Outcomes Following Surgery As the Main Intervention for Endometriosis in a Low Socioeconomic Setting

Background and Objective: To evaluate the perioperative and long-term outcomes of surgical management of patients with endometriosis at a community hospital in a low socioeconomic district.

A total of 39 patients underwent surgical management for endometriosis between October 2022 and November 2024. Thirty-six patients were followed up for 1–24 months.

Among the 39 cases, 18 (42.6%) were identified incidentally in operations for other indications, while 21 (53.8%) were clinically diagnosed or confirmed with previous laparoscopy. Twelve (30.8%) cases were classified as stage I–II and 27 (69.2%) as stage III–IV. Surgical approaches included laparoscopy in 23 (59.0%) cases, robotic assistance in 13 (33.3%), and 2 cases were converted from laparoscopy to laparotomy. Advanced techniques utilized included ureterolysis, enterolysis, diaphragm resection, bowel shaving, bowel disc resection, segmental bowel resection, appendectomy, partial bladder cystectomy, and hypogastric nerve sparing. Intraoperative complications included 1 ureteral thermal injury and 1 bladder laceration. Postoperative complications consisted of 1 pyelonephritis and 1 incisional cellulitis. No complications related to urinary or bowel functional disorders occurred postoperatively. Among the 19 patients who regularly used pain medication before surgery, 16 patients discontinued pain medications, while 3 patients reduced their usage after surgery. Eight patients are actively trying to conceive, and 1 patient conceived spontaneously. Sixteen patients are receiving various forms of hormonal suppression.

With excellent skills and collaboration, the surgical management of endometriosis resulted in minimal complications and optimal postoperative outcomes, significantly benefiting patients in low socioeconomic areas.

Complications, Endometriosis, Socioeconomic, Surgery

Endometriosis is a devastating disease that affects about 10% of females of reproductive age.1 Although it is a systemic inflammatory disease, its main symptoms include heavy menstrual bleeding, dysmenorrhea, dyspareunia, and infertility. Patients may also experience bowel and bladder dysfunction, such as constipation, diarrhea, urinary frequency, urgency, and nocturia. Advanced endometriosis can spread to other organs or tissues, such as the pelvic nerve, bladder, bowel, or diaphragm, causing symptoms like back pain, leg pain, dysuria, hematuria, dyschezia, hematochezia, and chest pain, as well as catamenial pneumothorax or hemopneumothorax.2,3 The definitive diagnosis of endometriosis is established through diagnostic laparoscopy, which makes the clinical diagnosis challenging. On average, there is a delay of 7–8 years in diagnosing endometriosis for most patients.4 Fortunately, more individuals are becoming aware of this disease due to social media and public education efforts by endometriosis experts, including the Nezhat family’s EndoMarch.5 Despite advancements in awareness, the shortage of endometriosis specialists results in minimal improvement in the delays associated with diagnosing the condition. The treatment of endometriosis is prioritized based on symptoms of pain, infertility, or both. Nevertheless, it generally requires a multidisciplinary and multimodal approach. Managing pelvic pain may involve pain medication, physical therapy, trigger point injections, psychotherapy, cognitive therapy, sexual therapy, and surgery. For infertility, assisted reproductive technology (ART) and surgery are the most common recommendations.4 Surgical diagnosis and intervention are considered the major treatment for endometriosis with pelvic pain and/or infertility, according to the recommendation from 5 main international societies in the field of endometriosis, reproductive medicine, and gynecology worldwide, including the European Society of Human Reproduction and Embryology (ESHRE), American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Society of Obstetricians and Gynaecologists of Canada (SOGC), and Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO).6 However, the surgery management of deep infiltrating endometriosis is extremely challenging, demanding exceptional surgical skills. A multidisciplinary team is encouraged per the recommendation from ACOG, SOGC, and FEBRASGO.6 According to Dr. Horace Roman’s report on discoid bowel resection involving 492 patients, 59 patients (12%) experienced Clavien-Dindo grade III–IV complications, including rectal fistula, pelvic abscess, ureteral fistula, long-term self-catheterization, and ICU admission.7 In their experience with low rectal resection (less than 7 cm), 27 out of 211 (12.8%) patients had Clavien-Dindo grade III–IV complications, including rectovaginal fistula, ureteral fistula, rectal stenosis, ureteral stenosis, and pelvic abscess.8 Due to the significant challenges of endometriosis treatment and the limited availability of specialists, only a handful of endometriosis centers have been established at prestigious academic institutions. Moreover, some renowned endometriosis experts run private practices, which makes them largely inaccessible to patients from low socioeconomic backgrounds. However, these patients not only often suffer from advanced disease but also encounter other disadvantages, such as language barriers, limited education, a lack of income, minimal family and social support, and difficulties in accessing medical care. To support this patient group, physicians should adhere to consensus recommendations and implement various strategies to provide the best possible care. As a result, surgical intervention may be the main approach to treat endometriosis in this patient population. In this serial case study, we share our experience with endometriosis treatment in a community hospital in a low socioeconomic district.

An Institutional Review Board (IRB) approval was obtained, and a retrospective case series study was conducted at a community hospital in a socioeconomically disadvantaged area. Between October 2022 and November 2024, 39 patients diagnosed with endometriosis underwent surgical treatment. The follow-up period ranged from 1–24 months. The primary outcomes primarily focus on perioperative complications during the 1-month period. The secondary outcomes include decreases in pain medication usage related to pelvic pain and conception results for infertility. The study included patients who underwent surgical intervention for suspected or confirmed endometriosis during the study period. Data were collected retrospectively from medical records, encompassing patient demographics, clinical presentation, surgical findings, procedural details, intraoperative and postoperative complications, and follow-up outcomes. The inclusion criteria are all patients who underwent surgical treatment for endometriosis and were followed for at least 6 months after surgery. The exclusion criteria included: (1) Loss to follow-up for more than 6 months. (2) Undergoing another endometriosis surgery or other pelvic surgeries within 1 year. An experienced gynecological surgeon performed all surgeries, with general surgeons assisting in cases requiring bowel resection. Surgical techniques employed included laparoscopy, robotic-assisted laparoscopy, and laparotomy when conversion was necessary. Depending on intraoperative findings, advanced procedures such as ureterolysis, enterolysis, diaphragm resection, bowel shaving, bowel disc resection, segmental bowel resection, appendectomy, partial bladder cystectomy, and hypogastric nerve sparing were utilized. Endometriosis staging followed the revised ASRM (rASRM) classification system, categorizing cases as stage I–II (mild to moderate) or stage III–IV (severe).

Patient Population and Characteristics A total of 39 patients received surgical management for endometriosis during the study period. The cohort's mean age was 37.48 ± 6.53 years, with a mean BMI of 30.61 ± 5.73. Most patients were of Hispanic ethnicity (76.9%), while 23.1% were Afro-Americans. Endometriosis was incidentally discovered in 18 patients (46.2%) during surgeries for other indications. Another 21 patients (53.8%) were operated on for the treatment of endometriosis with clinical suspicion of endometriosis or a definitive diagnosis of endometriosis after a previous laparoscopy. Among all patients, 9 (42.9%) complained of severe pelvic pain, 2 (9.5%) presented with infertility, and 10 (47.6%) reported both pain and infertility. According to the rASRM staging system, 12 patients (30.8%) were classified as having stage I–II disease, while the majority, 27 patients (69.2%), had stage III–IV disease (Table 1). Table 1. | Age (years) | 37.48 ± 6.53 | | BMI | 30.61 ± 5.73 | | Race | | | Hispanic | 30 (76.9%) | | Afro-American | 9 (23.1%) | | Incidental finding | | | Yes | 18 (46.2%) | | No | 21 (53.8%) | | Presentation of endometriosis | | | Pain | 9 (42.9%) | | Infertility | 2 (9.5%) | | Pain/infertility | 10 (47.6%) | | Stage | | | I–II | 12 (30.8%) | | III–IV | 27 (69.2%) | Intraoperative Outcomes The average operative time was 254.76 ± 108.79 minutes, with an estimated blood loss (EBL) of 172.64 ± 206.69 mL. Most cases were performed using laparoscopy (59.0%), followed by robotic-assisted surgery (33.3%). Conversion to laparotomy occurred in 5.1% of cases (n = 2), and 1 case (2.6%) was carried out entirely via laparotomy. Various advanced surgical techniques were utilized, including ureterolysis in 64.1% (n = 25) of cases, enterolysis in 51.3% (n = 20), and nerve-sparing techniques in 59.0% (n = 23). Bowel surgeries included shaving in 23.1% (n = 9), discoid resection in 5.1% (n = 2), and segmental resection in 2.6% (n = 1). Additionally, appendectomy was performed in 7.7% (n = 3) of cases, partial cystectomy in 2.6% (n = 1), and diaphragm resection in 5.1% (n = 2) (Table 2). Table 2. | OR time (minutes) | 254.76 ± 108.79 | | EBL (mL) | 172.64 ± 206.69 | | Surgical mode | | | Laparoscopy | 23 (59.0%) | | Robot | 13 (33.3%) | | Converted to laparotomy | 2 (5.1%) | | Laparotomy | 1 (2.6%) | | Surgical techniques | | | Ureterolysis | 25 (64.1%) | | Enterolysis | 20 (51.3%) | | Nerve sparing | 23 (59.0%) | | Bowel surgery | | | Shaving | 9 (23.1%) | | Discoid resection | 2 (5.1%) | | Appendectomy | 3 (7.7%) | | Segmental resection | 1 (2.6%) | | Partial cystectomy | 1 (2.6%) | | Diaphragm | 2 (5.1%) | Postoperative Outcomes Patients were monitored for a period ranging from 1–24 months. Three patients were lost to follow-up after 6 months, and 36 patients were followed for up to 2 years. No urinary or bowel dysfunction was reported during the postoperative period. Among the 19 patients who used pain medications preoperatively, 84.2% (n = 16) were able to discontinue them altogether, while 15.8% (n = 3) reduced their usage after surgery. Regarding fertility outcomes, 8 patients are actively attempting to conceive, and 1 patient successfully conceived spontaneously. Additionally, 16 patients were placed on hormonal therapy as part of their postoperative management, and all patients were persistent in using the hormonal therapy (Table 3). Table 3. | Follow-up (months) | 1–24 | | Dysfunction | | | Urinary | 0 | | Bowel | 0 | | Pain medications | | | Off | 16/19 (84.2%) | | On | 3/19 (15.8%) | | Conceiving | 8 | | Conceived | 1 | | Hormonal therapy | 16 | Complications Intraoperative complications were observed in 3 patients (8.1%), which included 1 case of ureteral thermal injury, 1 bladder laceration, and another case that required a blood transfusion with an EBL of 1,200 ml. Postoperatively, 3 patients (8.1%) experienced complications, including 1 case of pyelonephritis, 1 case of superficial cellulitis, and another case that required a blood transfusion due to symptomatic anemia, with hemoglobin decreasing from 11.3 g/dL before surgery to 7.6 g/dL after surgery (Table 4). Table 4. | Intraoperative | | | Ureteral injury | 1 | | Bladder laceration | 1 | | Blood transfusion | 1 | | Total | 3 (8.1%) | | Postoperative | | | Pyelonephritis | 1 | | Superficial cellulitis | 1 | | Blood transfusion | 1 | | Total | 3 (8.1%) |

Challenging as it is to treat endometriosis, the patient population in community hospital settings of low socioeconomic areas presents several unique features and obstacles in treating endometriosis. Incidental Finding of Endometriosis As we are not an endometriosis center, most referrals come from primary providers within the institute or from satellite clinics for presumed symptomatic uterine fibroids presenting with heavy bleeding or pelvic pain. Unless imaging indicates an endometrioma or significant pelvic nodules, the diagnosis of endometriosis can only be confirmed during surgery. Consequently, the incidental diagnosis of endometriosis in our study was as high as 42.6%. It has been reported that the incidental finding of endometriosis during surgeries for uterine fibroids was 21.2%.9 Another study reported an even higher chance of incidental findings of endometriosis at about 87% in surgeries for patients with symptomatic uterine fibroids.10 Several reasons contribute to this phenomenon. Firstly, the occurrence of uterine fibroids is very common, with an estimated cumulative incidence of up to 70% in white women and approaching 80% in black women during the premenopausal years. About 15 to 30% of these patients are symptomatic.11 Secondly, both endometriosis and uterine fibroids share many common symptoms, such as heavy menstrual bleeding, dysmenorrhea, dyspareunia, and infertility, which makes it very difficult to differentiate between the 2 conditions clinically.10 Thirdly, imaging studies for uterine fibroids are highly sensitive and confirmative, leading to a predominant diagnosis of uterine fibroids, while the preoperative suspicion of endometriosis may be overlooked. Lastly, both uterine fibroids and endometriosis are female hormone-dependent diseases, which may predispose women to both conditions.9 Given the high potential complications related to endometriosis surgery, we generally counsel patients about the possibility of occult endometriosis during preoperative clinic visits. We also exercise greater caution regarding bowel endometriosis surgery in this context due to the absence of bowel preparation. Two cases were aborted during the first scheduled surgery, and 1 case required reoperation after thorough counseling and bowel prep. Another case is currently undergoing hormonal treatment. Advanced Endometriosis Disease Due to the challenges that patients face in accessing medical care and the shortage of endometriosis specialists, most patients present with advanced endometriosis in our patient population. Sixty-nine percent of our patients were at stage III or stage IV when they underwent surgery. Consequently, advanced surgical procedures were performed on these individuals. For example, 64.1% of patients underwent ureterolysis, 51.3% underwent enterolysis, and 59.0% underwent nerve-sparing dissection. There is no doubt that those procedures carry a significant risk of complications. Therefore, the surgeon’s expertise is essential in these types of surgeries. Not only must the surgeon be proficient in pelvic structure dissection, but they should also be adept at minor procedures on the bladder or bowel, such as laceration repair. Training endometriosis surgeons is urgent and ethically necessary. By increasing the number of skilled endometriosis surgeons, we can expand access to specialized care beyond the limits of large medical institutions, thereby addressing inequities in medical resources. Patient Education All the patients are Hispanic (76.9%) or Afro-American (23.1%), most of whom are non-English speakers. Although awareness of endometriosis grows in general populations, most patients still lack an educational background in understanding endometriosis or surgery.5 The communication barrier is another critical issue in patient care. Although using professional interpreters may improve disclosure in patient-provider communication and enhance patient satisfaction, there is insufficient data to demonstrate improved quality of care.12 Therefore, educating patients can be challenging. Conversely, patient education is essential for this population, as they are often misinformed or uninformed. We typically counsel patients and their families 2–3 times before performing surgeries. Forging the Endometriosis Team The management of endometriosis is primarily led by gynecology, but it is not the sole task of this specialty.4,6 Despite the limited support and resources in a community hospital setting within a low socioeconomic area, collaboration with physical therapy, infertility specialists, and other surgical fields, such as general surgery and urology, continues striving for the best possible outcomes. Education on endometriosis to other specialties is crucial when performing extensive bowel, bladder, or diaphragm surgeries, so the collaborative efforts will yield successful outcomes. For instance, we shared our experience of discoid resection using an EEA stapler (Medtronic, Minneapolis, MN) with general surgeons, which resulted in 2 successful discoid resections. Through close collaboration with urology, we addressed complications related to the ureter caused by thermal injury and ureteral stenosis successfully. Surgical Treatment of Endometriosis It is well-recognized that pelvic floor physical therapy and trigger point injections are effective nonsurgical approaches to treating chronic pelvic pain related to endometriosis.4 However, these centers are typically located in areas with higher socioeconomic status and often do not accept Medicaid or Medicare. Psychotherapy and cognitive therapy generally require regular and multiple office visits, making it challenging for this patient population to keep their appointments. Without proper treatment, many patients end up making frequent ER visits or seeking illicit drugs. Surgery is not a definitive cure for endometriosis; however, after the debulking of endometriosis lesions and continued hormonal suppression, most of our patients either stop or reduce their use of pain medication (84.2%). When they experience significant pain improvement after surgery, they also tend to maintain hormonal suppression. The substantial improvement in pain management within our patient population greatly helps decrease emergency department visits or the solicitation of illegal drugs. There is substantial evidence demonstrating the critical role of surgical intervention in treating endometriosis-related dysmenorrhea, dyspareunia, and chronic pelvic pain, especially for deep infiltrating endometriosis.4,6,7 Generally, ART is recommended as the first-line treatment for infertility associated with endometriosis.13 However, due to high costs, ART is not a possible option for most of our patient population. Therefore, surgical intervention might be their only choice to achieve conception. Two randomized clinical trials support surgical treatment for infertility in patients with stage I or II endometriosis.14 The benefits of surgery for advanced endometriosis are controversial.15 Still, some studies suggest that surgery performed by experts on stage III or IV endometriosis may enhance the chances of spontaneous pregnancy.16 Some studies also indicated that endometriosis surgery may also benefit patients who have failed more than 2 cycles of in vitro fertilization (IVF).17,18 Based on currently available data, we recommend surgical management to most of our infertility patients, provided they clearly understand the risks associated with surgery. In our study, 8 patients are attempting conception, and 1 patient became pregnant spontaneously 3 months after surgery. However, our sample size in this study was too small to demonstrate the actual benefit of surgery on fertility. A further collection of patients on this issue is needed. Another issue is the cost-effectiveness of surgical treatment for endometriosis. Unfortunately, studies in this area are limited and inconclusive. It is estimated that the annual social burden of endometriosis exceeds $49 billion in the United States.4 A recent systematic review illustrated that the major contributing factors to the cost of endometriosis include long-term healthcare, delayed diagnosis, and lack of efficient treatment. The direct costs primarily come from surgery, which ranges from $459–$20,239 per patient per year. However, the indirect costs associated with work loss, disability, and reduced productivity are also significant, ranging from $4,572–$14,079 per patient per year.19 A cost-effective model for treating dysmenorrhea associated with endometriosis showed that proceeding directly to surgery is the least cost-effective approach. A trial of hormonal management after NSAIDs before surgery may yield cost savings. However, delaying surgical management for individuals with pain unresponsive to more than 3 medications could decrease quality of life and increase costs.20 Given the substantial indirect costs associated with endometriosis, surgical intervention following unsuccessful medication may reduce the long-term health burden. More research on this subject is urgently needed. The primary goal in treating endometriosis is to alleviate the patient’s pain symptoms or enhance the possibility of fertility, therefore improving the quality of life. Adding more complications by surgery is a devastating consequence to those patients. Minimizing surgical complications is essential for all patients, but it is especially critical for our patient population due to their disadvantaged socioeconomic status. The most common sites of deep infiltrating endometriosis are the uterosacral ligaments and the parametrium. The hypogastric nerve complex, which affects bladder and bowel function, vaginal moisture, and sexual arousal, runs alongside the uterosacral ligament.21 Nerve-sparing dissection is the fundamental technique in the surgery for advanced endometriosis to minimize bladder, bowel, or sexual dysfunctions.8,22 We applied nerve-sparing surgery to every patient as needed, and as a result, none of our patients experienced complications related to bladder or bowel function. There was 1 case of ureteral thermal injury caused by the incidental activation of monopolar scissors while it was used to retract the ureter. A stent was placed, and the affected area was oversutured with 4-0 Vicryl. Unfortunately, ureteral stenosis developed after the removal of the stent. A dilation procedure was performed, followed by another 4-week stenting. Ultimately, the stenosis was resolved. Additionally, there was a complication of bladder laceration during surgery. The laceration was repaired in 2 layers using 0 Vicryl suture. The Foley catheter was removed after 10 days, and the bladder healed well. Overall, our experience indicated that surgical management of endometriosis-related pelvic pain or infertility may be the primary intervention for patients in low socioeconomic areas due to limited access to nonsurgical treatments. Therefore, the availability of endometriosis specialists, especially endometriosis surgeons, is especially needed in low socioeconomic communities. Advanced surgical skills are critical in achieving the best outcomes and minimizing potential patient complications. Footnotes Conflict of interests: none. Funding sources: none. Disclosure: none. Contributor Information Salma Moustafa, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Moustafa, Uzianbaeva, Kumari, Pylypiv, Mehdizadeh, and Wang). Liaisan Uzianbaeva, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Moustafa, Uzianbaeva, Kumari, Pylypiv, Mehdizadeh, and Wang). Swati Kumari, Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Moustafa, Uzianbaeva, Kumari, Pylypiv, Mehdizadeh, and Wang). Oksana Pylypiv, Department of Obstetrics & Gynecology and Reproductive Science, the Icahn School of Medicine at Mt Sinai, New York, NY. (Drs. Pylypiv, Mehdizadeh, and Wang); Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Moustafa, Uzianbaeva, Kumari, Pylypiv, Mehdizadeh, and Wang). Alireza Mehdizadeh, Department of Obstetrics & Gynecology and Reproductive Science, the Icahn School of Medicine at Mt Sinai, New York, NY. (Drs. Pylypiv, Mehdizadeh, and Wang); Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Moustafa, Uzianbaeva, Kumari, Pylypiv, Mehdizadeh, and Wang). Daniel T. Farkas, Department of General Surgery, BronxCare Health system, Bronx, NY. (Dr. Farkas). Pengfei Wang, Department of Obstetrics & Gynecology and Reproductive Science, the Icahn School of Medicine at Mt Sinai, New York, NY. (Drs. Pylypiv, Mehdizadeh, and Wang); Department of Obstetrics and Gynecology, BronxCare Health System, Bronx, NY. (Drs. Moustafa, Uzianbaeva, Kumari, Pylypiv, Mehdizadeh, and Wang).

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