Avaliação da cistoscopia dinâmica pré-operatória no tratamento cirúrgico da endometriose profunda

Abstract

Endometriosis is a condition defined by the presence of endometrial cells outside the uterus. It affects about 6-10 % of women in reproductive age. Urinary endometriosis corresponds to 1% of cases, and bladder endometriosis (BE) accounts for 84% of urinary tract involvement. Transvaginal Ultrasound and Nuclear Magnetic Resonance have a well-established role in the evaluation of these patients. Cystoscopy can be used in this evaluation, however, data about its use is scarce. The aim of the study is to evaluate the importance of preoperative dynamic cystoscopy (DC) in patients undergoing surgery for deep endometriosis. Furthermore, to assess sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DC in patients with deep endometriosis undergoing surgery, besides describing the main findings in this procedure. This is a cross-sectional observational study, with a prospective preplanned data collection to evaluate the importance of preoperative DC in a series of patients undergoing minimally invasive surgery for the treatment of deep endometriosis in the period from January 2011 to March 2022. Inclusion criteria were all women with multicompartimental endometriosis who underwent preoperative DC. Exclusion criteria were patients who, throughout this study, referred to some condition that, although not associated with endometriosis or its treatment, is evidently liable to confuse the analysis, such as previous pelvic or perineal surgeries, women already submitted to pelvic radiation and pelvic organ prolapse. DC differs from conventional cystoscopy in that it combines bimanual palpation. Abnormal cystoscopy findings included the superficial (mucosa) typical red or bluish mass (BE type 2) and the deep nodules in the bladder, seen only as a bulge adhered to the bladder wall (BE type 1). To estimate sensitivity, specificity, PPV and NPV, laparoscopic findings of bladder involvement and histopathological report of the surgical specimen were used as the gold standard. During this period, 157 patients were included. The median patient’s age was 39 years and 41 (26,1%) had abnormal findings in cystoscopy. Of these, 39 had bladder abnormalities confirmed intraoperatively, and 38 confirmed by histopathology. In the group with normal cystoscopy (116 patients), 28 had bladder abnormalities confirmed intraoperatively, and among these patients, 20 had organ involvement confirmed by histopathology report. Test sensitivity was 58,21% (46,27 - 69,26% CI 95%), specificity was 97,78% (92,26 - 99,39% CI 95%). PPV was 95,12% (90,54-97,54% CI 95%), and NPV was 75,86% (68,60-81,88% CI 95%). Diagnostic odds ratio (OR) was 61,28 (13,9-270,1 CI 95%). Patients with BE type 2 had a higher rate of partial cystectomy than those with BE type 1 lesions (OR 9,72 CI 95% 1,9-49,1). In conclusion, DC appears to be a highly specific test with lower sensitivity. DC abnormalities are associated with a higher ratio of bladder surgery for the treatment of deep endometriosis, and BE type 2 seems to be associated with a greater ratio of partial cystectomy