Surgical Management of Urinary-Symptom-Dominant Endometriosis: Addressing Persistent Voiding Dysfunction and Pelvic...

Urinary tract endometriosis (UTE) commonly presents with urinary urgency, frequency, retention, and hesitancy. Although surgical excision consistently improves storage symptoms postoperatively, voiding dysfunction often persists due to interactions between clearing lesions, potential neural injury, and pelvic floor dysfunction. Understanding these mechanisms is vital for optimizing outcomes and minimizing long-term morbidity.

We conducted a structured narrative review on surgical management of endometriosis with urinary symptom predominance in PubMed, Scopus, and Cochrane. We thematically synthesized studies on surgical techniques, urinary outcomes, pelvic floor dysfunction, and adjunct neuromodulation to provide insight into current practices, mechanistic understanding, and new approaches.

Initially, 928 studies were identified, 798 titles and abstracts were screened after elimination of duplicates, and 63 studies were included after full text screening. Continued improvements in storage symptoms were seen regardless of surgical approach (partial cystectomy, bladder shaving, ureteral procedures) but up to 50% of patients experienced persistent voiding dysfunction. This was due to potential neural injury, fibrosis, and hypertonicity of the pelvic floor. Although nerve-sparing techniques had less dysfunction, they did not eliminate it. Adjuncts, including pelvic floor physiotherapy and neuromodulation, were supported as novel therapies. Advanced imaging techniques might improve risk stratification prior to surgery but prospective level evidence is lacking.

The significant proportion of patients with voiding dysfunction after UTE surgery indicates a need for multi-disciplinary pathways. In addition to lesion excision, co-management with pelvic floor rehabilitation, advanced imaging, and neuromodulation may optimize recovery. There are important priorities for the future, including standardized urodynamic outcomes and prospective study designs.