Women who undergo endometriosis surgery via diagnostic laparoscopy are significantly more likely to require repeat surgery within the first postoperative year, whereas women who have major conservative surgery are significantly less likely to require another surgery within the first year, according to a Canadian study in the American Journal of Obstetrics and Gynecology.
The authors noted there is limited literature assessing long-term outcomes of endometriosis surgery at a population level. “This information is important to the health care provider to accurately counsel the patient as they navigate treatment decisions,” they wrote.
The population-based cohort study of 84,885 women, aged 18 to 50, was culled from a universal coverage health database for the province of Ontario, Canada. All women underwent endometriosis surgery between April 2002 and March 2018.
Among the cohort, 3.2% had diagnostic laparoscopy, 25.4% had minor conservative surgery, 33.6% had major conservative with ovarian preservation, 2.5% had major conservative without ovarian preservation, 25.5% had hysterectomy with ovarian preservation and 9.9% had a hysterectomy without ovarian preservation.
Patients were followed for a median of 10 years, during which time the risk of repeat surgery was low for those who underwent a hysterectomy: 1.9% for those who underwent a hysterectomy with ovarian preservation and 0.4% for hysterectomy without ovarian preservation.
In the first postoperative year, women who underwent diagnostic laparoscopy were significantly more likely to require repeat surgery: adjusted hazard ratio (aHR) 1.68 (95% confidence interval [CI]: 1.51 to 1.87.
But those having major conservative surgery were significantly less likely to require repeat surgery in the first year; for ovarian preservation the aHR was 0.44 (95% CI: 0.41 to 0.48) and without ovarian preservation the aHR was 0.05 (95% CI: 0.03 to 0.09).
For women who did not receive repeat surgery in the first year, those who had diagnostic laparoscopy (aHR 0.85; 95% CI: 0.76 to 0.95) and major conservative surgery without ovarian preservation were less likely to undergo repeat surgery (aHR 0.12; 95% CI: 0.09 to 0.18) than those who initially had minor surgery.
Compared to patients who initially had minor surgery, women who underwent other treatment modalities were less likely to undergo hysterectomy in the first year: diagnostic laparoscopy aHR 0.85 (95% CI: 0.75 to 0.96); major surgery with ovarian preservation aHR 0.60 (95% CI: 0.57 to 0.64); and major surgery without ovarian preservation aHR 0.05 (95% CI: 0.03 to 0.08).
Following minor conservative with ovarian preservation surgery, 38.6% of patients scheduled an infertility consult, compared to 33.3% who underwent minor conservative with ovarian preservation surgery.
Two years after the index surgery, 15.8% of patients who had diagnostic laparoscopy, 16.0% of patients who had minor conservative surgery and 11.7% of patients who had major conservative without ovarian conservative surgery had given birth.
Similarly, within 5 years of index surgery, 28.5% of patients who had diagnostic laparoscopy, 29.4% of patients who had minor conservative surgery and 20.7% who had major conservative with ovarian preservation surgery had given birth at least once.
“These findings may inform preoperative counseling with regards to recurrence of symptoms, fertility outcomes and need for reoperation for women seeking surgical management of endometriosis,” wrote the authors.
The authors pointed out, however, that recurrence of pain does not necessarily infer recurrence of endometriosis, and that many patients who experience recurrence in symptoms will not require repeat surgical interventions
“Future studies should consider outcomes of patient satisfaction and quality of life under the current practices for management of endometriosis,” wrote the authors.
Bougie O, McClintock C, Pudwell J, et al. Long term follow-up of endometriosis surgery in Ontario: a population-based cohort study. Am J Obstet Gynecol. Published online April 21, 2021. doi:10.1016/j.ajog.2021.04.237