Objective: 
The primary purpose of this study was to determine if treating endometriosis with optimal excision surgery leads to lower rates of repeat surgery as compared to historical rates of repeat surgery by ablation. A secondary outcome was to examine whether the use of hormonal suppression differed before surgery, depending on the stage of endometriosis found at surgery.
Study design: 
We performed a prospective cohort study (Canadian Task Force class II-3).
Materials and methods: 
Preoperative data, operative data, and follow-up postoperative data were collected prospectively (IRB 20900) at the Saint Louis University Center for Endometriosis, a referral center for the surgical management of endometriosis specializing in the optimal excision of endometriosis, from time frame 2012-2019. Optimal excision was defined as completely excising all areas of abnormal peritoneum, wherever found in the pelvis, having looked systematically with near contact laparoscopy. All surgeries were performed by a single surgeon specializing in optimal excision. Follow-up data was collected from annual questionnaires sent postoperatively to patients.
Results: 
Of the 756 patients in the database who underwent surgery for endometriosis, 620 patients had histological confirmation of endometriosis in any location excised, yielding a rate of finding tissue-proven endometriosis to be 82%. The mean follow-up time period in months was 32 months (range 5-136 months). Of the 620 patients with tissue-proven endometriosis, 570 women had optimal excision (OE) surgery for endometriosis (91.9%) of which 14 patients underwent repeat surgery (2.5%). Of the 620 patients, 366 women (60%) were on hormonal suppression specifically: 96.4% of the 366 women on hormonal contraceptives, 29.5% on GnRH agonists/antagonists/chemical menopause, and 14.6% on progesterone-secreting IUDs with a median length of suppression of 36 months. At surgery, 62.9% of patients were categorized as endometriosis stage 1 or 2, 11.8% for stage 3, and 25.3% for stage 4. There was also no significant association between hormonal suppression before endometriosis excision surgery with the stage of endometriosis found at surgery. 
Conclusion: 
The rate of repeat surgery is an important clinical factor when looking at surgical outcomes. The rate of repeat surgery after optimal excision surgery for endometriosis was remarkably low (2.5%) as compared to historical rates of repeat surgery by ablation (40-60% in 1-2 years following initial procedure ). Additionally, the lack of significant evidence between hormonal suppression use and progression of stage of endometriosis provides implicit evidence that hormonal suppression does not prevent progression of the disease. Further controlled studies are needed to verify these findings.


The Rate of Repeat Surgery After Optimal Excision Surgery of Endometriosis at a Single Tertiary Referral Center

Clinical and Translational Research 2

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