Recurrence Patterns after Surgery in Patients with Different Endometriosis Subtypes: A Long-Term Hospital-Based Cohort Study

Abstract

Recurrence of endometriosis after surgery constitutes a serious challenge. Whether there is an evolution of lesion subtypes with each recurrence and whether certain lesions subtypes tend to recur faster than others is not adequately addressed. Medical records of all patients who underwent surgery for endometriosis between 1997 and 2018 in the Department of Gynecology and Obstetrics, University of Bern, were reviewed. Inclusion criteria was surgically confirmed endometriosis recurrence, defined as a subsequent surgery for endometriosis after a previous complete surgical excision of endometriosis lesions. Three subtypes of endometriosis were defined: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). Time to recurrence and variation in endometriosis subtype between the first and recurrent surgeries were the primary outcome measures. Out of the 322 patients with recurrent surgery that were identified, for 234 of them, the endometriosis subtype at first surgery was confirmed and classified (SUP = 56, OMA = 124, DIE = 54). No statistically significant difference was found for time to recurrence between lesion subtypes. SUP compared to the other groups had a higher possibility of presenting with SUP at recurrence (Odds Ratio (OR): 3.65, 95% confidence interval (CI): 1.74-7.51) and OMA compared to the other groups had a higher possibility of presenting with OMA at recurrence (OR: 3.72, 95% CI: 2.04-6.74). Nevertheless, a large number of SUP patients subsequently presented with OMA (10/56: 17.9%) or DIE (27/56: 48.2%) lesions at recurrence. Similarly, a large number of OMA patients subsequently presented with DIE (49/124: 39.5%) lesions at recurrence. In conclusion, although SUP and OMA patients compared to the others are more likely to present with the same subtype at recurrence, increasing lesion subtype severity occurs in a substantial proportion of patients. Time to recurrence is independent from the lesion subtype at first surgery.Laparoscopic surgery is associated with decreased overall pain, both at 6 and 12 months after surgery [6]. However, despite complete removal of endometriotic tissue, a high proportion of patients will require additional surgery due to endometriosis recurrence. In a recent UK population-based report, 48% of patients with endometriosis received surgical treatment. Approximately one-fifth of these patients required further surgical treatment, within three years of the index procedure [7]. Other studies have reported total recurrence rates of 21.5% and 40%-50% at two and five years, respectively [8,9].Endometriosis lesions are a heterogenous group of lesions that are currently split into three subtypes based on the location and infiltration depth: superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE) [10,11]. Although patients with SUP may suffer from pelvic pain, OMA and DIE generally cause heavier symptoms, have more serious long-term complications, are more difficult t...

Epithelial–Mesenchymal Transition in Endometriosis—When Does It Happen?

“…Again, this does not exclude other hypotheses in the pathogenesis of endometriosis. Remarkably, recently, it was found that the time to recurrence is independent of the three endometriotic subtypes (ovarian, peritoneal, and DIE) at first surgery [ 34 ].…”

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis – a retrospective single center analysis

“…A recurrence that led to repeated surgery developed in 21.8% of patients in our sturdy population. This value falls into the lower range of data published in the literature, where a recurrence rate of between 18.9 and 57% after 5 years is specified [ 18 – 20 , 22 , 38 – 40 ]. It should be kept in mind that in some of our patients, 14 years had passed since surgery.…”

“…Unfortunately, the rate of recurrence after endometriosis surgery is considerable at times and varies between 6 and 67% after 5 years [ 18 – 22 ]. The rate of recurrence increases in relation to the extent of endometriosis at baseline [ 18 ].…”

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis.

“…Nirgianakis et al evaluated the recurrence patterns after surgery depending on the different endometriosis subtypes: superficial peritoneal endometriosis, ovarian endometrioma and deep infiltrating endometriosis. Although peritoneal endometriosis and ovarian endometrioma are more likely to present with the same subtype at recurrence, the time to recurrence was independent of the lesion subtype at first surgery [22].…”

“…Unfortunately, the rate of recurrence after endometriosis surgery is considerable at times and varies between 6% and 67% after five years [18][19][20][21][22]. The rate of recurrence increased the more extensive the baseline finding [18].…”