Surgical outcome in patients with complex deep infiltrating endometriosis

Background: Endometriosis (EN) is the most common gynaecological disease, presented by the presence of endometrial-like tissue outside the uterine cavity. It is still poorly understood and not so widely investigated, although endometriosis was first described in 19th century. Till nowadays the etiology and the pathophysiology of EN is unclear and so far, there is no clear statement about the treatment of EN. One of the reasons is complex anatomical dissemination of the lesions. Endometriosis is categorized in three different phenotypes: ovarian endometrioma, superficial peritoneal endometriosis and deep infiltrating endometriosis (DIE). DIE is the most severe form of this disease with an estimated prevalence in 8–12% of women with EN and in 1% of all women in reproductive age. Methodology: This study encloses seven-year data of the patients with DIE in their reproductive age, who underwent organ sparing surgery. These patients were divided in 3 different groups according to the anatomical manifestation of DIE. The first group of n=148 comprised patients with central (CPE) and lateral pelvic endometriosis (LPE) including n=41 cases of deep lateral pelvic endometriosis (dLPE) affecting sacral plexus. The second group enclosed n=34 patients with rectovaginal (RVE) and retrocervical endometriosis (RCE). N=54 patients were enrolled in the third group with complex DIE involving posterior compartment peritoneum (PCPE). The database was made based on clinical history, surgical technique, intra-operative findings, pre- and postoperative questionnaire and postoperative follow-up, enclosing EN-related symptoms, complications, fertility rate and recurrence rate. Final results were evaluated by visual analog scale (VAS), numerical rating scale (NRS) and statistical analysis Graph pad Prism 5. Results: In general, all three study groups demonstrated postoperatively improvement of EN-complaints, fertility rate and low rate of complications. The intensity of the symptoms was analysed by VAS score (pain scale system from 0-10). First group of patients with dLPE demonstrated median VAS score drop for EN-related symptoms from 5-8 to zero and only n=3 recurrences postoperatively. Second group with RVE and RCE endometriosis reported completely symptom free status in n=18 patients (53%), zero recurrence and n=12 postoperative pregnancies (from n=17 patients with primary or secondary infertility preoperatively). Third group, with complex DIE accompanied by posterior compartment peritoneum EN showed also complete absence of EN-related symptoms postoperatively in n=36(67%) patients. N=28 women seeking fertility had a high rate of postoperative fertility, reporting n=12(43%) successful pregnancies. Conclusion: Proper clinical diagnosis could limit disease development and prevent the delay in time of diagnosis. But for patients with already existing DIE, choosing an appropriate treatment strategy including surgical technique is crucial to avoid further EN progression and improve their quality of life.