Recurrence Rate Of Endometriosis Research Articles

Clinical outcome after CO2 laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis

Laparoscopic segmental bowel resection and reanastomosis for endometriosis with colorectal wall invasion can be associated with high complication rates. This study was performed to test the hypothesis that this high complication rate can be prevented and combined with a good clinical outcome, following a multidisciplinary surgical approach. A retrospective cohort study of all patients with deep endometriosis and colorectal invasion treated by CO₂ laser laparoscopic radical excision between September 2004 and September 2006 (n = 45) to document the clinical outcome: complications, recurrence and fertility (life table analysis), pain, quality of life (QOL) and sexual function. No immediate major post-operative complications requiring surgical reintervention were recorded. Gynaecological pain (P < 0.0001), sexual function (P < 0.03) and QOL (P< 0.0001), improved significantly after a median follow-up period of 27 (range: 16-40) months. Although five patients (11%) had a surgical reintervention, histologically proven recurrent endometriosis was observed in only two (4%), with a cumulative endometriosis recurrence rate of 2.2 and 4.4% after 1 and 3 years, respectively. Thirteen of 28 patients who wanted to become pregnant conceived after surgery. One patient delivered twice. These 14 pregnancies were achieved spontaneously (n = 9) or after IVF (n = 5). The cumulative pregnancy rate was 47% after 3 years. Pain, sexual function and QOL improved significantly and were associated with a good fertility rate and a low complication and recurrence rate after a CO₂ laser laparoscopic radical excision of endometriosis with colorectal wall invasion combined with laparoscopic segmental bowel resection and reanastomosis.

Regional lymphatic spread in women with pelvic endometriosis

Endometriosis is defined by the presence of endometrial tissue outside the uterine cavity and is associated with chronic pelvic pain and infertility. After surgical and/or medical treatment, endometriosis has a high recurrence rate which increases with the length of follow-up. To delay or to eliminate recurrence is a main task in the control of this disease. To date, little is known about the mechanism of recurrence and its management is not efficacious. Recently, it has been observed that regional lymph node involvement by endometriosis is a common phenomenon in women with endometriosis. Endometriotic cells in regional lymph node are a potential target of hormonal stimulation in the postoperative period and may be a major source of disease recurrence. We hypothesize that the resection of regional lymph nodes can decrease the recurrence rate of endometriosis and hence should become part of the surgical treatment of this disease.

Surgical treatment of deeply infiltrating endometriosis with colorectal involvement

Treatment of colorectal endometriosis is difficult and challenging. We reviewed the clinical outcome of surgical treatment of deeply infiltrating endometriosis (DIE) with colorectal involvement. Review was based upon a literature search using following search terms: (1) 'surgery' and 'colorectal endometriosis', (2) 'bowel' and 'endometriosis' and 'surgery'. clear explanation of surgical technique and follow-up data on at least one of the following items: complications, pain, quality of life (QOL), fertility and recurrence. Most of the 49 studies included complications (94%) and pain (67%); few studies reported recurrence (41%), fertility (37%) and QOL (10%); only 29% reported (loss of) follow-up. Out of 3894 patients, 71% received bowel resection anastomosis, 10% received full-thickness disc excision and 17% were treated with superficial surgery. Comparison of clinical outcome between different surgical techniques was not possible. Post-operative complications were present in 0-3% of the patients. Although pain improvement was reported in most studies, pain evaluation was patient-based in <50% (Visual Analogue Scale in only 18%). While QOL was improved in most studies, prospective data were only available for 149 patients. Pregnancy rates were 23-57% with a cumulative pregnancy rate of 58-70% within 4 years. The overall endometriosis recurrence rate in studies (>2 years follow-up) was 5-25% with most of the studies reporting 10%. Owing to highly variable study design and data collection, a CONSORT-inspired checklist was developed for future studies. Prospective studies reporting standardized and well-defined clinical outcome after surgical treatment of DIE with colorectal involvement with long-term follow-up are needed.

Vaginal Parturition Decreases Recurrence of Endometriosis

Objective To evaluate the role of parturition in the recurrence of endometriosis. Design Retrospectively analyzed, prospectively obtained data. Setting Unit of Physiopathology of Reproduction, Health Care Unit of Rimini, and University of Bologna Cervesi General Hospital, Cattolica, Italy. Patient(s) Three hundred forty-five patients with stage II–IV endometriosis, dysmenorrhea, and infertility were treated for endometriosis and divided into four groups according to parity and mode of parturition. Intervention(s) The patients were laparoscopically treated for endometriosis upon the occurrence and recurrence of the disease. Ultrasound measurements of the uterine internal ostium (IOS) were performed at each study interval. Main Outcome Measure(s) Degree of dysmenorrhea, occurrence and recurrence of endometriosis, and uterine IOS measurements were established and related to parity and mode of parturition. Result(s) After parturition, dysmenorrhea recurrence was significantly higher in nulliparous women than in women with vaginal parturition. The endometriosis recurrence rate was higher in women who did not have vaginal parturition. The IOS significantly enlarged after vaginal delivery but not after cesarean delivery. There were significant negative correlations between IOS and the recurrence of endometriosis and dysmenorrhea. Odds ratios indicated that as the IOS enlarged, the risk of recurrence decreased. Conclusion(s) Vaginal parturition plays a protective role in the recurrence of endometriosis.

A comparison of the effect of short-term aromatase inhibitor (letrozole) and GnRH agonist (triptorelin) versus case control on pregnancy rate and symptom and sign recurrence after laparoscopic treatment of endometriosis

To compare the role of an aromatase inhibitor (letrozole) with a GnRH agonist (triptorelin) versus case control on the pregnancy rate and recurrence of symptoms and signs in patients with endometriosis. In a prospective randomized clinical trial, after treatment of 144 infertile women in their reproductive age by laparoscopy (whose endometriosis was confirmed by prior laparoscopy), they were divided into 3 groups: group 1 (47 cases) who received letrozole for 2 months, group 2 (40 patients) who were prescribed triptorelin for 2 months and group 3 who were 57 patients in the control group and did not receive any medication. We followed up each group at least for 12 months after their restoration of regular cycle. Pregnancy rate was 23.4% in group 1, 27.5% in group 2, and 28.1% in group 3. The results did not show significant differences among the 3 groups. Recurrence rate of endometriosis was 6.4% in group 1, 5% group 2 and 5.3% in group 3, which was not statistically significantly different as well. Pregnancy rate and endometriosis recurrence rate are comparable among the 3 groups.

Vaginal parturition decreases recurrence of endometriosis

To evaluate the role of parturition in the recurrence of endometriosis. Retrospectively analyzed, prospectively obtained data. Unit of Physiopathology of Reproduction, Health Care Unit of Rimini, and University of Bologna Cervesi General Hospital, Cattolica, Italy. Three hundred forty-five patients with stage II-IV endometriosis, dysmenorrhea, and infertility were treated for endometriosis and divided into four groups according to parity and mode of parturition. The patients were laparoscopically treated for endometriosis upon the occurrence and recurrence of the disease. Ultrasound measurements of the uterine internal ostium (IOS) were performed at each study interval. Degree of dysmenorrhea, occurrence and recurrence of endometriosis, and uterine IOS measurements were established and related to parity and mode of parturition. After parturition, dysmenorrhea recurrence was significantly higher in nulliparous women than in women with vaginal parturition. The endometriosis recurrence rate was higher in women who did not have vaginal parturition. The IOS significantly enlarged after vaginal delivery but not after cesarean delivery. There were significant negative correlations between IOS and the recurrence of endometriosis and dysmenorrhea. Odds ratios indicated that as the IOS enlarged, the risk of recurrence decreased. Vaginal parturition plays a protective role in the recurrence of endometriosis.

Outcome after multidisciplinary CO 2 laser laparoscopic excision of deep infiltrating colorectal endometriosis

The aim of this retrospective cohort study was to evaluate clinical outcome after multidisciplinary laparoscopic excision of deep endometriosis. Patients ( n = 56) were asked to complete questionnaires regarding quality of life (QOL), pain, fertility and sexuality to compare their status before and after surgery, and their medical files were analysed. Statistical analysis was performed with life table analysis, paired Wilcoxon and McNemar tests. Gynaecological pain, QOL and sexual activity improved significantly ( P < 0.001; P < 0.0001 to P = 0.008 and P < 0.0001 to P = 0.0003 respectively) during a median follow-up 29 months after surgery. Post operative complications occurred in 11% but were directly related to surgery in only 5%. The cumulative recurrence rate of endometriosis was 2 and 7% at 1 and 4 years after surgery respectively. Cumulative pregnancy rate was 31 and 70% at 1 and 4 years after surgery respectively. In conclusion, multidisciplinary CO 2 laser laparoscopic excision of deep endometriosis with colorectal extension improves pain, QOL and sexuality with high fertility and low complication and recurrence rates.

RECTAL ENDOMETRIOSIS: RESULTS OF RADICAL EXCISION AND REVIEW OF PUBLISHED WORK

The aim of this paper is to review the results of surgical excision of rectal endometriosis and review the published work on this challenging condition. All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed. Between 1995 and 2005, 213 rectal procedures were carried out on 203 patients together with an endogynaecologist. Eighteen cases involved dissection of endometriosis off the rectal wall, 58 involved full-thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were carried out. A loop ileostomy was required in 7 (5%) of the segmental resections. Seventy-five per cent of the cases were either laparoscopic or laparoscopically assisted. Infertility was significantly more common in the group requiring a segmental resection (P=0.026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P=0.031). There were no other significant differences between the different types of rectal surgery. The morbidity for all rectal procedures was 7% and there was one anastomotic leak in the segmental resection group. The actuarial rectal recurrence rate of endometriosis was 22.2% 95% confidence interval (CI) (2.5, 42.0) for dissection off the rectal wall and this was significantly different from the recurrence of 5.17% 95%CI (0.0, 10.9) for anterior rectal wall excision and 2.19% 95%CI (0.0, 4.6) for segmental rectal resection (P=0.007). The overall rectal recurrence for all cases was 4.69% 95%CI (1.8, 7.5). Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full-thickness excision of the anterior rectal wall or segmental resection of the rectum.

Is the endometriosis recurrence rate increased after ovarian hyperstimulation?

To test the hypothesis that the cumulative endometriosis recurrence rate (CERR) after fertility surgery for endometriosis stage III or IV is increased in women exposed to very high E(2) levels during ovarian hyperstimulation (OH) for IVF when compared with women exposed to less high E(2) levels during OH for intrauterine insemination (IUI). Retrospective cohort study including infertility patients with endometriosis stage III or IV. Leuven University Fertility Center, between 1990 and 2001. Patients (n = 67) with endometriosis stage III (n = 45) or IV (n = 22) who underwent pelvic reconstructive surgery and subsequently started fertility treatment with either IVF only (n = 39), both IVF and IUI in different cycles (n = 11), or IUI only (n = 17). Life table analysis was used to calculate the CERR. The CERR based on histologic or cytologic proof of disease recurrence. At 21 months after the start of OH the overall CERR was 31% and was significantly lower in patients treated with IVF only (7%) or women treated with both IVF and IUI in different cycles (43 %) than in those treated with IUI only (70%). At 36 months after the start of OH, the overall CERR was 63%. In contrast to our hypothesis, the results from this study showed that the CERR is lower after ovarian hyperstimulation for IVF than after lower-dose ovarian stimulation for IUI, suggesting that temporary exposure to very high E(2) levels in women during OH for IVF is not a major risk factor for endometriosis recurrence in women treated with assisted reproductive technology.

Determinants of short term recurrence rate of endometriosis

Objective: To analyse the frequency and the determinants of recurrence rate of clinically detectable endometriosis. Study design: Prospective cohort multicenter study. Eligible for the study were all women observed for the first time during the period January–June 1998 at the participating centres with a laparoscopically confirmed first diagnosis of endometriosis. After diagnosis, patients were treated according to standard care of each centre and desire for pregnancy. The protocol required all women to be followed up at the centre each year for 2 years with a clinical examination, an ultrasound pelvic examination and a CA125 assay, unless pregnancy occurred. Second look laparoscopy was performed on a clinical basis. Results: A total of 311 women (median age 36 years) entered the study. The two-year recurrence rate was 5.7% among cases stage I-II and 14.4% among stage III–IV ( χ 1 2 adjusted for indication for surgery, p < 0.05). The recurrence rates tended to increase with age, being 4.6% among women aged 20–30 and 13.1% among women aged >30, but this finding was not statistically significant. Conclusion: The recurrence rate of clinically detectable endometriosis tends to be higher in older women with advanced stages of the disease and lower in women with infertility.

Recurrence of endometriosis in women with abnormal uterine contractility

Objective: To establish the recurrence rate of endometriosis in patients with abnormal uterine contractility (UC). Design: Prospective randomized controlled study. Materials and Methods: Forty-six women who had laparoscopy for endometriosis (Stage III–IV ASRM revised classification-Fertil Steril 1997;67,5: 8–19) were selected in order to obtain a study group (group I) with abnormal UCs (n 23) (Human Reprod 2001;16,12: 2676–9 -Fertil Steril 2002;77,6: 1156–61) and a control group (group II) with normal UCs at the menses (n 23) (Human Reprod 2000;15 Suppl 1: 81–9). All patients were surgically treated for endometriosis and studied as for their UCs by Ultrasound (US) before and three months after surgery.The recurrence rate was detected by a second look laparoscopy on those patients who had severe and unacceptable pelvic pain/dysmenorrehea (PP/D) within two years from the previous surgery. Results: Thirty-six women (78%) had recurrence of PP/D and 28 (78%) of those underwent a 2nd laparoscopy (group I n 22-group II n 6).Endometriosis was found in 19 of 22 group I (86%) and 2 of 6 group II (33%) women. The most common abnormal UCs observed in the study group I was the high frequency of UCs (66%) and the fundus to cervix displacementof the UCs themselves (85%).We found a significant correlation between the frequency of UCs and the recurrence of endometriosis (p<0.002) and between the pattern of UCs“fundus to cervix” and the recurrence of this disease (p<0.001). Conclusion: Patients with high frequency patterns of UCs and dominant fundus to cervix displacement show a higher risk of recurrence of endometriosis.

Endometriosis. Absence of Recurrence Rate in Patients with Endometrial Ablation

Objectives: Abnormal Uterine Contractility was found in close relationship with endometriosis and retrograde bleeding; tubal efflux of endometrial debris into the pelvic cavity may cause recurrence of this disease. The present study was undertaken to evaluate differences between patients with and without eutopic endometrium in the recurrence of ectopic endometriotic implants. Design: 28 women with at least 1 child, age 24 to 40, who underwent laparoscopy twice during menses for unacceptable dysmenorrhea, with diagnosis of endometriosis stage II to IV and retrograde bleeding were recruited for the study. All patients did not received benefit from the first laparoscopy and they underwent endometrial ablation (EA) and the second laparoscopy after 18–24 months (n=14) or a second laparoscopy without EA after 18 to 36 months (n=14) from the first laparoscopy. Materials and Methods: The first and the second laparoscopy was done to remove endometriotic implants by using bipolar instruments or by excision of the implants themselves. Endometrial ablation was performed with resectoscopical procedure. Endometrial implants were carefully identified as well as the retrograde bleeding during the first and the second laparoscopy. The cul de sac’s blood was collected and endometrial cells were identified and counted by cytofluximetry. The scores of pain was detected and compared between the two groups. Analysis of data was performed with paired T-Student Test. Results: Nine of the 14 patients underwent endometrial ablation reported a disappearance and 3 a significant reduction of the pain during menses while only 3 of the other group did have significant amelioration of the symptom (p<0.05). Patients who underwent EA procedures did not exhibit recurrence rate of endometriosis while 9 patients without the procedure had significant recurrence rate of the disease (p<0.002). The endometrial cell founded in the debris of the cul de sac of 8 patients who did not undergo EA were both stromal and epithelial cells; two patients without dysmenorrhea had significant amount of blood and cells. No blood or blood cells were found in the cul de sac of patients who underwent EA. Conclusions: Human uterus, in vitro and in vivo, exhibits spontaneous during menstrual cycle and abnormal uterine contractility were previously described. The present study is supporting the crucial role of endometrial contractility in the recurrence rate of this disease. The abnormal uterine contractility may account for several other gynecological pathologies, such as sterility and infertility.

Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: A prospective, randomized trial

Objective: We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis. Study Design: In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms. Results: Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months. Conclusion: Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis. (Am J Obstet Gynecol 2000;183:588-92.)

Recurrent Endometriosis

The recurrence of pelvic endometriosis some time after the initial treatment is a common finding in clinical practice. When symptoms of endometriosis reappear several months after treatment, it is difficult to distinguish between recurrence and persistence of the disease. In this review, the current hypotheses about the biological basis of endometriosis recurrence/persistence are discussed. The results of several clinical trials estimating the recurrence rate of endometriosis after medical, surgical, and combined treatments are presented. In addition, a critical analysis of the tools available for the diagnosis of recurrent endometriosis is made, and some therapeutic options to treat recurrent endometriosis are discussed with recommendations for their use.

Gonadotropin-Releasing Hormone Analogues for the Treatment of Endometriosis: Long-Term Follow-up

Objective To determine the long-term recurrence rate of endometriosis after treatment with gonadotropin-releasing hormone analogues (GnRH-a). Design A historical prospective study. Setting Royal Free Hospital, London, a tertiary referral center for the treatment of endometriosis. Patients One hundred thirty patients with endometriosis had treatment with GnRH-a buserelin acetate, goserelin, and nafarelin acetate between the years 1985 and 1987. Patients no longer being followed in the gynecology clinic were sent a questionnaire to determine their state of health. Information was also requested from the patient's general practitioner. Main Outcome Measures The cumulative recurrence rate for the fifth year after treatment ended was 53.4%. Results Patients with a higher disease stage at the outset were more likely to experience recurrence and experience it earlier than patients with minimal disease. Fifth-year recurrence rates were 36.9% for minimal disease and 74.4% for severe disease. The change in endometriosis stage classification scores at second-look laparoscopy for those patients whose disease recurred after treatment was not significantly different from those whose disease did not recur during the study period. Conclusions Patients with endometriosis treated with GnRH-a are highly likely to suffer a recurrence of their disease, particularly if their disease is severe at the outset.

Gonadotropin-releasing hormone analogues for the treatment of endometriosis: long-term follow-up

To determine the long-term recurrence rate of endometriosis after treatment with gonadotropin-releasing hormone analogues (GnRH-a). A historical prospective study. Royal Free Hospital, London, a tertiary referral center for the treatment of endometriosis. One hundred thirty patients with endometriosis had treatment with GnRH-a buserelin acetate, goserelin, and nafarelin acetate between the years 1985 and 1987. Patients no longer being followed in the gynecology clinic were sent a questionnaire to determine their state of health. Information was also requested from the patient's general practitioner. The cumulative recurrence rate for the fifth year after treatment ended was 53.4%. Patients with a higher disease stage at the outset were more likely to experience recurrence and experience it earlier than patients with minimal disease. Fifth-year recurrence rates were 36.9% for minimal disease and 74.4% for severe disease. The change in endometriosis stage classification scores at second-look laparoscopy for those patients whose disease recurred after treatment was not significantly different from those whose disease did not recur during the study period. Patients with endometriosis treated with GnRH-a are highly likely to suffer a recurrence of their disease, particularly if their disease is severe at the outset.