Clinical Features Of Recurrent Ovarian Endometriosis And Prognosis Analysis After Secondary Surgery

Objective:Recurrent endometriosis(EMs)suffers from severe pelvic adhesions,disturbed anatomical relationships,and impaired ovarian function.There is a lack of effective clinical solutions for recurrent ovarian EMs.In this study,we analyzed the clinical characteristics of recurrent ovarian EMs undergoing secondary surgery,the diagnostic and treatment characteristics,recurrence after secondary surgery and related influencing factors of recurrent ovarian EMs to provide an important clinical reference basis for clinicians to choose the best treatment plan.Methods:Retrospective analysis of 69 cases of recurrent ovarian-type EMs undergoing secondary surgery admitted to the gynecology departments of Taiyuan Central Hospital and Yuncheng Central Hospital from January 2019 to June 2022.Information on secondary surgery such as general characteristics,past history,clinical features(pain symptoms,cyst diameter,cyst side),ancillary examinations(serum CA125,FIB,ultrasonography),surgical records(surgical approach,surgical staging,operative time,postoperative pathological findings,combined with other EMs pathological subtypes)were collected to analyze the clinicopathological characteristics,false-positive cases,treatment of recurrent ovarian-type EMs At the same time,the recurrence after the second surgery was followed up,and the recurrence rate after the second surgery was calculated,and the recurrence group was divided into the recurrence group and the non-recurrence group according to whether recurrence occurred after the second surgery,and the analysis of age,maximum diameter of recurrent cyst,recurrent dysmenorrhea symptoms,Cancer Antigen 125(CA125),Fibrinogen(FIB),surgical staging,degree of Douglas fossa involvement,two postoperative medications and postoperative pregnancy were differed in the two groups,and univariate and multifactorial analyses were performed.The software SPSS 26.0 was used to organize and analyze the data.In this study,the t-test was used for comparison between groups for those whose measurement data obeyed normal distribution,and the rank sum test was used for comparison between groups for those who did not obey normal distribution.The Chi-square test or Fisher’s exact test was used for group comparisons of the count data.Kaplan-Meier was used to express the cumulative recurrence rate,and the Log-rank method was applied to test.Multifactorial analysis was performed using the Cox proportional risk regression model,and differences were statistically significant at P<0.05.Results:1.Clinical characteristics of secondary surgery.(1)The left ovary predominated in the recurrence of ovarian-type EMs(36.23%),and the difference between the side of recurrent ovarian-type EMs and the primary side was not statistically significant(P>0.05);(2)In the recurrence of ovarian EMs,69.56%were ovarian-only,21.74%were combined with Deep Infiltrating Endometriosis(DIE),and 8.70%were combined with peritoneal type;compared with the recurrence of ovarian-only and combined with peritoneal type,patients with recurrence of combined DIE had a higher proportion of concomitant painful symptoms(X~2=11.173,P=0.004)and higher pain VAS scores(Z=15.718,P<0.001),with statistically significant differences.Although their time interval between surgeries was shorter and their recurrent CA125 levels were higher,the difference was not statistically significant(P>0.05);(3)Among the 31 cases with preoperative diagnosis of bilateral ovarian-type EMs,25.81%were diagnosed with unilateral ovarian-type EMs combined with false-positive masses by surgical pathology,and the overall surgical diagnosis compliance rate was88.41%.Compared with bilateral ovarian EMs,the clinical symptoms and ultrasound manifestations of combined inflammatory encapsulated effusion were similar to them,but the level of tumor markers was low;(4)Comparing the changes in anti-Müllerian hormone(AMH)levels before and after conservative surgery for recurrent ovarian EMs,AMH levels decreased in all groups at 6 months postoperatively compared with preoperatively,with statistically significant differences in the bilateral,age<35years and age≥35years groups(P<0.001),but no statistically significant differences in the unilateral group(P>0.05).The preoperative and postoperative AMH levels were higher in the unilateral and age<35years groups than in the bilateral and age≥35 years groups,and the differences were statistically significant(P<0.05).2.recurrence after the second surgery.(1)Recurrent ovarian-type EMs were followed up from 6 months to 40 months after the second surgery,during which 13 cases(18.84%)of recurrence were accumulated,with cumulative recurrence rates of 7.35%,14.52%,16.90%,19.87%,19.87%,and32.33%at 6,12,18,24,30,and 40 months after the second surgery,respectively;(2)Univariate results showed that time to initial postoperative medication(X~2=9.412,P=0.002),secondary ASRM surgery staging(X~2=9.639,P=0.002),and secondary ASRM surgery score(X~2=6.187,P=0.013)were risk factors for recurrence after secondary surgery for recurrent ovarian-type EMs(P<0.05),while patient’s age at both surgeries,and time of medication after the second surgery,pregnancy after both surgeries,diameter of recurrent cyst,presence of painful symptoms of recurrence,CA125 level and FIB level had no effect on recurrence of recurrent ovarian-type EMs after the second surgery(P>0.05);(3)Multifactorial Cox regression analysis showed that time on medication<3months after initial surgery(HR=5.152,95%CI 1.228～21.621,P=0.025),and secondary surgery score≥70(HR=8.849,95%CI 1.202～65.139,P=0.032)were independent risk factors for recurrence after secondary surgery,and the difference was statistically significant(P<0.05).Conclusion:The site of recurrence of recurrent ovarian EMs does not correlate with the primary site.When recurrent ovarian EMs are associated with severe pain symptoms,be alert to the occurrence of concurrent DIE and make a good preoperative evaluation plan.The differential diagnosis should be improved before making treatment decisions for recurrent ovarian EMs.The ovarian reserve function is severely reduced after secondary surgery,and individualized selection should be made according to the patient’s age,cyst site,and the requirement for fertility,etc.The recurrence rate increases gradually with the extension of follow-up time after secondary surgery,so we should improve the long-term postoperative management and monitoring to protect the ovarian reproductive endocrine function and improve the quality of life of patients.