Study Of Surgical Treatment For Deeply Infiltrating Endometriosis

PrefaceDeeply infiltrating endometriosis(DIE) is defined as an endometriotic lesion penetrating to a depth of at least 5mm which locates on uterosacral ligaments, vagina, bladder, ureter or even intestine. The main symptom is pelvic pain which correlated with the location of the main lesion. In recent decade, study of DIE gradually turned from case report to systematic review on pathogenesis, surgical management and long-term follow up.Our study aims to find appropriate plans for the perioperative treatment of DIE patients which put more emphasis on the optimal management for the surgery and improvement of the quality of life.Part I Diagnosis and Surgical Treatment for DIEObjective:To investigate the diagnosis, surgical management for deeply infiltrating endometriosis.Methods:From December 2011 to December 2013, all of 93 patients diagnosed deeply infiltrating endometriosis in Obstetrics&Gynecology Hospital of Fudan University were evaluated in the study. Surgery includes complete removal of the lesion and non-complete treatment. The statistics were analyzed with T test, rank-sum test and chi-square test in SPSS 20.0 for windows.Results:The incidence of DIE in endometrial diseases is estimated 3.04%. The mean age of the patients was 35.1±7.2 years (range:24～55 years). The main clinical signs are dysmenorrheal 64.52%, chronic pelvic pain 30.11%, deep dyspareunia 17.20%. 41.9% lesions locate most on uterosacral ligament. MRI performs 80.6% diagnosis of the lesions. Serum CA125 values were significantly elevated in patients with ovarian and pelvic endometriosis or adenomyosis (66.5% VS 29.4%, P=0.021). A total of 93 patients was performed surgery.91.4% of the patients accepted laparoscopic surgery, 9 were performed laparotomy and 1 with transvaginal surgery. Surgeons attended 80% of the complete removal surgery which non-complete with 7.9% attended(80% VS 7.9%, P<0.001). More patients with complete lesion removal surgery was carried adnexectomy or hysterectomy (16.4% VS 2.6%, P=0.022) and presented a higher complication rate (9.1 VS 0%, P<0.001).Conclusion:Deeply infiltrating endometriosis is a kind of complicated and severe disease. Clinical diagnosis should integrate history, body examination and imaging investigation. Laparoscopic surgical procedure is suggested. Surgeons’attending is needed in most complete removal surgery.Part Ⅱ Study of the Surgical Efficacy for DIEObjective:To study the surgical efficacy and perioperative management for deeply infiltrating endometriosis.Methods:Visual Analogue Scale was used to investigate the pain degree, WHOQOL-BREF for the quality of life, rAFS to evaluate the severity of DIE, EFI for the reproductive function.Results:85(91.4%) patients was followed up. The mean follow-up time was 18.3±8.7 months (range,3-36 months). The mean visual analog scale (VAS) score of pain was significantly lower postoperatively (0.89±1.6 VS 5.4±3.9, P<0.001), and complete surgery improved more the non-complete surgery(5.6±3.9 VS 2.9±3.3, P=0.001). Postoperative QOL improved. Recurrence rate of complete lesion removal surgery was lower than non-complete surgery (3.9% VS 35.3%, P<0.001).27 women had fertility requirement whose postsurgical conceive rate was 48.1%and mean conceive time 7.0±4.0 months (range,3-18 months). When EFI≥5, a higher conceive rate was expected. Complete lesion removal didn’t improve reproductive outcome. Patents with light EMs got a better improval in self-evaluation score of QOL (10.0±1.6 VS 6.8±2.7, P=0.034) while those severe EMs patients with more pain relief ((6.1±4.3 VS 2.9±3.4, P=0.002) and low recurrence (5.9% VS 36.7%, P=0.002). Postsurical GnRHa therapy for patients with non-complete lesion surgey obtained more pain relief than those with no postsurgical therapy (4.5±3.2 VS 1.2±2.7, P=0.003). When treated with 4-6 cycles of GnRHa other than 1-3 cycles, patients complained more incidence of osteoporosis (25% VS 2.4%, P=0.011) but lower recurrence (0% VS 14.6%, P=0.040).Conclusion:Surgical treatment for deeply inflitating endometriosis improves patient’s feeling of pain and quality of life. EFI is valuable to predict reproductive outcome of DIE patients. Complete lesion removal together with adnexectomy or hysterectomy can be a choice for perimenopausal patients. Postsurgical medicine treatment prevents recurrence.