Effect of Surgical Treatment for Deep Infiltrating Endometriosis on Pelvic Floor Disorders: A Systematic Review with Meta-analysis

Fraga, Mirian Vieira; Benetti-Pinto, Cristina Laguna; Yela, Daniela Angerame; Mira, Ticiana Alves de; Brito, Luiz Gustavo Oliveira

doi:10.1055/s-0042-1742293

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Sumário

Review • Rev. Bras. Ginecol. Obstet. 44 (5) • May 2022 • https://doi.org/10.1055/s-0042-1742293 copy

Effect of Surgical Treatment for Deep Infiltrating Endometriosis on Pelvic Floor Disorders: A Systematic Review with Meta-analysis

Efeito do tratamento cirúrgico para endometriose infiltrante profunda nas disfunções do assoalho pélvico: Uma revisão sistemática com metanálise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

To evaluate the impact of surgical treatment of deep infiltrative endometriosis (DIE) on pelvic floor dysfunction (urinary incontinence [UI], pelvic organ prolapse [POP], fecal incontinence [FI)] or constipation, and sexual function [dyspareunia]).

Data Source

The present systematic review was performed in the PubMed database. For the selection of studies, articles should be published by January 5, 2021, without language restriction.

Study Selection

Six randomized controlled studies that evaluated surgical treatment for DIE and the comparison of different surgical techniques were included.

Data Collection

The studies were selected independently by title and abstract by two authors. Disagreements were resolved by a third author. All included studies were also evaluated according to the Cochrane risk of bias tool and the quality of the evidence was analyzed using the GRADE criteria. Subgroup analysis by different treatments and follow-up periods was also performed.

Results

Six studies were included in the quantitative analysis. The risk of bias between studies showed an uncertain risk of bias for most studies, with concealment of allocation being the least reported category. The quality of the evidence was considered low. High heterogeneity was found between the studies. No study has evaluated UI or POP comparatively before and after surgery.

Conclusion

Dyspareunia and FI have improved after the surgical procedure, but it was not possible to demonstratewhich surgical technique was related to these outcomes as there was surgical heterogeneity. This diversity was found across data, with the recommendation of future prospective studies addressing pelvic floor disorders withDIE.

Keywords:
systematic review; endometriosis; fecal incontinence; urinary incontinence; pelvic floor

Author/ Year	Sample	Intervention	Follow-up	Assessment methods	Preoperative PFDs	FI	UI	Dyspareunia	POP
Daraï et al. (2010)¹¹11 Daraï E, Dubernard G, Coutant C, Frey C, Rouzier R, Ballester M. Randomized trial of laparoscopically assisted versus open colorectal resection for endometriosis: morbidity, symptoms, quality of life, and fertility. Ann Surg. 2010;251(06):1018-1023. Doi: 10.1097/SLA.0b013e3181d9691d https://doi.org/10.1097/SLA.0b013e3181d9...	n =52Laparoscopy (n = 26) versus open surgery (n = 26)	Laparoscopy versus open surgery	1 and 6 months, then every 6 months up to 3 years	1.Pain VAS	There is no report in the study	There is no report in the study	There is no report in the study	When the overall result was assessed, there was a reduction in pain in both groups. However, when analyzed separately, the reduction of the complaint was not significant	There is no report in the study
Roman et al. (2018)¹²12 Roman H, Bubenheim M, Huet E, Bridoux V, Zacharopoulou C, Daraï E, et al. Conservative surgery versus colorectal resection in deep endometriosis infiltrating the rectum: a randomized trial. Hum Reprod. 2018;33(01):47-57. Doi: 10.1093/humrep/dex336 https://doi.org/10.1093/humrep/dex336...	n= 60Conservative surgery (n = 27) versusRadical surgery (n = 33)	Conservative surgery versus radical rectal resection	6-month intervals for 2 years	1.Fecal IncontinenceGIQLI, Kess and Wexner score2. Urinary Incontinence USP score3. Pain and quality of life VAS and SF-36	Patients presented gastrointestinal disorders such as fecal incontinence and gas loss, in addition to dyspareunia in both groups studied	Both groups had gastrointestinal disorders after the 24-month evaluation, with no significant difference for the types of surgery	There is no report in the study	Despite the reduction in VAS in the groups studied, there was no significant difference for the types of surgery	There is no report in the study
Roman et al. (2019)¹³13 Roman H, Tuech JJ, Huet E, Bridoux V, Khalil H, Hennetier C, et al. Excisionversus colorectal resection in deep endometriosis infiltrating the rectum: 5-year follow-up of patients enrolled in a randomized controlled trial. Hum Reprod. 2019;34(12):2362-2371. Doi: 10.1093/humrep/dez217 https://doi.org/10.1093/humrep/dez217...	n= 55Excision (n = 27) versus Resection (n = 28)	Excision versus Colorectal segmental resection	5 years	1.Fecal Incontinence GIQLI, Kess, and Wexner score2.Urinary Incontinence USP score3. Pain and quality of life VAS and SF-36	Patients presented gastrointestinal disorders such as fecal incontinence and gas loss, in addition to dyspareunia in both groups studied	Both groups had gastrointestinal disorders after a 5-year assessment. Despite the improvement when compared with preoperative values, there was no significant difference between the groups	There is no report in the study	Despite the reduction in VAS in the groups, there was no significant difference for the types of surgery	There is no report in the study
Roman et al. (2019)¹⁴14 Roman H, Bubenheim M, Huet E, Bridoux V, Zacharapoulou C, Collinet P, et al. Baseline severe constipation negatively impacts functional outcomes of surgery for deep endometriosis infiltrating the rectum: Results of the ENDORE randomized trial. J Gynecol Obstet Hum Reprod. 2019;48(08):625-629. Doi: 10.1016/j.jogoh.2019.03.013 https://doi.org/10.1016/j.jogoh.2019.03....	n = 60Conservative surgery (n = 27) versus segmental resection (n = 33)	Conservative surgery versus segmental resection	6,12,18 and 24 months	1.Fecal Incontinence GIQLI, Kess and Wexner score2.Urinary Incontinence USP score	Patients had gastrointestinal disorders such as fecal incontinence and gas loss in both groups. The groups were not analyzed separately regarding the type of surgery	Both groups showed significant improvement after an evaluation when compared together. When analyzed separately, there was no significant difference between groups	There is no report in the study	There is no report in the study	There is no report in the study
Posadzka et al. (2015)¹⁵15 Posadzka E, Jach R, Pitynski K, Jablonski MJ. Treatment efficacy for pain complaints in women with endometriosis of the lesser pelvis after laparoscopic electroablationvs. CO2 laser ablation. LasersMed Sci. 2015;30(01):147-152. Doi: 10.1007/s10103-014-1630-4 https://doi.org/10.1007/s10103-014-1630-...	n= 48Electroablation (n = 33) versus CO2 laser ablation (n = 15)	Electroablation of endometriosis versus CO2 laser ablation	3 and 6 months	1. Pain NRS	Both groups had dyspareunia.	There is no report in the study	There is no report in the study	After an initial improvement verified in 3 months, the complaint worsened significantly in the exam of 6 months for the CO2 laser group. For the electroablation group, the complaint also increased significantly, 50% of the patients reported a level ≥ 10 points after 6 months	There is no report in the study
Candiani et al. (1992)¹⁶16 Candiani GB, Fedele L, Vercellini P, Bianchi S, Di Nola G. Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study. Am J Obstet Gynecol. 1992; 167(01):100-103. Doi: 10.1016/s0002-9378(11)91636-6 https://doi.org/10.1016/s0002-9378(11)91...	n = 71Conservative surgery (n = 36) versus Presacral neurectomy (n = 35)	Conservative surgery versus Presacral neurectomy	12 months	1. Pain Andersch and Milsom Multidimensional Scoring System	Both groups had dyspareunia (mild, moderate, and severe)	There is no report in the study	There is no report in the study	Although not significant, there was a reduction in complaints in both groups	There is no report in the study

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[1] Address for correspondence
Luiz Gustavo Oliveira Brito, MD, PhD, Rua Alexander Fleming, 101, Cidade Universitária, Campinas, SP, Brazil (e-mail: lgobrito@unicamp.br).