal shavings, 357 discoid excisions, and 728 segmental resections).

Rectal shaving was statistically less associated with postoperative voiding dysfunction than segmental colorectal resection: odds ratio (OR) = 0.34; 95% confidence interval (CI): 0.18 to 0.63; statistical heterogeneity (I2) = 0% (P = 0.0006).

Rectal shaving was also statistically less likely to be asssociated with PVD than discoid excision: OR = 0.22; 95% CI: 0.09 to 0.51; I2 = 0% (P = 0.0004).

But there was no significant difference in the occurrence of PVD between discoid excision and segmental colorectal resection: OR = 0.74; 95% CI: 0.32 to 1.69; I2 = 29%; (P = 0.47).

However, compared to segmental colorectal resection, rectal shaving was linked to a significantly lower risk of self-catheterization lasting longer than 1 month: OR = 0.3; 95% CI: 0.14 to 0.66; I2 = 0% (P = 0.003). That outcome, however, was not significant when comparing discoid excision and segmental colorectal resection: OR = 0.72; 95% CI: 0.4 to 1.31; I2 = 63% (P = 0.28).

Although the mean time of self-catheterization could not be estimated for each group because not all the studies reported exact catheterization time, the median time of self-catheterization after segmental colorectal resection, according to eight studies, was 31.5 days (± 6.1 days).

Overall, a lower risk of PVD was achieved with conservative surgery (rectal shaving or discoid excision) than with radical surgery (segmental colorectal resection): risk difference = -0.04; 95% CI: -0.07 to -0.02; I2= 23%, (P = 0.001).

For conservative surgery, PVD occurred with a nerve-sparing (NS) technique in 4.4% of patients and in 1.8% of patients with a non-NS technique (P = 0.03). These data must be interpreted with caution because the descriptions of the surgical techniques were not consistently included and use of NS techniques may have been more likely in the more complicated cases.

For radical surgery, the condition occurred in 12.9% of patients with an NS technique, and in 11.3% of patients with a non-NS technique (P = 0.15).

Based on the study’s findings, assessing urinary function preoperatively is “of paramount importance in digestive endometriosis,” wrote the authors.

Patients should also be informed beforehand of the profound impact that bowel surgery for deep endometriosis has on urinary function, despite the technique.

In addition, because rectal shaving causes less PVD than either discoid excision or segmental resection, it is “essential to detect preoperative urinary symptoms and to define a high-risk group for which urodynamic testing could be helpful,” the authors wrote.

A consensus definition of PVD and the indication for self-catheterization also would be helpful for crafting a predictive tool for use when counseling patients and determining clinical trial eligibility.

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Reference

1. Versale E, Roman H, Moawad G, et al. Voiding dysfunction after colorectal surgery for endometriosis: a systematic review and meta-analysis. J Minim Invas Gyn. Published online July 27, 2020. doi:10.1016/j.jmig.2020.07.019