Anatomical classification system can standardize parametrectomy procedures and outcomes in deep endometriosis: Study

Deep endometriosis, characterized by the presence of endometrial tissue infiltrating at least 5mm into the peritoneum, is considered the most severe type of endometriosis. This condition commonly affects the dorsolateral parametrium, leading to severe pain, diminished quality of life, and dysfunction of pelvic organs or somatic innervation, especially as it progresses laterally and deeper in the pelvis. Recent prospective single-center study examined the complication rate and functional outcomes of nerve-sparing parametrectomy for deep endometriosis, based on the anatomical extent of the surgical procedure. The researchers divided dorsolateral parametrectomies into three groups - superficial parametrectomy (SP), deep parametrectomy type 1 (DP1), and deep parametrectomy types 2 and 3 (DP2, DP3) - determined by whether the procedure extended beyond established anatomical landmarks like the presacral fascia and medial rectal artery.

The study included 185 patients who underwent parametrectomy for deep endometriosis between 2020-2023. Intraoperative complications were low overall (3.2%), but bladder voiding deficit occurred in 9.7% of cases, with higher rates in the DP2 (20.8%) and DP3 (30%) groups. Urinary tract infections also differed, appearing in 7.6% of patients, with 11.8% in DP1 and 20.8% in DP2. Self-catheterization was required long-term in 1.6% of patients, more common in the deeper parametrectomy groups. Mean operative time and blood loss were longest in the DP3 group.

Functional Outcomes

Functional outcomes were evaluated using validated questionnaires. A significant improvement over time in bowel function (KESS score) was seen in the SP, DP1 and DP3 groups, but not DP2. Urinary function (BFLUTS) only improved in DP3. Sexual function (FSFI) did not concurrently improve with parametrectomy in any group.

Conclusions

The researchers conclude that their anatomical classification system can standardize the reporting of parametrectomy procedures and associated outcomes. Even with nerve-sparing techniques, a non-negligible rate of bladder voiding deficit was observed, particularly in cases requiring deeper, more lateral dissection (DP2, DP3). Parametrectomy alone did not reliably improve functional outcomes related to bowel, bladder or sexual function. The authors suggest the concept of a "dominant hemipelvis" from a neurofunctional standpoint may explain the variable impact on pelvic organ function.

Key Points

1. The study examined the complication rate and functional outcomes of nerve-sparing parametrectomy for deep endometriosis, based on the anatomical extent of the surgical procedure.

2. The researchers divided dorsolateral parametrectomies into three groups - superficial parametrectomy (SP), deep parametrectomy type 1 (DP1), and deep parametrectomy types 2 and 3 (DP2, DP3) - determined by whether the procedure extended beyond anatomical landmarks.

3. Intraoperative complications were low overall (3.2%), but bladder voiding deficit occurred in 9.7% of cases, with higher rates in the DP2 (20.8%) and DP3 (30%) groups. Urinary tract infections also differed, appearing in 7.6% of patients, with 11.8% in DP1 and 20.8% in DP2. Self-catheterization was required long-term in 1.6% of patients, more common in the deeper parametrectomy groups.

4. A significant improvement over time in bowel function (KESS score) was seen in the SP, DP1 and DP3 groups, but not DP2. Urinary function (BFLUTS) only improved in DP3. Sexual function (FSFI) did not concurrently improve with parametrectomy in any group.

5. The researchers conclude that their anatomical classification system can standardize the reporting of parametrectomy procedures and associated outcomes.

6. Even with nerve-sparing techniques, a non-negligible rate of bladder voiding deficit was observed, particularly in cases requiring deeper, more lateral dissection (DP2, DP3). Parametrectomy alone did not reliably improve functional outcomes related to bowel, bladder or sexual function.

Reference –

M. Ianieri et al. (2024). Anatomical-Based Classification Of Dorsolateral Parametrectomy For Deep Endometriosis. Correlation With Surgical Complications And Functional Outcomes: A Single- Center Prospective Study.. *International Journal Of Gynaecology And Obstetrics: The Official Organ Of The International Federation Of Gynaecology And Obstetrics*. https://doi.org/10.1002/ijgo.15781