Effects of laparoscopic radical surgery for deep endometriosis on endometriosis-related pelvic pain

Correlation Between Surgical Phenotype and Pain Improvement After Endometriosis Surgery

STUDY OBJECTIVE

To examine pain improvement after endometriosis surgery and whether it can be predicted by the observed surgical phenotype.

DESIGN

Prospective longitudinal survey study.

SETTING

A University hospital.

PATIENTS

A total of 125 patients completed a preoperative questionnaire (response rate: n = 227 of 277, 81.9%), had surgically confirmed endometriosis (n = 202 of 227), and returned a second postoperative questionnaire (response rate: n = 125 of 202, 61.9%).

INTERVENTIONS

All patients underwent complete laparoscopic removal of the endometriotic lesions. Surgical phenotype was classified according to the rASRM and #Enzian classification.

MEASUREMENTS AND MAIN RESULTS

The intensity of 5 specific pain symptoms was questioned by postal paper-pencil questionnaires with a numerical rating scale (0-10) both preoperatively (3.01 ± 2.72 months before surgery) and one year after surgery (12.62 ± 1.59 months). A postoperative pain improvement score was computed (postoperative pain-preoperative pain) for each specific pain symptom (0-10) and for the overall/global pain sum score (0-50). The mean intensity of all pain scores was lower postoperatively as compared with preoperatively (p <.0001). A statistically significant weak correlation was observed between the surgical phenotype "rectovaginal endometriosis" and postoperative improvement of dyspareunia (r = .265; p = .003). The other 11 hypothesized correlations between surgical phenotype and postoperative improvement of pain intensity failed to reach statistical significance.

CONCLUSION

Clinicians can inform patients that surgery is effective in reducing endometriosis-related pain symptoms and the overall/global pain scores at 12 months postoperatively. From our data, we can conclude that patients with rectovaginal endometriosis might benefit the most from the reduction of their sexual pain. On the basis of these results, we could suggest that deep dyspareunia (even if present as an isolated symptom) might be a valid indication for surgery. Further research could explore the association between a certain surgical phenotype and more detailed assessments of sexual functioning, as well as explore whether feedback from the surgeon on expected pain improvement affects patient-reported outcomes.

Quality of Life in Women after Deep Endometriosis Surgery: Comparison with Spanish Standardized Values

The quality of life (QoL) of women who have been surgically treated for endometriosis may be severely impaired. Therefore, QoL can be a determining factor in the recovery of these patients. The aims of this study were to evaluate if the QoL of women surgically treated for deep endometriosis differs from a healthy age-matched population from Catalonia (Spain) and to analyze the QoL of these women considering concomitant events. This is an observational cross-sectional study, where 112 women (between 18 and 48 years old), with endometriosis treated by surgery at Hospital Universitario La Paz (Madrid, Spain), were enrolled to assess the QoL using the second version of the 12-item short form (SF-12) questionnaire. The QoL in these women were tested against a reference population of healthy women using a standardized one-sample comparison method. In addition, the QoL was compared according to the pathophysiology and type of surgery. In women with endometriosis, the physical health component, but not mental health component, was positively correlated with age (r = 0.19; p-Value = 0.048). In addition, physical (20.3 ± 29.2) and social functions (29.7 ± 38.3) and the overall physical health component (37.8 ± 19.4) were significantly lower than the reference population. On the contrary, the body pain (64.1 ± 41.2), emotional role (62.5 ± 42.2), mental health (54.4 ± 26.0), vitality (59.3 ± 31.2), and the overall mental health component (59.4 ± 26.6) had significantly higher scores than the reference. The anatomical compartment of endometriosis, reintervention, bowel nodule resection, and fertility preservation did not show statistical differences in QoL. Women with deep endometriosis had worse physical and social functions, and the overall physical health, compared to the norm in Spanish women. Bodily pain, emotional role, vitality, and the overall mental health improved. These areas could be considered protective factors in this disease. Considering the importance of QoL in adjustments in mental and physical health, it would be necessary to improve these areas of QoL in women surgically treated for deep endometriosis.

Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery

Background

Up to 28% of endometriosis patients do not get pain relief from therapeutic laparoscopy but this subgroup is not defined.

Objectives

To identify any prognostic patient-specific factors (such as but not limited to patients’ type or location of endometriosis, sociodemographics and lifestyle) associated with a clinically meaningful reduction in post-surgical pain response to operative laparoscopic surgery for endometriosis.

Search strategy

PubMed, Cochrane and Embase databases were searched from inception to 19 May 2020 without language restrictions. Backward and forward citation tracking was used.

Selection criteria, data collection and analysis:

Cohort studies reporting prognostic factors, along with scores for domains of pain associated with endometriosis before and after surgery, were included. Studies that compared surgeries, or laboratory tests, or outcomes without stratification were excluded. Results were synthesised but variation in study designs and inconsistency of outcome reporting precluded us from doing a meta-analysis.

Main results

Five studies were included. Quality assessment using the Newcastle–Ottawa scale graded three studies as high, one as moderate and one as having a low risk of bias. Four of five included studies separately reported that a relationship exists between more severe endometriosis and stronger pain relief from laparoscopic surgery.

Conclusion

Currently, there are few studies of appropriate quality to answer the research question. We recommend future studies report core outcome sets to enable meta-analysis.

Lay summary

Endometriosis is a painful condition caused by displaced cells from the lining of the womb, causing inflammation and scarring inside the body. It affects 6–10% of women and there is no permanent cure. Medical and laparoscopic surgical treatments are available, but about 28% of patients do not get the hoped-for pain relief after surgery. Currently, there is no way of predicting who gets better and who does not. We systematically searched the world literature to establish who may get better, in order to improve counselling when women choose treatment options. We identified five studies of variable quality showing: More complex disease (in specialist hands) responds better to surgery than less, but more studies needed.

Stepwise Approach to the Management of Endometriosis-Related Dysmenorrhea: A Cost-Effectiveness Analysis

OBJECTIVE

To evaluate the cost effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea.

METHODS

A cost-effectiveness model was created to compare three stepwise medical and surgical treatment strategies compared with immediate surgical management for dysmenorrhea using a health care payor perspective. A theoretical study cohort was derived from the estimated number of reproductive age (18-45) women in the United States with endometriosis-related dysmenorrhea. The treatment strategies modeled were: strategy 1) nonsteroidal antiinflammatory drugs (NSAIDs) followed by surgery; strategy 2) NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery; strategy 3) NSAIDs, then a short-acting reversible contraceptive or LARC, then a LARC or gonadotropin-releasing hormone modulator followed by surgery; strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. Outcomes included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Univariate, bivariate, and multivariate sensitivity analyses were performed.

RESULTS

In this theoretical cohort of 4,817,894 women with endometriosis-related dysmenorrhea, all medical and surgical treatment strategies were cost effective at a standard willingness-to-pay threshold of $100,000 per QALY gained when compared with surgery alone. Strategy 2 was associated with the lowest cost per QALY gained ($1,155). Requiring a trial of a third medication before surgery would cost an additional $257 million, compared with proceeding to surgery after failing two medical treatments. The probability of improvement with surgery would need to exceed 83% for this to be the preferred first-line approach.

CONCLUSION

All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost effective when compared with surgery alone. A trial of hormonal management after NSAIDs, before proceeding to surgery, may provide cost savings. Delaying surgical management in an individual with pain refractory to more than three medications may decrease quality of life and increase cost.

Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis

Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general.

Sexual function in women undergoing surgery for deep infiltrating endometriosis: a comparison with healthy women

BACKGROUND

Endometriosis is a chronic and progressive condition of women of reproductive age. It is strongly associated with significant impairment of sexual function.

AIM

To objectively evaluate the impact of laparoscopic excision of endometriosis on sexual function in patients with deep infiltrating endometriosis (DIE) compared to healthy women.

SETTING AND DESIGN

Prospective study, including 250 patients with a diagnosis of DIE scheduled for laparoscopic surgery and 250 healthy women.

METHODS

A sexual activity questionnaire, SHOW-Q (Sexual Health Outcomes in Women Questionnaire), was used to collect data pertaining to women's satisfaction, orgasm, desire and pelvic problem interference with sexual function. Women with DIE underwent complete excision of endometriotic lesions. All participants were asked to complete the SHOW-Q questionnaire before and after surgery.

RESULTS

SHOW-Q scores in the endometriosis group before and 6 months after surgery were compared with the healthy group scores. A significant improvement was found between pre- and post-treatment in the scores of the satisfaction scale, desire scale and pelvic problem interference scale of SHOW-Q. The distribution of post-surgery SHOW-Q scores was comparable to healthy women's scores apart from the orgasm scale score, which was unchanged in the post-surgery group.

CONCLUSIONS

The surgical approach to treatment has a positive impact not only on organ impairment but also on sexual function in women affected by DIE.

Diagnosis, management, and long-term outcomes of rectovaginal endometriosis

Rectovaginal endometriosis is the most severe form of endometriosis. Clinically, it presents with a number of symptoms including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and rectal bleeding. The gold standard for diagnosis is laparoscopy with histological confirmation; however, there are a number of options for presurgical diagnosis, including clinical examination, transvaginal/transrectal ultrasound, magnetic resonance imagining, colonoscopy, and computed tomography colonography. Treatment can be medical or surgical. Medical therapies include birth control pills, oral progestins, gonadotropin-releasing hormone agonists, danazol, and injectable progestins. Analgesics are often used as well. Surgery improves up to 70% of symptoms. Surgery is either ablative or excisional, and is conducted via transvaginal, laparoscopic, laparotomy, or combined approaches. Common surgical techniques involve shaving of the superficial rectal lesion, laparoscopic anterior discoid resection, and low anterior bowel resection and reanastomosis. Outcomes are generally favorable, but postoperative complications may include intra-abdominal bleeding, anastomotic leaks, rectovaginal fistulas, strictures, chronic constipation, and the need for reoperation. Recurrence of rectal endometriosis is a possibility as well. Other outcomes are improved pain-related symptoms and fertility. Long-term outcomes vary according to the management strategy used. This review will provide the most recent approaches and techniques for the diagnosis and treatment of rectovaginal endometriosis.