Clinical characteristics difference between early and late recurrence of ovarian endometriosis after laparoscopic cystectomy

Risk factors for recurrent endometriosis after conservative surgery in a quaternary care center in southern Thailand

OBJECTIVES

To determine the 2-year recurrence rate of endometriosis after conservative surgery and the risk factors for recurrence.

METHODS

This study retrospectively analyzed women with endometriosis who underwent conservative surgery and had at least a 2-year follow-up at a quaternary care hospital in southern Thailand from January 2000 to December 2019. Recurrent endometriosis was defined as either presence of endometrioma with a diameter ≥ 2 cm for more than three consecutive menstrual cycles or relapse of pelvic pain with the same or higher visual analog scale (VAS) score as before surgery. Multivariate logistic regression analysis was used to identify the risk factors for recurrence.

RESULTS

The median (interquartile range [IQR]) age was 34 (29, 38) years in 362 cases and nearly three-quarters (74.2%) were nulliparous. Cyclic pain was the most common clinical presentation (48.9%) and the median (IQR) VAS score of pelvic pain was 6 (5, 9). Ovarian cystectomy was the most common procedure (68.1%). The 2-year recurrent endometriosis rate after conservative surgery was 23.2%, and the overall recurrence rate was 56.4%. The risk factors of recurrence were preoperative moderate to severe pelvic pain (adjusted odds ratio [aOR] 1.93; 95% confidence interval [CI], 1.12-3.34; p = 0.017), adhesiolysis/ablation/ovarian cystectomy without unilateral oophorectomy (aOR 2.71; 95% CI, 1.40-5.23; p = 0.002), and duration of postoperative hormonal treatment < 24 months (aOR 10.58; 95% CI, 5.47-20.47; p < 0.001).

CONCLUSION

The 2-year recurrence rate after conservative surgery for endometriosis was 23.2%. Preoperative moderate to severe pelvic pain, procedures except unilateral oophorectomy, and postoperative hormonal treatment < 24 months were risk factors for recurrence.

The presence of living endometrial cells in ovarian endometriotic cyst fluid may contribute to the recurrence of endometriosis after surgical excision of endometriomas

BACKGROUND

Many factors can affect the recurrence of endometriosis after surgery, however, whether endometriotic cyst fluid contributes to endometriosis recurrence after surgical excision of ovarian endometriomas remains unclear. The objective of this study was to determine the presence of endometrial cells in ovarian endometriosis cyst fluid and the potential differences between these cells and those in the cyst wall.

METHODS

Samples of cyst fluid (n = 39) and drainage fluid (n = 14) were collected from patients with ovarian endometriomas undergoing laparoscopic surgery. Drainage fluid from 14 patients without endometriosis was used as a control. The presence of endometrial cells in cyst fluid and drainage fluid was determined by cell culture in vitro and immunostaining. In addition, cyst fluid endometrial fragments and viscosity were analysed by transcriptome sequencing analysis and apparent diffusion coefficients, respectively. An animal model was used to confirm the ability of endometrial cells in cyst fluid to form new lesions.

RESULTS

We found endometrium-like tissues in 71.8% (28/39) of cyst fluid and 71.4% (10/14) of drainage fluid samples by histopathological examination, and the presence of endometrioid tissue in cyst fluid was related to the viscosity of the cyst fluid. The living endometrial cells in cyst fluid and drainage fluid were confirmed by cell culture in vitro and immunostaining. Moreover, the adhesion ability of endometrial fragments in cyst fluid was significantly higher than that of ectopic tissues in the cyst wall (P < 0.05). In addition, living endometrial cells in the cyst fluid were able to adhere and alive in the animal model.

CONCLUSIONS

The existence of living endometrial cells with high adhesion ability in ovarian endometriotic cyst fluid may contribute to the recurrence of endometriosis after surgical excision of endometriomas due to cyst fluid outflow during the surgical procedure.

Extrinsic Adenomyosis Is Associated With Postoperative Recurrence of Ovarian Endometrioma

Objective: To determine whether endometrioma recurrence is closely related to the presence of extrinsic adenomyosis, which was demonstrated by magnetic resonance imaging (MRI). Design: Observational crosssectional study involving patients with the recurrence of ovarian endometrioma (OMA). Correlations of endometrioma recurrence and adenomyosis subtypes shown by MRI were analyzed. Method: Between January 2018 and December 2020, a total of 233 patients with recurrence of OMA after ovarian cystectomy were administered for surgery at our institution. All patients were divided into subtype II (Group A), subtype I+IV (Group B), and nonadenomyosis (Group C) groups at preoperative MRI imaging. The correlations of endometrioma recurrence with clinical features, imaging appearance, and surgical findings were retrospectively analyzed. Results: We found 112 (48.07%) patients of endometrioma recurrence combined with subtype II adenomyosis, 8 (3.43%) subtype I adenomyosis, 47 (20.17%) subtype IV adenomyosis, 66 (28.32%) nonadenomyosis. The mean time of OMA recurrence (44.28 ± 8.37, vs. 63.96 ± 10.28, vs. 69.36 ± 9.34 mon), rate of pain symptoms (85.71, vs. 69.10, vs. 18.18%), and primary infertility (31.25, vs. 14.55, vs. 10.77%) were higher in Group A. Uterine volume (257.37± 42.61, vs. 203.14 ± 33.52, vs. 100.85 ± 26.67 cm³), and mean OMA size (4.97 ± 2.25, vs. 4.36 ± 2.38, vs. 4.46 ± 2.70 cm) were significantly larger in Group A. The rate of DIE (83.93, vs. 45.45, vs. 40.91%), the number of DIE (3.6 ± 1.8 vs. 2.3 ± 1.5 vs. 2.2 ± 1.3), the mean total revised American Society for Reproductive Medicine score (rASRM, 103.14 ± 23.89 vs. 74.23 ± 16.72 vs. 36.51 ± 14.23) were significantly higher in Group A. After a multiple logistic regression analysis, extrinsic adenomyosis (OR 2.5, 95% CI 1.2-3.4), DIE lesions (OR 2.1, 95% CI 1.4-2.8), and primary infertility (OR 1.8, 95% CI 1.3-4.3) were significantly associated with early recurrence (in 3-year) of OMA. Conclusions: Extrinsic adenomyosis was associated with postoperative recurrence of OMA. In addition, a pathogenic link between extrinsic adenomyosis and pelvic endometriosis needs to be clarified.

Comparing the effect of adjunctive N-acetylcysteine plus low dose contraceptive with low dose contraceptive alone on recurrence of ovarian endometrioma and chronic pelvic pain after conservative laparoscopic surgery: a randomised clinical trial study

This study aimed to compare the effectiveness of NAC plus low dose contraceptive with low dose contraceptives alone. This was a randomised trial on a sample of women who underwent conservative laparoscopic surgery for ovarian endometrioma. Patients were randomly assigned either to the NAC plus low dose contraceptive group (n = 48) or low dose contraceptive alone (n = 52). To evaluate the recurrence rate transvaginal ultrasound was performed. Pelvic pain was assessed using a visual analogue scale (VAS). All assessments were performed at two points in time: 3 and 6 months post-surgery and compared between the two regimens. The findings indicated that reduction in the recurrence rate of endometrioma and pelvic pain were similar between both groups. The findings showed that adding N-acetylcysteine to low dose contraceptive treatment has a similar effect in reducing the recurrence rate of endometrioma and pelvic pain when compared to low dose contraceptives alone.Impact statementWhat is already known on this subject? Endometriosis is a frequent benign disease-producing inflammatory response with mild to severe symptoms. Although surgical removal of ectopic lesions is the first-line intervention, the recurrence rate of the disease is high. Thus this study aimed to compare the effectiveness of N-acetylcysteine plus low dose contraceptive with low dose contraceptive alone.What do the results of this study add? The findings showed that adding N-acetylcysteine to low dose contraceptive treatment has a similar effect in reducing the recurrence rate of endometrioma and pelvic pain when compared to low dose contraceptives alone.What are the implications of these findings for clinical practice and/or further research? It is recommended to increase the duration of drug administration in future studies.

Clinical analysis of 52 adolescent patients with ovarian masses ≥10 cm in diameter

Objective

To investigate the clinical characteristics and treatment of large ovarian masses in adolescents.

Methods

Adolescents with large ovarian masses (≥10 cm in diameter) who were treated in Beijing Obstetrics and Gynecology Hospital from March 2010 to December 2018 were retrospectively assessed.

Results

Fifty-two female patients (mean age: 16.17±2.04 years [11–19 years]) were included and 19 (36.5%) presented with abdominal pain. The blood flow signal rate in ultrasonography was significantly different among benign, borderline and malignant ovarian masses, unlike strong echo, dotted echo and septation rates. Carbohydrate antigen 125 positivity rates were significantly different among pathological types and the endometriotic cyst group showed the highest value (75.0%). Alpha-fetoprotein positivity rates were also different among pathological types. For ovarian cystectomy, 14 and 32 patients underwent laparotomy and laparoscopy, respectively. Mass diameters were significantly higher in the laparotomy group and the operative duration was significantly shorter in the laparoscopy group. There were no significant differences in intraoperative blood loss or postoperative recurrence rates between the two groups.

Conclusion

Teratomas constitute the greatest group of large ovarian masses in adolescents. Benign tumors should be treated by laparoscopic resection, while borderline or malignant tumors require individualized treatment of tumors and fertility-sparing treatments.