Department of Obstetrics and Gynaecology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada.
Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Ontario, Canada.
Am J Obstet Gynecol. 2021 Sep;225(3):270.e1-270.e19. doi: 10.1016/j.ajog.2021.04.237. Epub 2021 Apr 21.
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.
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.
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.
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.
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.
子宫内膜异位症是一种影响大约 10%生育年龄女性的慢性妇科疾病，会降低生活质量和生产力。尽管有有效的医疗选择，但许多女性仍需要手术治疗子宫内膜异位症。目前关于子宫内膜异位症手术的长期结果的文献有限。
本研究旨在描述接受手术治疗子宫内膜异位症的患者的长期结果，包括症状复发、生育结局和再次手术的需求。
这是一项基于人群的队列研究，使用加拿大安大略省的全民健康数据库，确定了 2002 年 4 月 1 日至 2018 年 3 月 31 日期间因子宫内膜异位症接受手术的年龄在 18 至 50 岁的女性。手术分为诊断性腹腔镜检查、保守性或保留子宫（轻度或重度，有或无卵巢保留）或子宫切除术（有或无卵巢保留）。从索引手术后 30 天到研究结束或截止日期评估结局。使用 Cox 比例风险回归模型，在调整混杂因素后，估计暴露与结局之间的风险比。
共纳入 84885 名女性，其中 2718 名（3.2%）接受诊断性腹腔镜检查，21594 名（25.4%）接受轻度保守性手术，28484 名（33.6%）接受重度保守性手术伴卵巢保留，2102 名（2.5%）接受重度保守性手术不伴卵巢保留，21609 名（25.5%）接受子宫切除术伴卵巢保留，8378 名（9.9%）接受子宫切除术不伴卵巢保留），并随访了中位数为 10 年（四分位距为 6-13 年）。在术后第一年，接受诊断性腹腔镜检查的女性再次手术的可能性显著更高（调整后的风险比，1.68；95%置信区间，1.51-1.87），而接受大手术的女性再次手术的可能性显著较低（伴卵巢保留：调整后的风险比，0.44；95%置信区间，0.41-0.48；不伴卵巢保留：调整后的风险比，0.05；95%置信区间，0.03-0.09）。在第一年未接受再次手术的女性中，接受诊断性腹腔镜检查（调整后的风险比，0.85；95%置信区间，0.76-0.95）和不伴卵巢保留的大手术的女性再次手术的可能性显著低于最初接受小手术的女性（调整后的风险比，0.12；95%置信区间，0.09-0.18）。与最初接受小手术的女性相比，接受其他治疗方式的女性接受子宫切除术的可能性较低（诊断性腹腔镜检查：调整后的风险比，0.85；95%置信区间，0.75-0.96；伴卵巢保留的大手术：调整后的风险比，0.60；95%置信区间，0.57-0.64；不伴卵巢保留的大手术：调整后的风险比，0.05；95%置信区间，0.03-0.08）。在接受轻度和重度保留卵巢的保守性手术后，分别有 8331（38.6%）和 9498（33.3%）名患者在 1 年内寻求不孕咨询。在索引手术后的 5 年内，接受轻度保守性手术的 5290 名（29.4%）和接受重度保留卵巢的保守性手术的 4528 名（20.7%）患者中，至少有一人曾生育过一次。
我们的研究表明，只有少数接受子宫切除术的子宫内膜异位症患者需要再次手术；然而，多达 1/4 接受小手术的患者和 1/5 接受大手术伴卵巢保留的患者需要进一步的子宫内膜异位症手术。多达 1/3 接受保留子宫的子宫内膜异位症手术的患者随后寻求不孕评估。这些发现可能为寻求手术治疗子宫内膜异位症的女性提供关于症状复发、生育结局和再次手术需求的术前咨询。未来的研究应考虑基于当前子宫内膜异位症管理实践的患者满意度和生活质量的结果。
