Case selection for urological input in planned laparoscopic rectovaginal endometriosis surgery

Surgery for deep endometriosis often requires input from urological surgeons. This study aims to determine pre-operative and intra-operative factors that influence the need for urological input in laparoscopic resection of rectovaginal endometriosis and to assess the usefulness of a scoring system to predict this.

We conducted a retrospective cohort study of 230 patients undergoing laparoscopic excision of deep endometriosis, at a tertiary referral centre for endometriosis in London UK, 2011 to 2015. Data from pre-operative assessment, surgery and post-operative follow up were analysed and patients were categorised according to their pre-operative and intra-operative risk factors. The primary outcome measure was the requirement of intra-operative input by urological surgeons.

The median age was 35 years. In addition to the excision of endometriosis, 19.6% patients (45 patients) underwent hysterectomy, 14.8% (34 patients) required JJ stent placement, 6.1% (14 patients) had bowel resections and 2.6% (6 patients) required an ileostomy. 93.9% (216 patients) were considered normal-risk pre-operatively, of whom 89.4% (193/216) did not require any intra-operative urological input. 10.6% of this normal-risk group (23/216) required JJ stents, of whom 69.6% (16/23) also required a hysterectomy or bowel resection. Post operative complications occurred in 0.9% (2/216) of normal-risk patients, with none having required intra-operative urological reconstruction.Six percent (14 patients) were deemed to be increased-risk pre-operatively, of whom 78.6% (11/14) required JJ stent insertion. Thirty-six percent of increased-risk patients (5/14) had pre-operative renal dysfunction demonstrated on MAG3/DMSA and 80.0% of these (4/5) required intra-operative ureteric reconstruction.

Patients considered normal-risk pre-operatively, planned for excision, without hysterectomy or bowel resection, can be safely managed without specific urology input. Patients with risk-features are highly likely to require urological input, particularly for JJ stent insertion. Patients with pre-operative renal dysfunction, demonstrated on MAG3/DMSA, have a high chance of requiring intra-operative ureteric reconstruction and are best managed with pre-planned reconstructive urologist input.