Long-term follow-up after laparoscopic treatment for endometriosis: multivariate analysis of predictive factors for recurrence of endometriotic lesions and pain

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Abstract

Objective

To investigate factors that might influence the recurrence of both painful symptoms and endometriotic lesions following laparoscopic treatment of endometriosis.

Study design

Retrospective cohort study in a University teaching hospital. We reviewed data from patients referred for laparoscopy between March 1993 and November 2007. We selected women who were followed up throughout Transvaginal-ultrasound (TV-US) after a first conservative laparoscopy for endometriosis. After laparoscopy, all patients were followed up according to an internal protocol: a standard gynaecologic examination, the assessment of painful symptoms and a TV-US scan that were repeated at 3, 6, and 12 months, and subsequently on a yearly basis. Sixteen factors were assessed by univariable and multivariable Cox proportional hazards models to evaluate their associations with recurrence of endometriotic lesions and pain related-endometriosis.

Results

401 women were enrolled. A total of 154 (38.4%) experienced moderate or severe pain after laparoscopy; endometriotic lesions were observed by TV-US in 74 (18.4%) patients. In the multivariable model, age at menarche, severity of chronic pelvic pain (CPP) and dysmenorrhoea prior to surgery were significant risk factors for recurrence/occurrence of pain. Age at the first laparoscopy, stage of disease, pre-operative severity of CPP, and pregnancy were predictive factors of the recurrence for such lesions.

Conclusion

The severity of CPP prior to the first laparoscopy showed the only significant factor in the overall prediction of recurrence of pain and endometriotic lesions. Patients with severe CPP at the time of their first surgery might represent a sub-group of women with a more aggressive form of endometriosis.

Introduction

The existence of a relationship between pain and endometriosis is widely accepted by gynaecologists [1], [2]. Laparoscopic excision of endometriosis results in pain relief, improved reproductive outcomes, and increased quality of life. Unfortunately, even with surgeons experienced in laparoscopy, 6–51% of women will have a recurrence of endometriosis within 5 years of surgery [3], [4].

Few studies have analysed the determinants of recurrence rate in endometriosis, and the available data are controversial. The inconsistencies found in literature may be due to the complexity of endometriosis itself or to widespread methodological problems in the current studies: (i) limited and/or heterogeneous samples, (ii) few studies conducted with a second-look surgery, (iii) failure to control for endometriosis stage and symptomatology, as well as (iv) use of improper statistical analyses. Although some authors have considered recurrence of pain (dysmenorrhoea, dyspareunia or chronic pelvic pain) [3], [5] ultrasound findings [3], [5], [6], [7] or increased CA125 levels [3], [5] to be the definition of endometriosis recurrence, there is still absence of a standardised definition.

The aim of this study was to analyse the effectiveness of laparoscopic treatment of endometriosis and to assess prognostic factors that might influence the recurrence rate for pain and endometriosis.

In a further analysis, we hypothesised that patients with recurrence/occurrence of pelvic pain may be at increased risk for the recurrence of endometriosis and sought to investigate this relationship.

Section snippets

Materials and methods

We reviewed the medical records of 593 consecutive patients who underwent laparoscopy for endometriosis between March 1993 and November 2007 in the Department of Gynaecology, Perinatology and Human Reproduction at the University of Florence, Italy. Inclusion criteria were: first conservative laparoscopy for endometriosis, diagnosis of endometriosis histologically confirmed, Transvaginal-ultrasound (TV-US) follow-up after laparoscopy. Following these criteria, 401 women were included in our

Results

Among 593 consecutive patients submitted to laparoscopy for endometriosis, 401 (67.6%) underwent periodic TV-US after surgery (114 with stage I or II endometriosis; 287 with stage III or IV endometriosis). The mean duration of observation per patient was 6.2 ± 4.1 years (median time 6 years, range 2–11 years). Table 1 shows the general features of the sample that received TV-US after surgery (Table 1).

Comments

Our study confirms the effectiveness of treating endometriosis with laparoscopic excision in order to reduce patients’ pain, a finding also reported by others [14], [15], [16], [17]. Of 278 women suffering from painful symptoms before surgery, 140 (50.3%) did not experience such symptoms after laparoscopic treatment. Of the 216 infertile women in our sample, 117 (54.2%) were able to achieve pregnancy after surgery.

A younger age at menarche and dysmenorrhoea severity demonstrated risk factors

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