Risk factors for recurrence of ovarian endometriomas after surgical excision

Abstract

Ovarian endometrioma is a common form of endometriosis, which may cause infertility, dysmenorrhea and pelvic pain in women of reproductive age. Although surgery is the treatment of choice for endometriomas, recurrence poses a formidable frustration. This study investigated potential risk factors of endometriomas recurrence, aiming to better understand its pathogenesis. A total of 307 patients with endometriomas were followed up for an average of 28.6 months and the 1-, 2- and 3-year cumulative recurrence rate was 9.5%, 21.9%, and 29.2%, respectively. Twenty-one potential risk factors for endometriomas recurrence were evaluated using Cox’s proportional hazards models. Total revised American Fertility Society (rAFS) score was significantly associated with higher recurrence (OR=1.858, 95% CI=1.122–3.075, P=0.016), as well as younger age at surgery (OR=0.953, 95% CI=0.915–0.992, P=0.020). Semiradical surgical treatment was defined as surgical removal of cyst plus hysterectomy with preservation of bilateral or unilateral ovary, and was a significant factor that was associated with lower recurrence than the conservative surgery (OR=0.318, 95% CI=0.107–0.951, P=0.040). Postoperative pregnancy was favorable factors for disease recurrence (OR=0.217, 95% CI=0.102–0.460, P=0.000). The results suggest that endometrioma recurrence is inversely associated with age at surgery and postoperative pregnancy, and may correlate with total rAFS score and conservative surgery method.

Keywords

ovarian endometriomas / recurrence / risk factors / surgery

References

[1] KoninckxPR, MeulemanC, DemeyereS, et al.. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril, 1991, 55(4): 759-765

[2] ChapronC, Pietin-VialleC, BorgheseB, et al.. Associated ovarian endometrioma is a marker for greater severity of deeply infiltrating endometriosis. Fertil Steril, 2009, 92(2): 453-457

[3] KennedyS, BergqvistA, ChapronC, et al.. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod, 2005, 20(10): 2698-2704

[4] ChapronC, SantulliP, de ZieglerD, et al.. Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis. Hum Reprod, 2012, 27(3): 702-711

[5] ExacoustosC, ZupiE, AmadioA, et al.. Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue. Am J Obstet Gynecol, 2004, 191(1): 68-72

[6] BusaccaM, ChiaffarinoF, CandianiM, et al.. Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis. Am J Obstet Gynecol, 2006, 195(2): 426-432

[7] KogaK, TakemuraY, OsugaY, et al.. Recurrence of ovarian endometrioma after laparoscopic excision. Hum Reprod, 2006, 21(8): 2171-2174

[8] LiuX, YuanL, ShenF, et al.. Patterns of and risk factors for recurrence in women with ovarian endometriomas. Obstet Gynecol, 2007, 109(6): 1411-1420

[9] GuoSW. Recurrence of endometriosis and its control. Hum Reprod Update, 2009, 15(4): 441-461

[10] FedeleL, BianchiS, ZanconatoG, et al.. Long-term follow-up after conservative surgery for rectovaginal endometriosis. Am J Obstet Gynecol, 2004, 190(4): 1020-1024

[11] KikuchiI, TakeuchiH, KitadeM, et al.. Recurrence rate of endometriomas following a laparoscopic cystectomy. Acta Obstet Gynecol Scand, 2006, 85(9): 1120-1124

[12] ExacoustosC, ZupiE, AmadioA, et al.. Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery. J Minim Invasive Gynecol, 2006, 13(4): 281-288

[13] MissmerSA, CramerDW. The epidemiology of endometriosis. Obstet Gynecol Clin North Am, 2003, 30(1): 11-19

[14] ChapronC, ChopinN, BorgheseB, et al.. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod, 2006, 21(7): 1839-1845

[15] FarquharC. Endometriosis. BMJ, 2007, 334(7587): 249-253

[16] BullettiC, MontiniA, SettiPL, et al.. Vaginal parturition decreases recurrence of endometriosis. Fertil Steril, 2010, 94(3): 850-855

[17] SestiF, CapozzoloT, PietropolliA, et al.. Recurrence rate of endometrioma after laparoscopic cystectomy: a comparative randomized trial between post-operative hormonal suppression treatment or dietary therapy vs. placebo. Eur J Obstet Gynecol Reprod Biol, 2009, 147(1): 72-77

[18] BusaccaM, SomiglianaE, BianchiS, et al.. Post-operative GnRH analogue treatment after conservative surgery for symptomatic endometriosis stage III–IV: a randomized controlled trial. Hum Reprod, 2001, 16(11): 2399-2402

[19] BhattacharyaSM. Health-related quality of life following surgical menopause and following gonadotrophin-releasing hormone analogue-induced pseudomenopause. Gynecol Endocrinol, 2009, 25(9): 621-623

[20] WuL, WuQ, LiuL. Oral contraceptive pills for endometriosis after conservative surgery: a systematic review and meta-analysis. Gynecol Endocrinol, 2013, 29(10): 883-890

[21] Abou-SettaAM, HoustonB, Al-InanyHG, et al.. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev, 2013, 1: CD005072

[22] TakamuraM, KogaK, OsugaY, et al.. Post-operative oral contraceptive use reduces the risk of ovarian endometrioma recurrence after laparoscopic excision. Hum Reprod, 2009, 24(12): 3042-3048

[23] GoncalvesMO, DiasJAJr, PodgaecS, et al.. Transvaginal ultrasound for diagnosis of deeply infiltrating endometriosis. Int J Gynaecol Obstet, 2009, 104(2): 156-160

[24] GoncalvesMO, PodgaecS, DiasJAJr, et al.. Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy. Hum Reprod, 2010, 25(3): 665-671