Quality of life improves after endometriosis surgery independent of #ENZIAN classification: a multicenter cohort study

Endometriosis is a chronic inflammatory disease associated with substantial impairment of quality of life. Although the #ENZIAN classification enables detailed anatomical characterization of disease distribution, its relevance for predicting patient-reported outcomes after surgery remains uncertain. Clarifying this relationship is essential for patient counseling and outcome-oriented surgical decision making. This multicenter study, registered on ClinicalTrials.gov (NCT05624567), prospectively recruited consecutive women aged 18 to 50 years undergoing surgery for suspected endometriosis at certified endometriosis centers in Austria, Germany, and Switzerland. Only women with surgically and histopathologically confirmed endometriosis who completed the baseline Endometriosis Health Profile-30 (EHP-30) questionnaire were included in the final analysis. Disease localization was classified intraoperatively using the #ENZIAN and rASRM systems. Quality of life was assessed using the EHP-30 questionnaire preoperatively and at 6 and 12 months after surgery. Longitudinal changes and predictors of quality-of-life outcomes were analyzed using ordinal logistic regression models. A total of 627 women were included at baseline, with 430 and 325 completing 6- and 12-month follow-up, respectively. Surgical treatment was associated with a marked and clinically meaningful improvement in quality of life, with EHP-30 scores improving significantly within the first 6 months after surgery and remaining stable at 12 months. This improvement was observed consistently across all #ENZIAN compartments, including deep infiltrating and multifocal disease. Anatomical disease distribution and rASRM stage were not significantly associated with baseline quality-of-life or postoperative recovery trajectories. In contrast, baseline symptom burden and complete surgical resection emerged as the strongest predictors of early postoperative quality-of-life improvement. Surgical treatment of endometriosis was associated with substantial and sustained improvement in patient-reported quality of life, independent of anatomical disease distribution as classified by #ENZIAN. These findings suggest that meaningful postoperative benefit can be achieved across all disease localizations and underscore the importance of focusing on symptom severity and surgical completeness rather than anatomical staging alone. Incorporating patient-reported outcome measures alongside anatomical classification is essential for comprehensive evaluation of treatment success.