Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series

Abstract

Objective: To assess the long-term risk of repeated surgery in women undergoing complete excision of endometriosis by an experienced surgeon and to identify circumstances leading up to repeat surgery.

Design: Retrospective study based on data recorded in a large prospective database.

Setting: University Hospital.

Patient(s): A total of 1,092 patients managed for endometriosis, from June 2009 to June 2018, by one surgeon.

Intervention(s): Complete excision of endometriosis lesions.

Main outcome measure(s): The recording of a repeated surgery linked to endometriosis performed during follow-up.

Result(s): Endometriosis was exclusively superficial in 122 patients (11.2%) and 54 women (5%) had endometriomas without associated deep endometriosis nodules. Deep endometriosis was managed in 916 women (83.9%), leading to infiltration or not of the bowel in 688 (63%) and 228 (20.9%) patients, respectively. A majority of patients were managed for severe endometriosis infiltrating the rectum (58.4%). Mean and median follow-up was 60 months. A total of 155 patients underwent a repeated surgery relating to endometriosis; 108 procedures were required because of recurrences (9.9%), 39 surgeries were related to the management of infertility by assisted reproductive techniques (3.6%), and in 8 surgeries, a direct relationship between surgery and endometriosis was probable but not certain (0.8%). The majority of procedures involved hysterectomy for adenomyosis (n=45, 4.1%). The probability of requiring repeated surgery at 1, 3, 5, 7, and 10 years was 3%, 11%, 18%, 23%, and 28%, respectively. Cox's multivariate model identified postoperative pregnancy and hysterectomy as being statistically significant independent predictors for a reduction in the probability of having a repeated surgery, after adjustment on continuous postoperative amenorrhea, the main localization of the disease, and management for endometriosis infiltrating the rectum during the first surgery.

Conclusion(s): Up to 28% of patients may require a repeated surgical procedure during the 10 years after complete excision of endometriosis. Conservation of the uterus is followed by an increased risk of repeated surgery. The study is based on outcomes resulting from a single surgeon, which limits the generalizability of results.

Keywords: Deep endometriosis; follow-up; long term; rectum; recurrence.