Background
Endometriosis is a chronic gynecological disease affecting approximately 10% of reproductive
aged females and leads to decreased quality of life and productivity. Despite effective
medical options, many women do require surgery for endometriosis. There is limited
literature examining long term outcomes of endometriosis surgery.
Objective
This study aimed to characterize the long-term outcomes, including recurrence of symptoms,
fertility outcomes, and need for reoperation, of patients who underwent surgical management
for endometriosis.
Study Design
This was a population-based cohort study in which the universal coverage health database
for the province of Ontario, Canada, was used to identify women aged 18 to 50 years
who underwent surgery for endometriosis from April 1, 2002, through March 31, 2018.
Surgery was classified as diagnostic laparoscopy, conservative or uterine preserving
(minor or major, with and without ovarian preservation), or hysterectomy (with and
without ovarian preservation). The outcomes were evaluated from 30 days after the
index surgery to the end of the study period or at censoring. Cox proportional hazard
regression models were used to estimate the hazard ratios between exposures and outcomes
following adjustment for confounders.
Results
A total of 84,885 women 2,718 (3.2%) diagnostic laparoscopy, 21,594 (25.4%) minor
conservative surgery, 28,484 (33.6%); major conservative with ovarian preservation,
2,102 (2.5%) major conservative without ovarian preservation, 21,609 (25.5%) hysterectomy
with ovarian preservation, and 8,378 (9.9%) hysterectomy without ovarian preservation)
were included in the cohort and followed for a median of 10 years (interquartile range,
6–13 years). In the first postoperative year, women who underwent diagnostic laparoscopy
were significantly more likely to require repeat surgery (adjusted hazard ratio, 1.68;
95% confidence interval, 1.51–1.87), whereas those who underwent major conservative
surgery were significantly less likely to require repeat surgery (with ovarian preservation:
adjusted hazard ratio, 0.44; 95% confidence interval, 0.41–0.48; without ovarian preservation:
adjusted hazard ratio, 0.05; 95% confidence interval, 0.03–0.09). Among women who
did not receive repeat surgery in the first year, those who underwent a diagnostic
laparoscopy (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76–0.95) and
major conservative surgery without ovarian preservation were less likely to undergo
repeat surgery (adjusted hazard ratio, 0.12; 95% confidence interval, 0.09–0.18) than
those who initially had minor surgery. Compared with those who initially underwent
minor surgery, patients who underwent other treatment modalities were less likely
to undergo a hysterectomy (diagnostic laparoscopy: adjusted hazard ratio, 0.85; 95%
confidence interval, 0.75–0.96; major surgery with ovarian preservation: adjusted
hazard ratio, 0.60; 95% confidence interval, 0.57–0.64; major surgery without ovarian
preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03–0.08). Following
minor and major conservative with ovarian preservation surgery, 8,331 (38.6%) and
9,498 (33.3%) of patients sought an infertility consult within 1 year, respectively.
By 5 years after the index surgery, 5,290 (29.4%) of patients who had minor conservative
surgery and 4,528 (20.7%) of those who had major conservative with ovarian preservation
surgery had given birth at least once.
Conclusion
Our study suggests that only a few endometriosis patients who undergo hysterectomy
surgery require repeat surgery; however, up to 1 in 4 who undergo minor surgery and
1 in 5 who undergo major conservative surgery with ovarian preservation require additional
endometriosis surgery. Up to 1 in 3 patients who had uterine sparing endometriosis
surgery subsequently sought an infertility assessment. These findings may inform preoperative
counseling in terms of recurrence of symptoms, fertility outcomes, and need for reoperation
of women seeking surgical management for endometriosis. Future studies should consider
the outcomes of patient satisfaction and quality of life based on the current practices
for management of endometriosis.
Key words
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Article Info
Publication History
Published online: April 21, 2021
Accepted:
April 17,
2021
Received in revised form:
April 2,
2021
Received:
January 29,
2021
Footnotes
O.B. reports receiving honoraria from Hologic, Bayer, Allergan, and AbbVie for Continuing Medical Education presentations not related to the submitted work. O.B. also reports serving as the principal investigator for trials funded by Bayer and Allergan not related to the submitted work. O.B. reports serving as the principal investigator for a study funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development not related to the submitted work. The remaining authors declare no conflict of interest.
This study was funded by the Queen’s University Department of Obstetrics and Gynaecology. The funder had no role in the in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. In addition, this study was supported by the Institute for Clinical Evaluative Sciences (ICES), Queen’s University, Kingston, ON, Canada, that is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).
The opinions, results, and conclusions reported in this article are those of the authors and are independent of the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed in the material are those of the authors and do not necessarily reflect the views of CIHI.
Cite this article as: 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 2021;225:270.e1-19.
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