Clinical outcomes following surgical management of deep infiltrating endometriosis: a retrospective cohort study

Clinical outcomes following surgical management of deep infiltrating endometriosis: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Clinical outcomes following surgical management of deep infiltrating endometriosis: a retrospective cohort study Perrine LEBORNE, Stephanie HUBERLANT, Florent MASIA, Renaud DE TAYRAC, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1821397/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Objectives: The main aim of the study was to evaluate severe post-operative complications following deep endometriosis surgery in a tertiary referral centre. Methods: This is a retrospective cohort study that included women who had surgery for deep infiltrating endometriosis between 1 st January 2013 and 31st December 2019. Endometriosis was diagnosed based on clinical, imaging and histological parameters. We evaluated the rates of post-operative complications, potential risk factors for such complications and postoperative pregnancy rates. Results: A total of 165 patients were included in the final analysis. The median follow-up was 63 (25 - 106) months. Thirty-seven patients (22.42%) had hysterectomy, 60 (36.81%) had ureterolysis and 44 (26.67%) had colorectal surgery. The overall and severe rates of post-operative complications were 16.20% (n=23) and 2.42% (n=4) respectively. Of the variables assessed, operative time and age were the only statistically significant risk factor for complications on multivariate analysis. Among the women operated on for infertility, 34.5% (n=20/58) got pregnant following surgery with 30% of these spontaneously. Conclusions: This study demonstrates acceptable overall and severe post-operative complications and pregnancy rates after deep endometriosis surgery. This information should help clinicians when counselling women to enable them make an informed choice about their management. Figures Figure 1 Introduction Endometriosis is defined as the presence of endometrial cells outside of the uterine cavity. There is wide variation in the reported prevalence of endometriosis. According to the French National Authority for Health (HAS) the prevalence varies between 2 and 74% in women suffering from chronic pelvic pain and it exceeds 33% in women presenting with acute pelvic pain. 1 The clinical presentation and impact of the disease are also variable and do not correlate to the extent of the endometriotic lesions. 2 Surgical treatment is a management option when considering the woman’s symptoms, desire for pregnancy, age, severity of the condition and its site. 1 However, endometriosis surgery often entails a complex procedure necessitating extensive adhesiolysis with associated urological or gastrointestinal interventions. Studies that evaluated prognostic factors for operative complications in relation to endometriosis surgery suggest that it is associated with the depth of endometriotic lesions within the tissues, presence of recto-vaginal involvement, the patient’s age and previous surgical history. 3 4 It has been reported that the rate of major and minor complications following surgery for deep infiltrating endometriosis is around 3–4% and 10–15% respectively. The most commonly reported major complications are bowel related fistulae, particularly in patients with rectal or sigmoid colon involvement. Moreover, it is reported that 5–16% of women suffer with voiding dysfunction after such surgery. 5 4 3 6 7 8 9 In view of these complications and the complexity of surgery for endometriosis, the French National Authority for Health recommends a multidisciplinary and specialised approach. 1 These recommendations were further supported by the findings of a pilot expert centre study, which demonstrated improved clinical, patient reported and surgical outcomes. It also highlighted the potential research benefits of this centralised care. 10 These encouraging results were followed by the creation of several endometriosis expert centres for diagnostic, clinical care and applied research purposes. 10 Further support to these recommendations came from the reporting of the initial results of these centres in a study that involved more than 490 patients, which revealed low complications rates for deep endometriosis surgery. 5 Nevertheless, severe cases of endometriosis were overrepresented in this study limiting the generalizability of its findings. The French National Authority for Health and the French National college of gynaecologists and obstetricians (CNGOF) recommend that each endometriosis care centre would regularly report its endometriosis-related surgical outcomes and complications. 11 The main aim of this study was to review and report the surgical complications rates following surgery for deep infiltrating endometriosis in our university affiliated hospital. We also wanted to explore potential risk factors for such complications and postoperative pregnancy rates. Materials And Methods This was a retrospective cohort study conducted in a tertiary referral university affiliated hospital. All experimental protocols were approved by the Institutional Review Board (IRB) n° 21.06.03. We identified the study cohort by screening our electronic patient medical information system (PMSI) for patients undergoing surgery related to endometriosis. We used clinical codes corresponding to uterine, ovarian, Fallopian tube, pelvic peritoneum, vaginal, recto vaginal wall, bowel and cutaneous scar endometriosis between January 2013 and December 2019. Informed consent was obtained from all subjects prior to any surgical intervention. In our unit, the diagnosis of endometriosis is based on clinical symptoms (dysmenorrhea, dyspareunia or both), clinical examination and imaging involving MRI and / or ultrasound scans. MRI diagnosis depends on signal and morphologic abnormalities in line with previously published studies. Signal abnormalities are defined as hyperintense foci that correspond to hemorrhagic areas on T1-weighted MR images or small hyper intense cavities on T2-weighted MR images. 12 13 If rectal or sigmoid colon involvement is suspected, a colonoscopy combined with ultrasonography is performed to assess for the degree of gastrointestinal involvement complying with CNGOF recommendations. 14 If involvement of the anterior compartment was suspected, patients are often referred for cystoscopy to confirm or refute transmural bladder involvement. A pre or post-operative double J catheter is occasionally used if ureteric involvement is suspected. Women are considered for surgical excision of endometriosis if medical management failed to control their pain or to improve their fertility outcomes. The preferred surgical route is laparoscopic with the possibility of conversion to laparotomy in case of technical difficulties. During the study period, the surgical procedures were performed by one of 5 different surgeons in association with a colorectal surgeon or a urologist in case of gastrointestinal or urinary tract involvement respectively. All women were routinely given a post-operative follow-up appointment 6 weeks after surgery. Any excised tissue was sent for histological assessment. Only women with a confirmed histological diagnosis of endometriosis were included in our final analysis. All methods were carried out in accordance with relevant guidelines and regulations. Patients’ demographic, clinical, surgical and follow-up details were retrieved from their clinical hospital records. The primary endpoint of interest was the rate of severe post-operative complications. We used the Clavien Dindo classification 15 16 17 to report the different complications and any complications classed as stage III or more were considered “severe”. Our secondary endpoints included the overall complications rate, length of hospital stay and re-admission rates. We also collected data on live birth rate following surgery, for the subgroup of women who underwent surgery for subfertility reasons. Data are reported as the median and interquartile range (IQR), or number (n) and frequency, as appropriate. We used univariate analysis to identify potential risk factors for post-operative complications. All variables with a P < .2 and known risk factors based on previous studies (BMI and history of endometriosis surgery) were evaluated further using a multivariate logistic regression analysis. Results of this analysis are expressed as odds ratios (ORs) and 95% CI. A p value of < 0.05 was considered statistically significant. Statistical analysis was performed using R 2.9.2 (R Development Core Team (2009) R Foundation for Statistical Computing, Vienna, Austria). Results Study participants A total of 403 patients were identified from our initial screen of hospital electronic patient records. Of these, 126 women had surgery for, either another reason than endometriosis or had superficial endometriosis. The remaining 277 patients underwent surgery for endometriosis or adenomyosis. However, 112 women had no proof of the disease on histological examination or had adenomyosis without deep endometriosis leaving a total of 165 patients who fulfilled our inclusion criteria and contributed to the final analysis (Fig. 1 ). The demographic details of our study cohort are presented in Table 1 . Table 1 Demographic characteristics of the study population Variable Median (IQR) or n (%) Age 34,00 (11,00) BMI 23,00 (6,00) ASA score 1 114 (70,37%) Nulliparous 100 (61,35%) Parity = 1 34 (20,86%) Parity ≥ 2 29 (17,80%) History of endometriosis surgery 53 (31.93%) Number of previous surgery 0.00 (1.00) Dysmenorrhea 119 (72.56%) Dyspareunia 87 (53.37%) Pain when defecating 20 (12.20%) Operative details The main indications for surgery were pain, infertility and both pain and infertility in 99 (62%), 33 (21%) and 24 (15%) women respectively. Four patients (2%) had surgery for dysmenorrhea and heavy menstrual bleeding. The median operative time was 126 (IQR = 110.75) minutes and the median hospital stay was 3 (IQR = 3) days. Surgery was performed laparoscopically in 160 cases (96.97%); one of these was converted to laparotomy because of the need for ureteric implantation. Two patients had combined laparoscopic and vaginal procedures, one had robotic-assisted surgery and 2 had a laparotomy because of previous complex surgical histories. Hysterectomy was performed in 37 patients (22.42%), Bowel surgery was required in 44 cases (26.67%), of these 8 (4.58%) had segment resection, 2 (1.21%) had a discoid resection and 34 (20.61%) had bowel shaving of endometriotic deposits. Six patients (3.64%) had a temporary protective ileostomy following their resection anastomosis. Of these, 5 were performed immediately and one as a delayed procedure when the patient was re-operated on. Sixty patients (36.81%) had ureterolysis and 5 (3.03%) had vesical resection. All surgical procedures are presented in Table 2 . Table 2 Surgical procedures and pelvic structures involvement Variable Median (IQR) or n (%) Gynaecological structures involvement Excision of nodules on uterosacral ligament 48 (29,09%) Excision of nodules on the torus uterinum 22 (13.41%) Hysterectomy 37 (22.42%) Salpingectomy 58 (35.15%) Ovarian cystectomy 69 (41,82%) Urological involvement Ureterolysis 60 (36.81%) Ureteral reimplantation 3 (1.82%) Excision of nodules in vesico uterine space 10 (6.06%) Bladder resection 5 (3.03%) Bowel involvement Rectal surgery Segment resection Discoid resection Shaving 44 (26,67%) 8 (4.85%) 2 (1.21%) 34 (20.61%) Ileocaecal resection 1 (0.61%) Appendicectomy 4 (2.42%) Protective stoma 6 (3,64%) Outcomes of interest Our study cohort had a median follow-up duration of 63 (IQR = 81) months. Among the 165 patients operated on for deep invasive endometriosis, 20.6% (n = 34) had recurrence of their pain after a median time of 12 (IQR = 83) months from surgery. For which, a total of 23 women (13.9%) had to have an additional surgical procedure after a median period of 22 (IQR = 82) months from their initial surgery. Based on the Clavien Dindo classification, among the 165 patients, 2.42% (n = 4) had severe complications, where 3 (1.82%) women had grade IIIB and one (0.61%) had grade IVA complications. Two of these complications occurred at the beginning and 2 at the end of the study period. With regards to the IIIB complications, 2 patients had to be re-operated on following a hysterectomy, one had vaginal vault dehiscence and the other had excessive vaginal bleeding 15 days after her primary surgery. The third patient presented with fever and investigations suggesting acute inflammation 5 days after bilateral ureterolysis and rectal shaving of endometriotic nodules. The patient was diagnosed with a ureteric fistula. The fistula healed spontaneously after the insertion of a left ureteral stent. The patient presenting with a grade IVA complication had a hysterectomy with right adnexectomy and recto-sigmoid junction resection. She presented with an anastomotic fistula 3 days after surgery requiring a re-operation for peritoneal lavage, drainage and an ileostomy. Her postoperative recovery was complicated by a septic shock and renal dysfunction. The patient was discharged 44 days after her repeat surgery with fully recovered renal function. Four patients (2.42%) had to be re-admitted after a median period of 15 days (IQR = 20). Two of these were the grade IIIB complication patients described above. The third was re-admitted for suspected intestinal obstruction, which resolved spontaneously. While, the fourth patient was admitted for a cystography prior to removing her urinary catheter inserted for an intraoperative bladder injury. The overall rate of complications was 16.20% (n = 23). The most frequent complications were urinary tract infections (6.06%, n = 10) and unexplained fever (3.64%, n = 6). Pyelonephritis and an abdominal wall abscess occurred in 2 patients (1.21%) each. Post-operative voiding dysfunction occurred in 1.82% of cases (n = 3). Overall, the median time for onset of complications was within 6 (IQR: 11.75; range: 1–90) days post-operative. The full list of complications is presented in Table 3 . Table 3 Complications Variable Median (IQR) or n (%) Post-operative complication* 23 (16.20%) Clavien Dindo classification I Abdominal wall abscess Intestinal obstruction Voiding dysfunction 4 (2,42%) 2 (1,22%) 1 (0,61%) 3 (1,82%) II Unexplained fever Urinary tract infection Pyelonephritis 15 (9,09%) 6 (3,64%) 10 (6,06%) 2 (1,21%) III Vaginal vault dehiscence Ureteral fistula 3 (1,82%) 2 (1,21%) 1 (0,61%) IV Bowel anastomotic leakage 1 (0,61%) 1 (0,61%) * Some patients had more than one complication Among women operated on for infertility (n = 58), 34.5% (20/58) had successful pregnancies after surgery, of these, 70% and 30% had medically assisted and spontaneous conceptions respectively. The median duration from surgery to conception was 9 (IQR = 35) months. On univariate analysis, rectal surgery (OR 4.28 [1.98–9.25]; p < 0.001) and operative time (OR 1.01 [95% CI 1.01–1.02]; p < 0.001) were significantly associated with post-operative complications. However, on multivariate analysis, only the operative time remained significant (aOR 1.01 [95% CI 1.00–1.01]; p = 0.009). Additionally, age was also identified as an independent risk factor for post-operative complications (aOR 1.08 [1.02,1.14]; p = 0.005) (Table 4 ). Table 4 Logistic regression predicting post-operative complication: Univariate and multivariate analysis: Univariate analysis Multivariate analysis OR (95% CI) p value Adjusted OR (95%CI) p value Rectal surgery 4.28 (1.98–9.25) < 0.001 2.84 (0.89–9.12) 0.079 BMI 0.99 (0.93–1.05) 0.706 0.96 (0.89–1.04) 0.235 Age 1.04 (1.00–1.09) 0.077 1.08 (1.02–1.14) 0.005 Previous endometriosis surgery 1.19 (0.56–2.56) 0.65 0.83 (0.36–1.94) 0.665 Operative time 1.01 (1.01–1.02) < 0.001 1.01 (1.00–1.01) 0.009 Colpotomy 1.59 (0.17–14.63) 0.682 Discussion This study provides an overview of several clinical outcomes following surgical management of deep infiltrating endometriosis in a tertiary hospital in France. We report a rate of severe post-operative complications of 2.42% which is consistent with previous studies 7 9 8 . Our findings are also in agreement with other studies, which evaluated rates of complications and their risk factors in endometriosis surgery. 18 19 Lermann et al. 20 described a population of 134 patients who had surgical management for deep endometriosis and reported 3.7% and 12.7% rates of severe and minor complications respectively. These rates are comparable to our results, although, they excluded patients who required bowel resection. Of relevance, two of the patients in our study who presented with severe complications had extensive endometriosis involving their bowels requiring shaving or resection. The main complication after surgery in our study was urinary tract infection, which occurred in 6.06% of our cohort. Urinary tract infections might be explained by the fact that patients had a urinary catheter during and following surgery to mitigate the risk of post-operative voiding dysfunction. It has been shown that bacteriuria occurred more often with increased length of catheterisation. 21 However the risk of infection secondary to catheter insertion should be weighed against its benefits. Indeed, only 3 women included in our study had voiding dysfunction (1.82%) after surgery. In a comprehensive literature review, Campin et al. reported varying risk of post-operative voiding dysfunction ranging from 0.8 to 30%. 22 Furthermore, this rate has been more recently reported to be as high as 50% by others. 23 The rate of temporary protective ileostomy in our study was 3.64%, which is lower than previous reports. Indeed, in a national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015, Roman et al reported a protective stoma rate of 19%. 24 More recently, it was demonstrated that a protective stoma did not prevent the occurrence of a recto-vaginal fistula. 25 This is consistent with our results where our restrictive protective ileostomy policy was still associated with a low rate of serious complications. To reduce the rate of complications after colorectal procedures, conservative surgery, as rectal shaving and discoid excision, have been proposed. Roman et al., on behalf of the FRIENDS group, conducted a large national retrospective study including 1135 patients undergoing surgery for deep endometriosis of the rectum and colon. They showed significantly higher rate of recto-vaginal fistula following rectal resection compared to conservative treatment. 24 Findings from our centre also support this notion. Among the severe complications in our study, 2 occurred at the beginning and 2 at the end of our studied period. However, with advances in surgical techniques, specialisation and centralisation of care the number of women who had surgical management of endometriosis have increased over the years. In a large multicenter retrospective study, Bendifallah et al. 26 demonstrated that the rate of surgical complications when managing deep colorectal endometriosis was independently inversely linked to the annual number of procedures performed by centre and surgeon. In their study, the authors suggested that the optimal number of procedures required per surgeon per year to be between 7 and 13 operations. In our centre, the mean number of colorectal procedure performed per year was 7. It has been reported that the main surgical risk factors during deep endometriosis surgery are the opening of the vagina, a low colorectal anastomosis and resection of endometriosis in relation to the urinary bladder and ureters. 27 18 28 In our study, colpotomy was not identified as a risk factor for post-operative complications. Moreover, although rectal surgery was a significant factor on univariate analysis, it was not on multivariate analysis. However, it is possible that due to the small number of patients who had rectal surgery in our cohort, our study did not have enough power to demonstrate such association. Diabetes and obesity have been identified to be risk factors of wound and anastomosis healing 29 30 31 . The two patients with the most severe complications in our study did not have diabetes, but had body mass indices of 32 and 37. Nevertheless, body mass index (BMI) was not identified as a risk factor in our cohort, which could be because our study population were mostly not obese with a median BMI of 23 (IQR = 6). Operative time was identified as a risk factor for post-operative complications in our study. Arguably, complex surgical procedures with extensive adhesiolysis and bowel resections require longer operative time; nonetheless, this was demonstrated as an independent factor on multivariate analysis. Poupon et al. reported that the ENZIAN score is a good predictor of complications. 3 Other authors have studied the correlation between MRI and the ENZIAN score and showed good correlation between both. 32 33 We were not able to assess the predictive effect of this score on surgical complication rates in our patients because it was not used in our unit during the study period. This study has several strengths, which include the use of our comprehensive electronic patient record and clinical coding system to identify our study cohort minimising the risk of selection bias. Additionally, we mitigated the risk of contaminating our analysis by having clear and strict inclusion criteria. This has ensured that our findings are relevant to the group of women considered at higher risk for surgical management of their endometriosis. Therefore, we believe that our findings will help provide women with realistic information to enable them make an informed choice about their care. Finally, the use of an internationally recognised system to categorise post-operative complications adds to the external validity of our findings. However, we also recognise the limitations posed by the retrospective design of our study. Furthermore, the low rate of occurrence of severe complications could be perceived as a limitation. Nevertheless, our identified rates concur with other studies involving independent cohorts. In conclusion, the rate of severe post-operative complications after deep endometriosis surgery in a specialised centre is low. Our study demonstrated that operative time and age were independent risk factors for postoperative complications. This study adds evidence to the importance of multidisciplanrity and centralisation of care in the surgical management of deep infiltrating endometriosis. This information should help clinicians when counselling women to enable them make an informed choice about their management. Declarations ACKNOWLEDGMENT The authors would like to thank Superviseme ltd - medical writing services (http://www.superviseme.eu) for the help with the editing of the manuscript. AUTHOR CONTRIBUTIONS PL: conception of the study, data collection, manuscript writing SH: manuscript editing, protocol development FM: manuscript editing, protocol development RdT: manuscript editing, protocol development VL: conception of the study, manuscript editing LA: conception of the study, data analysis, manuscript writing, manuscript editing DATA AVAILABILITY The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The authors declare no competing interests. References Prise en charge de l’endométriose. Haute Autorité de Santé https://www.has-sante.fr/jcms/c_2819733/fr/prise-en-charge-de-l-endometriose . Nezhat, C., Vang, N., Tanaka, P. P. & Nezhat, C. Optimal Management of Endometriosis and Pain. Obstet. Gynecol. 134 , 834–839 (2019). Poupon, C. et al. Nomogram predicting the likelihood of complications after surgery for deep endometriosis without bowel involvement. Eur. J. Obstet. Gynecol. Reprod. Biol. 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Obesity-related immune responses and their impact on surgical outcomes. Int. J. Obes. 2005 39 , 877–883 (2015). Guo, S. & DiPietro, L. A. Factors Affecting Wound Healing. J. Dent. Res. 89 , 219–229 (2010). Paola, V. D. et al. Detection and localization of deep endometriosis by means of MRI and correlation with the ENZIAN score. Eur. J. Radiol. 84 , 568–574 (2015). Thomassin-Naggara, I. et al. Magnetic resonance imaging classification of deep pelvic endometriosis: Description and impact on surgical management. Hum. Reprod. Oxf. Engl. 35 , (2020). Carmona, F. et al. Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate? Fertil. Steril. 92 , 868–875 (2009). Vidal, F. et al. Spontaneous pregnancy rate following surgery for deep infiltrating endometriosis in infertile women: The impact of the learning curve. J. Gynecol. Obstet. Hum. Reprod. 50 , 101942 (2021). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 31 Oct, 2022 Reviews received at journal 27 Sep, 2022 Reviewers agreed at journal 27 Sep, 2022 Reviewers invited by journal 27 Sep, 2022 Editor assigned by journal 25 Sep, 2022 Editor invited by journal 08 Jul, 2022 Submission checks completed at journal 08 Jul, 2022 First submitted to journal 03 Jul, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1821397","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":119693244,"identity":"22bd79e2-06f9-4e09-af42-bcd802efe4fd","order_by":0,"name":"Perrine LEBORNE","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYLCCBCDmY+ABs+VAxIEHxGhhg2oxBmtJIMYmmJbEBpghuIA5e++zDw932DCwsfcefFy5wyZ9ftjhh0Bb7OR0G7Brsew5bjwj8UwaAxvPuWTDs2fScjfeTjMAakk2NjuAXYvBjTRmhsS2wwxsEjlmko1th3M3zk4AaTmQuA2XlvvPQFr+M7DJvwFp+Z9uODv9A34tN9hAWg4AbeEBaTmQIC+dg98Wyx6ww5J52Hjykg0b25INN0jnFBxIMMDtF3P2Y8yMP9vs5PjZzx582NhmJy8/O33zhw8VdnI4vQ+leRAiB5DF8WhBAPkG3KpHwSgYBaNgZAIA0ohahuBWrugAAAAASUVORK5CYII=","orcid":"","institution":"Centre Hospitalier Universitaire de Nîmes","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Perrine","middleName":"","lastName":"LEBORNE","suffix":""},{"id":119693245,"identity":"d053dd16-0d3d-49e2-a5b5-2a766b75b8b8","order_by":1,"name":"Stephanie HUBERLANT","email":"","orcid":"","institution":"Institut des Biomolécules Max Mousseron","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"HUBERLANT","suffix":""},{"id":119693246,"identity":"16e97441-73e6-47e4-965a-6137f6bec1c5","order_by":2,"name":"Florent MASIA","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Nîmes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Florent","middleName":"","lastName":"MASIA","suffix":""},{"id":119693247,"identity":"450da46e-f7ed-4ac2-8cc9-790868406848","order_by":3,"name":"Renaud DE TAYRAC","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Nîmes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Renaud","middleName":"","lastName":"DE TAYRAC","suffix":""},{"id":119693248,"identity":"fa0e0169-bbe0-48a0-8e46-388d8d210e37","order_by":4,"name":"Vincent LETOUZEY","email":"","orcid":"","institution":"Institut des Biomolécules Max Mousseron","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"LETOUZEY","suffix":""},{"id":119693249,"identity":"2ad8a83c-8758-4532-a7b5-46c14a413139","order_by":5,"name":"Lucie ALLEGRE","email":"","orcid":"","institution":"Centre Hospitalier Universitaire de Nîmes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lucie","middleName":"","lastName":"ALLEGRE","suffix":""}],"badges":[],"createdAt":"2022-07-03 19:14:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1821397/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1821397/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":23779411,"identity":"f10a8b2b-4311-458b-aad6-4cb738ec9b15","added_by":"auto","created_at":"2022-07-12 17:44:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12394,"visible":true,"origin":"","legend":"\u003cp\u003eFlow Chart of women screened and included into the study\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-1821397/v1/1615523f6d3ed33bbd520341.png"},{"id":23779412,"identity":"098a4568-7aa3-4715-a95b-b25a85da6b95","added_by":"auto","created_at":"2022-07-12 17:44:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322499,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1821397/v1/aad3ff26-c259-40a8-8519-6f903c9f66b2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical outcomes following surgical management of deep infiltrating endometriosis: a retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is defined as the presence of endometrial cells outside of the uterine cavity. There is wide variation in the reported prevalence of endometriosis. According to the French National Authority for Health (HAS) the prevalence varies between 2 and 74% in women suffering from chronic pelvic pain and it exceeds 33% in women presenting with acute pelvic pain.\u003csup\u003e1\u003c/sup\u003e The clinical presentation and impact of the disease are also variable and do not correlate to the extent of the endometriotic lesions.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSurgical treatment is a management option when considering the woman\u0026rsquo;s symptoms, desire for pregnancy, age, severity of the condition and its site.\u003csup\u003e1\u003c/sup\u003e However, endometriosis surgery often entails a complex procedure necessitating extensive adhesiolysis with associated urological or gastrointestinal interventions. Studies that evaluated prognostic factors for operative complications in relation to endometriosis surgery suggest that it is associated with the depth of endometriotic lesions within the tissues, presence of recto-vaginal involvement, the patient\u0026rsquo;s age and previous surgical history.\u003csup\u003e3 4\u003c/sup\u003e It has been reported that the rate of major and minor complications following surgery for deep infiltrating endometriosis is around 3\u0026ndash;4% and 10\u0026ndash;15% respectively. The most commonly reported major complications are bowel related fistulae, particularly in patients with rectal or sigmoid colon involvement. Moreover, it is reported that 5\u0026ndash;16% of women suffer with voiding dysfunction after such surgery.\u003csup\u003e5 4 3 6 7 8 9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn view of these complications and the complexity of surgery for endometriosis, the French National Authority for Health recommends a multidisciplinary and specialised approach.\u003csup\u003e1\u003c/sup\u003e These recommendations were further supported by the findings of a pilot expert centre study, which demonstrated improved clinical, patient reported and surgical outcomes. It also highlighted the potential research benefits of this centralised care.\u003csup\u003e10\u003c/sup\u003e These encouraging results were followed by the creation of several endometriosis expert centres for diagnostic, clinical care and applied research purposes.\u003csup\u003e10\u003c/sup\u003e Further support to these recommendations came from the reporting of the initial results of these centres in a study that involved more than 490 patients, which revealed low complications rates for deep endometriosis surgery.\u003csup\u003e5\u003c/sup\u003e Nevertheless, severe cases of endometriosis were overrepresented in this study limiting the generalizability of its findings.\u003c/p\u003e \u003cp\u003eThe French National Authority for Health and the French National college of gynaecologists and obstetricians (CNGOF) recommend that each endometriosis care centre would regularly report its endometriosis-related surgical outcomes and complications.\u003csup\u003e11\u003c/sup\u003e The main aim of this study was to review and report the surgical complications rates following surgery for deep infiltrating endometriosis in our university affiliated hospital. We also wanted to explore potential risk factors for such complications and postoperative pregnancy rates.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThis was a retrospective cohort study conducted in a tertiary referral university affiliated hospital. All experimental protocols were approved by the Institutional Review Board (IRB) n\u0026deg; 21.06.03.\u003c/p\u003e \u003cp\u003eWe identified the study cohort by screening our electronic patient medical information system (PMSI) for patients undergoing surgery related to endometriosis. We used clinical codes corresponding to uterine, ovarian, Fallopian tube, pelvic peritoneum, vaginal, recto vaginal wall, bowel and cutaneous scar endometriosis between January 2013 and December 2019.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from all subjects prior to any surgical intervention.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eIn our unit, the diagnosis of endometriosis is based on clinical symptoms (dysmenorrhea, dyspareunia or both), clinical examination and imaging involving MRI and / or ultrasound scans. MRI diagnosis depends on signal and morphologic abnormalities in line with previously published studies. Signal abnormalities are defined as hyperintense foci that correspond to hemorrhagic areas on T1-weighted MR images or small hyper intense cavities on T2-weighted MR images.\u003csup\u003e12 13\u003c/sup\u003e If rectal or sigmoid colon involvement is suspected, a colonoscopy combined with ultrasonography is performed to assess for the degree of gastrointestinal involvement complying with CNGOF recommendations.\u003csup\u003e14\u003c/sup\u003e If involvement of the anterior compartment was suspected, patients are often referred for cystoscopy to confirm or refute transmural bladder involvement. A pre or post-operative double J catheter is occasionally used if ureteric involvement is suspected. Women are considered for surgical excision of endometriosis if medical management failed to control their pain or to improve their fertility outcomes. The preferred surgical route is laparoscopic with the possibility of conversion to laparotomy in case of technical difficulties.\u003c/p\u003e \u003cp\u003eDuring the study period, the surgical procedures were performed by one of 5 different surgeons in association with a colorectal surgeon or a urologist in case of gastrointestinal or urinary tract involvement respectively. All women were routinely given a post-operative follow-up appointment 6 weeks after surgery. Any excised tissue was sent for histological assessment. Only women with a confirmed histological diagnosis of endometriosis were included in our final analysis.\u003c/p\u003e \u003cp\u003e All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; demographic, clinical, surgical and follow-up details were retrieved from their clinical hospital records. The primary endpoint of interest was the rate of severe post-operative complications. We used the Clavien Dindo classification\u003csup\u003e15 16 17\u003c/sup\u003e to report the different complications and any complications classed as stage III or more were considered \u0026ldquo;severe\u0026rdquo;. Our secondary endpoints included the overall complications rate, length of hospital stay and re-admission rates. We also collected data on live birth rate following surgery, for the subgroup of women who underwent surgery for subfertility reasons.\u003c/p\u003e \u003cp\u003eData are reported as the median and interquartile range (IQR), or number (n) and frequency, as appropriate. We used univariate analysis to identify potential risk factors for post-operative complications. All variables with a P\u0026thinsp;\u0026lt;\u0026thinsp;.2 and known risk factors based on previous studies (BMI and history of endometriosis surgery) were evaluated further using a multivariate logistic regression analysis. Results of this analysis are expressed as odds ratios (ORs) and 95% CI. A \u003cem\u003ep\u003c/em\u003e value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analysis was performed using R 2.9.2 (R Development Core Team (2009) R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy participants\u003c/h2\u003e \u003cp\u003eA total of 403 patients were identified from our initial screen of hospital electronic patient records. Of these, 126 women had surgery for, either another reason than endometriosis or had superficial endometriosis. The remaining 277 patients underwent surgery for endometriosis or adenomyosis. However, 112 women had no proof of the disease on histological examination or had adenomyosis without deep endometriosis leaving a total of 165 patients who fulfilled our inclusion criteria and contributed to the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe demographic details of our study cohort are presented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMedian (IQR) or n (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e34,00 (11,00)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e23,00 (6,00)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eASA score 1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e114 (70,37%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNulliparous\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e100 (61,35%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eParity\u0026nbsp;= 1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e34 (20,86%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eParity \u0026ge; 2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e29 (17,80%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHistory of endometriosis surgery\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e53 (31.93%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNumber of previous surgery\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e0.00 (1.00)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDysmenorrhea\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e119 (72.56%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDyspareunia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e87 (53.37%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePain when defecating\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e20 (12.20%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOperative details\u003c/h2\u003e \u003cp\u003eThe main indications for surgery were pain, infertility and both pain and infertility in 99 (62%), 33 (21%) and 24 (15%) women respectively. Four patients (2%) had surgery for dysmenorrhea and heavy menstrual bleeding. The median operative time was 126 (IQR\u0026thinsp;=\u0026thinsp;110.75) minutes and the median hospital stay was 3 (IQR\u0026thinsp;=\u0026thinsp;3) days. Surgery was performed laparoscopically in 160 cases (96.97%); one of these was converted to laparotomy because of the need for ureteric implantation. Two patients had combined laparoscopic and vaginal procedures, one had robotic-assisted surgery and 2 had a laparotomy because of previous complex surgical histories.\u003c/p\u003e \u003cp\u003eHysterectomy was performed in 37 patients (22.42%), Bowel surgery was required in 44 cases (26.67%), of these 8 (4.58%) had segment resection, 2 (1.21%) had a discoid resection and 34 (20.61%) had bowel shaving of endometriotic deposits. Six patients (3.64%) had a temporary protective ileostomy following their resection anastomosis. Of these, 5 were performed immediately and one as a delayed procedure when the patient was re-operated on. Sixty patients (36.81%) had ureterolysis and 5 (3.03%) had vesical resection. All surgical procedures are presented in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical procedures and pelvic structures involvement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR) or n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGynaecological structures involvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcision of nodules on uterosacral ligament\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (29,09%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcision of nodules on the torus uterinum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (13.41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (22.42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalpingectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (35.15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian cystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (41,82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUrological involvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreterolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (36.81%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUreteral reimplantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcision of nodules in vesico uterine space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.06%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.03%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBowel involvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectal surgery\u003c/p\u003e \u003cp\u003e\u003cem\u003eSegment resection\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eDiscoid resection\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eShaving\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (26,67%)\u003c/p\u003e \u003cp\u003e\u003cem\u003e8 (4.85%)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e2 (1.21%)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e34 (20.61%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleocaecal resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.61%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendicectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtective stoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3,64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes of interest\u003c/h2\u003e \u003cp\u003eOur study cohort had a median follow-up duration of 63 (IQR\u0026thinsp;=\u0026thinsp;81) months. Among the 165 patients operated on for deep invasive endometriosis, 20.6% (n\u0026thinsp;=\u0026thinsp;34) had recurrence of their pain after a median time of 12 (IQR\u0026thinsp;=\u0026thinsp;83) months from surgery. For which, a total of 23 women (13.9%) had to have an additional surgical procedure after a median period of 22 (IQR\u0026thinsp;=\u0026thinsp;82) months from their initial surgery.\u003c/p\u003e \u003cp\u003eBased on the Clavien Dindo classification, among the 165 patients, 2.42% (n\u0026thinsp;=\u0026thinsp;4) had severe complications, where 3 (1.82%) women had grade IIIB and one (0.61%) had grade IVA complications. Two of these complications occurred at the beginning and 2 at the end of the study period. With regards to the IIIB complications, 2 patients had to be re-operated on following a hysterectomy, one had vaginal vault dehiscence and the other had excessive vaginal bleeding 15 days after her primary surgery. The third patient presented with fever and investigations suggesting acute inflammation 5 days after bilateral ureterolysis and rectal shaving of endometriotic nodules. The patient was diagnosed with a ureteric fistula. The fistula healed spontaneously after the insertion of a left ureteral stent.\u003c/p\u003e \u003cp\u003eThe patient presenting with a grade IVA complication had a hysterectomy with right adnexectomy and recto-sigmoid junction resection. She presented with an anastomotic fistula 3 days after surgery requiring a re-operation for peritoneal lavage, drainage and an ileostomy. Her postoperative recovery was complicated by a septic shock and renal dysfunction. The patient was discharged 44 days after her repeat surgery with fully recovered renal function.\u003c/p\u003e \u003cp\u003eFour patients (2.42%) had to be re-admitted after a median period of 15 days (IQR\u0026thinsp;=\u0026thinsp;20). Two of these were the grade IIIB complication patients described above. The third was re-admitted for suspected intestinal obstruction, which resolved spontaneously. While, the fourth patient was admitted for a cystography prior to removing her urinary catheter inserted for an intraoperative bladder injury.\u003c/p\u003e \u003cp\u003eThe overall rate of complications was 16.20% (n\u0026thinsp;=\u0026thinsp;23). The most frequent complications were urinary tract infections (6.06%, n\u0026thinsp;=\u0026thinsp;10) and unexplained fever (3.64%, n\u0026thinsp;=\u0026thinsp;6). Pyelonephritis and an abdominal wall abscess occurred in 2 patients (1.21%) each. Post-operative voiding dysfunction occurred in 1.82% of cases (n\u0026thinsp;=\u0026thinsp;3). Overall, the median time for onset of complications was within 6 (IQR: 11.75; range: 1\u0026ndash;90) days post-operative. The full list of complications is presented in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR) or n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative complication*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (16.20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClavien Dindo classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eAbdominal wall abscess\u003c/p\u003e \u003cp\u003eIntestinal obstruction\u003c/p\u003e \u003cp\u003eVoiding dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2,42%)\u003c/p\u003e \u003cp\u003e2 (1,22%)\u003c/p\u003e \u003cp\u003e1 (0,61%)\u003c/p\u003e \u003cp\u003e3 (1,82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003cp\u003eUnexplained fever\u003c/p\u003e \u003cp\u003eUrinary tract infection\u003c/p\u003e \u003cp\u003ePyelonephritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (9,09%)\u003c/p\u003e \u003cp\u003e6 (3,64%)\u003c/p\u003e \u003cp\u003e10 (6,06%)\u003c/p\u003e \u003cp\u003e2 (1,21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003cp\u003eVaginal vault dehiscence\u003c/p\u003e \u003cp\u003eUreteral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1,82%)\u003c/p\u003e \u003cp\u003e2 (1,21%)\u003c/p\u003e \u003cp\u003e1 (0,61%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003cp\u003eBowel anastomotic leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,61%)\u003c/p\u003e \u003cp\u003e1 (0,61%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e* Some patients had more than one complication\u003c/h2\u003e \u003cp\u003eAmong women operated on for infertility (n\u0026thinsp;=\u0026thinsp;58), 34.5% (20/58) had successful pregnancies after surgery, of these, 70% and 30% had medically assisted and spontaneous conceptions respectively. The median duration from surgery to conception was 9 (IQR\u0026thinsp;=\u0026thinsp;35) months.\u003c/p\u003e \u003cp\u003eOn univariate analysis, rectal surgery (OR 4.28 [1.98\u0026ndash;9.25]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and operative time (OR 1.01 [95% CI 1.01\u0026ndash;1.02]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significantly associated with post-operative complications. However, on multivariate analysis, only the operative time remained significant (aOR 1.01 [95% CI 1.00\u0026ndash;1.01]; p\u0026thinsp;=\u0026thinsp;0.009). Additionally, age was also identified as an independent risk factor for post-operative complications (aOR 1.08 [1.02,1.14]; p\u0026thinsp;=\u0026thinsp;0.005) (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression predicting post-operative complication: Univariate and multivariate analysis:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003cp\u003e(1.98\u0026ndash;9.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.84\u003c/p\u003e \u003cp\u003e(0.89\u0026ndash;9.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003cp\u003e(0.93\u0026ndash;1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003cp\u003e(0.89\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003cp\u003e(1.00\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003cp\u003e(1.02\u0026ndash;1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious endometriosis surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003cp\u003e(0.56\u0026ndash;2.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003cp\u003e(0.36\u0026ndash;1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.665\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003cp\u003e(1.01\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003cp\u003e(1.00\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColpotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003cp\u003e(0.17\u0026ndash;14.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.682\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides an overview of several clinical outcomes following surgical management of deep infiltrating endometriosis in a tertiary hospital in France. We report a rate of severe post-operative complications of 2.42% which is consistent with previous studies\u003csup\u003e7 9 8\u003c/sup\u003e. Our findings are also in agreement with other studies, which evaluated rates of complications and their risk factors in endometriosis surgery. \u003csup\u003e18 19\u003c/sup\u003e Lermann et al.\u003csup\u003e20\u003c/sup\u003e described a population of 134 patients who had surgical management for deep endometriosis and reported 3.7% and 12.7% rates of severe and minor complications respectively. These rates are comparable to our results, although, they excluded patients who required bowel resection. Of relevance, two of the patients in our study who presented with severe complications had extensive endometriosis involving their bowels requiring shaving or resection.\u003c/p\u003e \u003cp\u003eThe main complication after surgery in our study was urinary tract infection, which occurred in 6.06% of our cohort. Urinary tract infections might be explained by the fact that patients had a urinary catheter during and following surgery to mitigate the risk of post-operative voiding dysfunction. It has been shown that bacteriuria occurred more often with increased length of catheterisation.\u003csup\u003e21\u003c/sup\u003e However the risk of infection secondary to catheter insertion should be weighed against its benefits. Indeed, only 3 women included in our study had voiding dysfunction (1.82%) after surgery. In a comprehensive literature review, Campin et al. reported varying risk of post-operative voiding dysfunction ranging from 0.8 to 30%.\u003csup\u003e22\u003c/sup\u003e Furthermore, this rate has been more recently reported to be as high as 50% by others.\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe rate of temporary protective ileostomy in our study was 3.64%, which is lower than previous reports. Indeed, in a national snapshot of the surgical management of deep infiltrating endometriosis of the rectum and colon in France in 2015, Roman et al reported a protective stoma rate of 19%.\u003csup\u003e24\u003c/sup\u003e More recently, it was demonstrated that a protective stoma did not prevent the occurrence of a recto-vaginal fistula.\u003csup\u003e25\u003c/sup\u003e This is consistent with our results where our restrictive protective ileostomy policy was still associated with a low rate of serious complications. To reduce the rate of complications after colorectal procedures, conservative surgery, as rectal shaving and discoid excision, have been proposed. Roman et al., on behalf of the FRIENDS group, conducted a large national retrospective study including 1135 patients undergoing surgery for deep endometriosis of the rectum and colon. They showed significantly higher rate of recto-vaginal fistula following rectal resection compared to conservative treatment.\u003csup\u003e24\u003c/sup\u003e Findings from our centre also support this notion.\u003c/p\u003e \u003cp\u003eAmong the severe complications in our study, 2 occurred at the beginning and 2 at the end of our studied period. However, with advances in surgical techniques, specialisation and centralisation of care the number of women who had surgical management of endometriosis have increased over the years. In a large multicenter retrospective study, Bendifallah et al.\u003csup\u003e26\u003c/sup\u003e demonstrated that the rate of surgical complications when managing deep colorectal endometriosis was independently inversely linked to the annual number of procedures performed by centre and surgeon. In their study, the authors suggested that the optimal number of procedures required per surgeon per year to be between 7 and 13 operations. In our centre, the mean number of colorectal procedure performed per year was 7.\u003c/p\u003e \u003cp\u003eIt has been reported that the main surgical risk factors during deep endometriosis surgery are the opening of the vagina, a low colorectal anastomosis and resection of endometriosis in relation to the urinary bladder and ureters.\u003csup\u003e27 18 28\u003c/sup\u003e In our study, colpotomy was not identified as a risk factor for post-operative complications. Moreover, although rectal surgery was a significant factor on univariate analysis, it was not on multivariate analysis. However, it is possible that due to the small number of patients who had rectal surgery in our cohort, our study did not have enough power to demonstrate such association. Diabetes and obesity have been identified to be risk factors of wound and anastomosis healing\u003csup\u003e29 30 31\u003c/sup\u003e. The two patients with the most severe complications in our study did not have diabetes, but had body mass indices of 32 and 37. Nevertheless, body mass index (BMI) was not identified as a risk factor in our cohort, which could be because our study population were mostly not obese with a median BMI of 23 (IQR\u0026thinsp;=\u0026thinsp;6).\u003c/p\u003e \u003cp\u003eOperative time was identified as a risk factor for post-operative complications in our study. Arguably, complex surgical procedures with extensive adhesiolysis and bowel resections require longer operative time; nonetheless, this was demonstrated as an independent factor on multivariate analysis. Poupon et al. reported that the ENZIAN score is a good predictor of complications.\u003csup\u003e3\u003c/sup\u003e Other authors have studied the correlation between MRI and the ENZIAN score and showed good correlation between both.\u003csup\u003e32 33\u003c/sup\u003e We were not able to assess the predictive effect of this score on surgical complication rates in our patients because it was not used in our unit during the study period.\u003c/p\u003e \u003cp\u003eThis study has several strengths, which include the use of our comprehensive electronic patient record and clinical coding system to identify our study cohort minimising the risk of selection bias. Additionally, we mitigated the risk of contaminating our analysis by having clear and strict inclusion criteria. This has ensured that our findings are relevant to the group of women considered at higher risk for surgical management of their endometriosis. Therefore, we believe that our findings will help provide women with realistic information to enable them make an informed choice about their care. Finally, the use of an internationally recognised system to categorise post-operative complications adds to the external validity of our findings. However, we also recognise the limitations posed by the retrospective design of our study. Furthermore, the low rate of occurrence of severe complications could be perceived as a limitation. Nevertheless, our identified rates concur with other studies involving independent cohorts.\u003c/p\u003e \u003cp\u003eIn conclusion, the rate of severe post-operative complications after deep endometriosis surgery in a specialised centre is low. Our study demonstrated that operative time and age were independent risk factors for postoperative complications. This study adds evidence to the importance of multidisciplanrity and centralisation of care in the surgical management of deep infiltrating endometriosis. This information should help clinicians when counselling women to enable them make an informed choice about their management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Superviseme ltd - medical writing services (http://www.superviseme.eu) for the help with the editing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePL: conception of the study, data collection, manuscript writing\u003c/p\u003e\n\u003cp\u003eSH: manuscript editing, protocol development\u003c/p\u003e\n\u003cp\u003eFM: manuscript editing, protocol development\u003c/p\u003e\n\u003cp\u003eRdT: manuscript editing, protocol development\u003c/p\u003e\n\u003cp\u003eVL: conception of the study, manuscript editing\u003c/p\u003e\n\u003cp\u003eLA: conception of the study, data analysis, manuscript writing, manuscript editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe authors declare no competing interests.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePrise en charge de l\u0026rsquo;endom\u0026eacute;triose. \u003cem\u003eHaute Autorit\u0026eacute; de Sant\u0026eacute;\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.has-sante.fr/jcms/c_2819733/fr/prise-en-charge-de-l-endometriose\u003c/span\u003e\u003cspan address=\"https://www.has-sante.fr/jcms/c_2819733/fr/prise-en-charge-de-l-endometriose\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNezhat, C., Vang, N., Tanaka, P. 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Radiol. \u003cb\u003e84\u003c/b\u003e, 568\u0026ndash;574 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomassin-Naggara, I. \u003cem\u003eet al.\u003c/em\u003e Magnetic resonance imaging classification of deep pelvic endometriosis: Description and impact on surgical management. Hum. Reprod. Oxf. Engl. \u003cb\u003e35\u003c/b\u003e, (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmona, F. \u003cem\u003eet al.\u003c/em\u003e Does the learning curve of conservative laparoscopic surgery in women with rectovaginal endometriosis impair the recurrence rate? Fertil. Steril. \u003cb\u003e92\u003c/b\u003e, 868\u0026ndash;875 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVidal, F. \u003cem\u003eet al.\u003c/em\u003e Spontaneous pregnancy rate following surgery for deep infiltrating endometriosis in infertile women: The impact of the learning curve. J. Gynecol. Obstet. Hum. Reprod. \u003cb\u003e50\u003c/b\u003e, 101942 (2021).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-1821397/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1821397/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjectives: The main aim of the study was to evaluate severe post-operative complications following deep endometriosis surgery in a tertiary referral centre.\u003c/p\u003e\u003cp\u003eMethods: This is a retrospective cohort study that included women who had surgery for deep infiltrating endometriosis between 1\u003csup\u003est\u003c/sup\u003e January 2013 and 31st December 2019. Endometriosis was diagnosed based on clinical, imaging and histological parameters. We evaluated the rates of post-operative complications, potential risk factors for such complications and postoperative pregnancy rates.\u003c/p\u003e\u003cp\u003eResults: A total of 165 patients were included in the final analysis. The median follow-up was 63 (25 - 106) months. Thirty-seven patients (22.42%) had hysterectomy, 60 (36.81%) had ureterolysis and 44 (26.67%) had colorectal surgery. The overall and severe rates of post-operative complications were 16.20% (n=23) and 2.42% (n=4) respectively. Of the variables assessed, operative time and age were the only statistically significant risk factor for complications on multivariate analysis. Among the women operated on for infertility, 34.5% (n=20/58) got pregnant following surgery with 30% of these spontaneously.\u003c/p\u003e\u003cp\u003eConclusions: This study demonstrates acceptable overall and severe post-operative complications and pregnancy rates after deep endometriosis surgery. This information should help clinicians when counselling women to enable them make an informed choice about their management.\u003c/p\u003e","manuscriptTitle":"Clinical outcomes following surgical management of deep infiltrating endometriosis: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-12 17:44:53","doi":"10.21203/rs.3.rs-1821397/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-10-31T07:27:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-27T09:04:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78a60429-df39-4ea2-9cff-d5fcf0b4d145","date":"2022-09-27T07:00:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-09-27T06:15:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-26T03:24:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-07-08T18:41:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-07-08T18:37:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2022-07-03T19:02:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2a19bb2-2571-4872-a9f6-9e8db3582915","owner":[],"postedDate":"July 12th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-12-05T06:59:32+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-12 17:44:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1821397","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1821397","identity":"rs-1821397","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}