Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy

Purpose Total laparoscopic hysterectomy (TLH) in the case of endometriosis may be extremely challenging. Our aim has been to analyze perioperative details and complications of TLH in women with vs. women without endometriosis.

Consecutive women who underwent TLH for endometriosis (endometriosis group) were compared with consecutive patients who had TLH for other conditions (controls) in terms of perioperative outcomes. Patients in the endometriosis group were analyzed, according to the severity of the disease.

One-hundred and twelve women in the endometriosis group, 29 (25.9 %) with minimal–mild, and 83 (74.1 %) with moderate–severe stage disease (rAFS score), respectively, were compared with 572 controls. Conversion rate was 0.8 vs. 0.5 % (P = 0.51), and median operative time was 75 vs. 55 min (pxxx = x) in the endometriosis group vs. controls. Intraoperative complications were similar between groups (P = 0.56). Postoperative complications occurred in 10 (12.3 %) women in the endometriosis group vs. 12 (3.3 %) among the controls (P = 0.002). The severity of complications according to Clavien–Dindo classification system was higher in the endometriosis group (Clavien–Dindo >2: 7.5 vs. 1.9 %). The risk of organ lesions, urinary lesions, postoperative complications, and severe adverse events was significantly higher in women with moderate–severe endometriosis vs. controls. No differences between patients with minimal–mild endometriosis and controls were found. Conclusion(s) TLH in the case of endometriosis is associated with longer operative time and an almost fourfold increase in the risk and severity of complications compared with controls. In particular, the adjunctive risk of adverse events is specific for moderate/severe-stage disease but not for minimal/mild endometriosis. Similar content being viewed by others

Burney RO, Giudice LC (2012) Pathogenesis and pathophysiology of endometriosis. Fertil Steril 98:511–519. doi:10.1016/j.fertnstert.2012.06.029 Rana N, Braun DP, House R, Gebel H, Rotman C, Dmowski WP (1996) Basal and stimulated secretion of cytokines by peritoneal macrophages in women with endometriosis. Fertil Steril 65:925–930 Buck Louis GM, Hediger ML, Peterson CM, Croughan M, Sundaram R, Stanford J, ENDO Study Working Group et al (2011) Incidence of endometriosis by study population and diagnostic method: the ENDO study. Fertil Steril 96:360–365 Eskenazi B, Warner ML (1997) Epidemiology of endometriosis. Obstet Gynecol Clin North Am 24:235–258 Kitawaki J, Kado N, Ishihara H, Koshiba H, Kitaoka Y, Honjo H (2002) Endometriosis: the pathophysiology as an estrogen-dependent disease. J Steroid Biochem Mol Biol 83:149–155 Bulun SE, Cheng YH, Yin P, Imir G, Utsunomiya H, Attar E et al (2006) Progesterone resistance in endometriosis: link to failure to metabolize estradiol. Mol Cell Endocrinol 248:94–103 Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W, European Society of Human Reproduction and Embryology (2014) ESHRE guideline: management of women with endometriosis. Hum Reprod 29:400–412 Vercellini P, Barbara G, Somigliana E, Bianchi S, Abbiati A, Fedele L (2010) Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Fertil Steril 93:2150–2161 Vercellini P, Frontino G, De Giorgi O, Pietropaolo G, Pasin R, Crosignani PG (2003) Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril 80:560–563 Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J (2012) Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 98:564–571 De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P (2011) Bowel resection for deep endometriosis: a systematic review. BJOG 118:285–291 Jacobson TZ, Duffy JM, Barlow D, Farquhar C, Koninckx PR, Olive D (2010) Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev 1:CD001398. doi:10.1002/14651858.CD001398.pub2 Jacobson TZ, Duffy JM, Barlow D, Koninckx PR, Garry R (2009) Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 4:CD001300. doi:10.1002/14651858.CD001300.pub2 Bosev D, Nicoll LM, Bhagan L, Lemyre M, Payne CK, Gill H, Nezhat C (2009) Laparoscopic management of ureteral endometriosis: the Stanford University hospital experience with 96 consecutive cases. J Urol 182:2748–2752 Mohr C, Nezhat FR, Nezhat CH, Seidman DS, Nezhat CR (2005) Fertility considerations in laparoscopic treatment of infiltrative bowel endometriosis. JSLS 9:16–24 Rausei S, Sambucci D, Spampatti S, Cassinotti E, Dionigi G, David G, Ghezzi F, Uccella S, Boni L (2015) Laparoscopic treatment of deep infiltrating endometriosis: results of the combined laparoscopic gynecologic and colorectal surgery. Surg Endosc 29:2904–2909 Uccella S, Cromi A, Casarin J, Bogani G, Pinelli C, Serati M, Ghezzi F (2014) Laparoscopy for ureteral endometriosis: surgical details, long-term follow-up, and fertility outcomes. Fertil Steril 102(160–166):e2 Fedele L, Bianchi S, Zanconato G, Berlanda N, Borruto F, Frontino G (2005) Tailoring radicality in demolitive surgery for deeply infiltrating endometriosis. Am J Obstet Gynecol 193:114–117 Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F (1991) Clinical assessment of venous thromboembolic risk in surgical patients. Semin Thromb Hemost 17 Suppl 3:304–312 Ceccaroni M, Clarizia R, Bruni F, D’Urso E, Gagliardi ML, Roviglione G, Minelli L, Ruffo G (2012) Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 26:2029–2045 Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213 Ghezzi F, Cromi A, Siesto G, Boni L, Uccella S, Bergamini V, Bolis P (2008) Needlescopic hysterectomy: incorporation of 3-mm instruments in laparoscopic hysterectomy. J Minim Invasive Gynecol 22:2153–2157 Uccella S, Cromi A, Casarin J, Bogani G, Serati M, Gisone B, Pinelli C, Fasola M, Ghezzi F (2015) Minilaparoscopic versus standard laparoscopic hysterectomy for uteri ≥16 weeks of gestation: surgical outcomes, postoperative quality of life, and cosmesis. J Laparoendosc Adv Surg Tech A 25(5):386–391 Uccella S, Ceccaroni M, Cromi A, Malzoni M, Berretta R, De Iaco P, Roviglione G, Bogani G, Minelli L, Ghezzi F (2012) Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol 120:516–523 Magrina JF, Espada M, Kho RM, Cetta R, Chang YH, Magtibay PM (2015) Surgical excision of advanced endometriosis: perioperative outcomes and impacting factors. J Minim Invasive Gynecol 22:944–950 Afors K, Murtada R, Centini G, Fernandes R, Meza C, Castellano J, Wattiez A (2014) Employing laparoscopic surgery for endometriosis. Womens Health (Lond Engl) 10:431–443. doi:10.2217/whe.14.28 Ceccaroni M, Clarizia R, Roviglione G, Ruffo G (2013) Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery. Surg Endosc 27:4386–4394 Uccella S, Cromi A, Bogani G, Casarin J, Formenti G, Ghezzi F (2013) Systematic implementation of laparoscopic hysterectomy independent of uterus size: clinical effect. J Minim Invasive Gynecol 20:505–516 Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, Clayton R, Phillips G, Whittaker M, Lilford R, Bridgman S, Brown J (2004) The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ 328(7432):129 Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB (2009) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 3:CD003677. doi:10.1002/14651858.CD003677.pub4 Author information Authors and Affiliations Corresponding author Ethics declarations Conflict of interest S. Uccella declares that he has no conflict of interest. N. Marconi declares that he has no conflict of interest. J. Casarin declares that he has no conflict of interest. M. Ceccaroni declares that he has no conflict of interest. L. Boni declares that he has no conflict of interest. D. Sturla declares that he has no conflict of interest. M. Serati declares that he has no conflict of interest. S. Carollo declares that she has no conflict of interest. C. Podestà-Alluvion declares that she has no conflict of interest. F. Ghezzi declares that he has no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study. Rights and permissions About this article Cite this article Uccella, S., Marconi, N., Casarin, J. et al. Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy. Arch Gynecol Obstet 294, 771–778 (2016). https://doi.org/10.1007/s00404-016-4115-9 Received: Accepted: Published: Issue date: DOI: https://doi.org/10.1007/s00404-016-4115-9