One of the main concerns of patients with endometriosis, as well as of endometriosis surgeons, is the risk of repeat surgery. But how often does this actually happen?
The answer to this question, although it may sound very basic, is not so simple. The most thorough study addressing this issue was published recently and found that up to 28% of patients may require repeat surgery within 10 years after their first surgery for endometriosis (1). Interestingly, performing a hysterectomy at the time of the first endometriosis surgery, as well as achieving pregnancy after surgery, were identified as independent protective factors against repeat surgery (1). The mean time interval between the first and repeat surgery was calculated to be 46 months (1).
We know that endometriosis is most likely a progressive disease with slow progression (2). An earlier publication by the same group of authors found that 36% of patients underwent repeat surgery, either due to recurrence of endometriosis, pain, or postoperative complications (3). However, this percentage was ten times higher than the rate of actual endometriosis recurrence. In the more recent publication (1), the majority of repeat operations were performed due to persistent pain or recurrence of endometriosis. Of course, when interpreting the results of this study, we must be cautious, as they reflect the outcomes of surgeries performed by a single surgeon with high expertise in endometriosis surgery. Therefore, these figures may differ when surgeries are performed by other surgeons.
Let us now consider what other studies report. A large Canadian study of nearly 85,000 patients who underwent surgery for endometriosis found that repeat surgery was required in 1 in 4 women after limited endometriosis surgery and in 1 in 5 women after extensive surgery with ovarian preservation (4). However, results from nationwide population-based studies are difficult to compare with those from specialized endometriosis centers.
It is also important to examine separately cases with confirmed recurrence of endometriosis. In Bafort’s study, 5% of patients underwent repeat surgery due to recurrence of an endometrioma (ovarian chocolate cyst) (5). Regarding bowel endometriosis, the study by Mabrouk reported a recurrence rate of rectal endometriosis ranging from 0 to 4% (6).
In conclusion, the results are encouraging, as 3 out of 4 women who undergo surgery for endometriosis will not require repeat surgery within 10 years of their first operation. Performing a hysterectomy at the time of the initial endometriosis surgery should be seriously considered in women who do not wish to have further children, as it appears to significantly reduce the risk of repeat surgery.
References:
- Roman H, Chanavaz-Lacheray I, Hennetier C, Tuech JJ, Dennis T, Verspyck E, Merlot B. Long-term risk of repeated surgeries in women managed for endometriosis: a 1,092 patient-series. Fertil Steril. 2023 Oct;120(4):870-879. doi: 10.1016/j.fertnstert.2023.05.156.
- Netter A, d’Avout-Fourdinier P, Agostini A, Chanavaz-Lacheray I, Lampika M, Farella M, et al. Progression of deep infiltrating rectosigmoid endometriotic nodules. Hum Reprod 2019;34:2144–52.
- Roman H, Huet E, Bridoux V, Khalil H, Hennetier C, Bubenheim M, et al. Long-term outcomes following surgical management of rectal endometriosis: seven-year follow-up of patients enrolled in a randomized trial. J Minim Invasive Gynecol 2022;29:767–75.
- Bougie O, McClintock C, Pudwell J, Brogly SB, Velez MP. Long-term followup of endometriosis surgery in Ontario: a population-based cohort study. Am J Obstet Gynecol 2021;225:270.e1–19.
- Bafort C, Tawfic NM, Meuleman C, Laenen A, Timmerman D, Van Schoubroeck D, et al. Similar long-term recurrence rates with cystectomy and CO2 laser vaporization for endometrioma: a retrospective study. Reprod Biomed Online 2022;45:101–8.
- Mabrouk M, Raimondo D, Altieri M, Arena A, Del Forno S, Moro E, et al. Surgical, clinical, and functional outcomes in patients with rectosigmoid endometriosis in the gray zone: 13-year long-term follow-up. J Minim Invasive Gynecol 2019;26:1110–6.