the risk of urinary retention after nerve...

THE RISK OF URINARY RETENTION AFTER NERVE-SPARING

SURGERY FOR DEEP INFILTRATING ENDOMETRIOSIS:

A SYSTEMATIC REVIEW AND META-ANALYSIS

JOSÉ ANACLETO RESENDE JR (Urology)

LUCIANA CAVALINI (Epidemiology)

CLAUDIO CRISPI (Gynecology)

MARLON FONSECA (Anesthesiology)

*Authors have no competing interests.

Background

• The radical surgical exeresis of the lesions can

improve symptoms and quality of life (the

mainstay of the treatment).

• Important urinary complications may occur

due to iatrogenic injury of autonomic pelvic

nerves.

SEUD 2015 - Marlon Fonseca - Brazil

Background

• Recently, nerve-sparing (NS) approaches have

been performed in order to prevent urinary

complications.

• What about the scientific evidences?


Objective

• To perform a systematic review and a meta-

analysis to assess the risk of urinary retention

(need of urinary catheterization) after a NS

surgery for DIE when compared to classical

(non-NS) techniques.


Methods

• The present review was conduced according

to the MOOSE guidelines for systematic

reviews of observational studies.

[Stroup DF, et al. Meta-analysis of observational studies in epidemiology: a proposal

for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.

JAMA 2000; 283:2008–2012]


Methods

• Published research articles (up to Dec/2014)

comparing NS technique to non-NS technique

regarding urinary complications after surgery

for DIE.

• Endpoint: relative risk for urinary retention.


Methods

• Inclusion criteria: randomized clinical trials,

intervention and observational studies.

• Exclusion criteria: cancer surgery, bladder or

ureteral resections.

• The same two authors evaluated all publications.

• There were no restrictions for language.

• No attempt was made to identify grey literature.


Combinations of medical subject heading terms (search strategy)

• (Endometriosis) AND (Surgery OR Resection OR Laparotomy OR Laparotomic OR

Open OR Laparoscopy OR Laparoscopic OR Hand Assisted OR Video Assisted OR

Robotic OR Robot OR Nerve sparing OR Colorectal OR Rectum OR Rectosigmoid OR

Intestine OR Bowel OR Pelvic OR Pelvis OR Uterosacral OR Parametrial OR

Parametrium OR Bladder OR Ureter) AND (Nerve OR Nervous OR Plexus) AND

(Urinary OR Retention OR Urethral OR Catheterization OR Complication OR Voiding

OR Disorders OR Dysfunction OR Urologic OR Urological OR Urology OR Bladder OR

Neurogenic OR Incontinence OR Stress OR Overactive OR Urge OR Urgency OR

Urination OR Urodynamics).





Robotic OR Robot OR Nerve sparing OR Colorectal OR Rectum OR Rectosigmoid

OR Intestine OR Bowel OR Pelvic OR Pelvis OR Uterosacral OR Parametrial OR













(Urinary OR Retention OR Urethral OR Catheterization OR Complication OR

Voiding OR Disorders OR Dysfunction OR Urologic OR Urological OR Urology OR

Bladder OR Neurogenic OR Incontinence OR Stress OR Overactive OR Urge OR

Urgency OR Urination OR Urodynamics).


1270 potentially relevant studies

1. Scin-finder 0

2. Scopus 393

3. Web of Science 577

4. Pubmed 204

5. Cochrane 0

6. Lilacs 96

7. Clinical Trials 0


1270 potentially relevant studies

1. Scin-finder 0

2. Scopus 393

3. Web of Science 577

4. Pubmed 204

5. Cochrane 0

6. Lilacs 96

7. Clinical Trials 0

5 publications were preliminarily

selected because its focus on

complications after NS surgery for

complete excision of DIE.

1 study was excluded due to lacks

regarding follow-up information.

Total = 4 publications


Methodological aspects of the four non-randomized observational studies included in the meta-analysis.

#Calculated. Age in years. NS: nerve-sparing technique. SD: standard deviation. BMI (body mass index) in Kg.m-2. Patients undergone bladder or ureteral resections were not included.

Publication Design and main endpoints Sample characteristics

Volpi et al., 2004

(Torino, Italy)

Retrospective study assessing urinary retention with focus

on preservation or not of the hypogastric plexus based on

videotape recordings.

Median age: 31.5 [Range 23-42]

Median BMI: 21.5 [Range: 17.3-28.0]

Kavallaris et al., 2011

(Luebeck, Germany)

Retrospective study comparing laparoscopic NS to non-NS

with respect to pain and bladder function.

Median age: 32 [Range 24-42]


Ceccaroni et al., 2012

(Verona, Italy)

Prospective study comparing NS to non-NS laparoscopy in

terms of bowel, bladder and sexual function.

Median age: 31 [Range: 24-43]

Mean BMI: 22.2 [SD: 3.0]

Che et al., 2014

(Zhejiang, China)

Prospective study investigating the efficacy and the bladder

and sexual dysfunction that follow NS (open and

laparoscopic) and non-NS.

Mean age: 33 [Range: 26-46]#

Mean BMI: 20 [Range: 16-25]#


Methodological aspects of the four non-randomized observational studies included in the meta-analysis.

#Calculated. Age in years. NS: nerve-sparing technique. SD: standard deviation. BMI (body mass index) in Kg.m-2. Patients undergone bladder or ureteral resections were not included.

Publication Design and main endpoints Sample characteristics

Volpi et al., 2004

(Torino, Italy)

Retrospective study assessing urinary retention with focus

on preservation or not of the hypogastric plexus based on

videotape recordings.

Median age: 31.5 [Range 23-42]


Kavallaris et al., 2011

(Luebeck, Germany)

Retrospective study comparing laparoscopic NS to non-NS

with respect to pain and bladder function.

Median age: 32 [Range 24-42]


Ceccaroni et al., 2012

(Verona, Italy)

Prospective study comparing NS to non-NS laparoscopy in

terms of bowel, bladder and sexual function.

Median age: 31 [Range: 24-43]

Mean BMI: 22.2 [SD: 3.0]

Che et al., 2014

(Zhejiang, China)

Prospective study investigating the efficacy and the bladder

and sexual dysfunction that follow NS (open and

laparoscopic) and non-NS.

Mean age: 33 [Range: 26-46]#

Mean BMI: 20 [Range: 16-25]#

Temporal evolution


What is nerve-sparing surgery..?

NS: nerve-sparing technique. Patients undergone bladder or ureteral resections were not included. DIE: deep infiltrating endometriosis.


Publication Description of nerve-sparing technique Urinary catheters after surgery

Volpi et al., 2004 Objective; based on radical hysterectomy technique described

by Trimbos et al. (2001).

Removed on 2nd

day.

Urinary retention was tested immediately after first voiding

(method not described).

Kavallaris et al., 2011 Comprehensive; representing a strategy to preserve nerves in

DIE surgery.

Removed on 1st day.

NS group: ISC if urinary residual urine volume >50 mL in two

ultrasound measurements.

Non-NS group: ISC if self-reported bladder dysfunction with

incomplete emptying of the bladder (details not described).

Ceccaroni et al., 2012 The most meticulous description; focused on DIE with segmental

rectal and parametrial resection.

Removed on 1st day.

ISC at discharge when voiding difficulty or urinary retention >100

mL on 3 consecutive catheterizations.

Che et al., 2014 Reported as the same used by Volpi et al (2004). Some patients needed ISC (criteria/methods not described).

What about postoperative management of urinary tract

NS: nerve-sparing technique. Patients undergone bladder or ureteral resections were not included. DIE: deep infiltrating endometriosis.


Publication Description of nerve-sparing technique Urinary catheters after surgery

Volpi et al., 2004 Objective; based on radical hysterectomy technique described

by Trimbos et al. (2001).

Removed on 2nd

day.

Urinary retention was tested immediately after first voiding

(method not described).

Kavallaris et al., 2011 Comprehensive; representing a strategy to preserve nerves in

DIE surgery.

Removed on 1st day.

NS group: ISC if urinary residual urine volume >50 mL in two

ultrasound measurements.

Non-NS group: ISC if self-reported bladder dysfunction with

incomplete emptying of the bladder (details not described).

Ceccaroni et al., 2012 The most meticulous description; focused on DIE with segmental

rectal and parametrial resection.

Removed on 1st day.

ISC at discharge when voiding difficulty or urinary retention >100

mL on 3 consecutive catheterizations.

Che et al., 2014 Reported as the same used by Volpi et al (2004). Some patients needed ISC (criteria/methods not described).

#Personal communication. NS: Nerve-sparing technique. ISC: intermittent self-catheterization.

RESULTS Frequency of urinary retention after nerve-sparing and non-nerve-sparing surgery for endometriosis (crosstabs).


#Personal communication. NS: Nerve-sparing technique. ISC: intermittent self-catheterization.

RESULTS Frequency of urinary retention after nerve-sparing and non-nerve-sparing surgery for endometriosis (crosstabs).


4 2

Heterogeneity among the 4 selected studies

• RR for urinary retention at

discharge.

I2 = 50.2 %

(P = 0.09)


I2 = total heterogeneity/total variability

Common RR for ISC at discharge in the NS group in relation

to the classical technique was 0.19 [95%CI: 0.03–1.17]


The common RR for need of ISC after 90 days was

0.16 [95%CI: 0.03-0.84]


Discussion

• A significant advantage of NS with respect to the

risk of persistent urinary retention (need of ISC for

3 months or more)

• No significant benefits of NS concerning the need of

ISC immediately after surgery (?)

• The criteria for indicating ISC after surgery has been

empirical (and not the same)


What about urinary function before surgery..?


CONCLUSION

• Considering the surgical treatment of DIE, a NS

technique showed a significant lower risk of

persistent urinary retention due to iatrogenic

injury of autonomic pelvic nerves when

compared to a classical (non-NS) technique.


Recommendations

• Clinical studies are required for evaluating concrete

consequences of different persistent residual urinary

volumes and the best individual postoperative

urinary tract management.

• Unnecessary invasive emptying of the bladder must

always be avoided, which is (at least) a risky,

inconvenient and uncomfortable duty.


the risk of urinary retention after nerve...

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