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.

Keywords: deep-infiltrative endometriosis; endometrioma; peritoneal endometriosis; progression; recurrence.

Figure 1

Time to first recurrent surgery according to the initial type of endometriosis. Legend: The time to recurrence is illustrated in different colors according to the endometriosis lesion subtype at initial surgery. No statistically significant difference was observed. Abbreviations: SUP, superficial peritoneal endometriosis; OMA, ovarian endometrioma; DIE, deep infiltrating endometriosis.

Figure 2

The evolution of SUP, OMA, and DIE at first recurrence. Legend: Graphical illustration of Table 2. The evolution of the lesions from the first to recurrent surgery is presented. Each group of patients is split into 3 colored columns with each color representing a certain lesion subtype at recurrent surgery. Abbreviations: SUP, superficial peritoneal endometriosis; OMA, ovarian endometrioma; DIE, deep infiltrating endometriosis.