P-743 Laparoscopic radical excision of deep endometriosis: A positive impact of fertility outcome
Authors: Liu H  M , Lee C  L , Desai T , Lee P  S , Huang K  G 
Published: July 2024

Abstract

Study question
Does laparoscopic radical excision of deep endometriosis (DE) and endometrioma enucleation impact fertility outcomes and recurrence rates when compared to partial excision group?

Summary answer
In stage IV endometriosis, laparoscopic radical surgery significantly reduced the recurrence rates.The laparoscopic radical excision group tended to have a higher rate of natural conception.

What is known already
Endometriosis-related symptoms can be significantly improved through surgery, leading to better pregnancy rates. However, the optimal surgical approach can vary due to the complexity of DE. As a result, the recurrence of postoperative symptoms and pregnancy rates can differ due to the lack of randomized trials comparing primary surgery with first-line IVF studies. Thus, the ESHRE stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rates. However, the higher probability of postoperative spontaneous conception in patients undergoing radical resection versus conservative treatment of DE has been reported.

Study design, size, duration
study design: Retrospective cohort study in a tertiary referral center.
size: 77 patients diagnosed with moderate or severe endometriosis and DE.
duration: between 2018 and 2020

Participants/materials, setting, methods
77 patients underwent laparoscopic surgery for dysmenorrhea or infertility. Group 1 (n = 22) underwent conservative treatment through partial excision of endometriosis, indicating incomplete resection. Group 2 (n = 55) underwent radical excision of endometriosis and restoration of pelvic anatomy, indicating complete resection. We compared the baseline characteristics, peri-operative data, and follow-up outcomes, aiming to investigate whether radical excision yields superior results in terms of recurrence rate, re-intervention, and pregnancy rate.

Main results and the role of chance
Main results: Group 2 showed significantly higher surgical complexity with higher revised American Fertility Society classification scores, a greater proportion of severe endometriosis, multiple sites with endometriotic lesions, and longer operation times. Both groups had comparable pregnancy, recurrence, and re-intervention outcomes during the follow-up period of 28.2±16.4 months. While Group 2 tended to have a higher pregnancy rate (84% versus 67%, p = 0.56) and higher live birth rates (80% versus 67%, p = 0.59) when compared with group 1. In the population with stage IV endometriosis, group 2 significantly reduced the recurrence rates (9% versus 50%, p = 0.04) when compared to group 1.
Conclusions: The group that underwent laparoscopic endometrioma enucleation with radical excision of extra-ovarian endometriosis exhibited significantly higher surgical complexity. In the population with stage IV endometriosis, radical surgery significantly reduced the recurrence rates. Surgical excision of ovarian endometriosis and extra-ovarian disease is advisable to limit disease progression and ensure complete symptom resolution. Additionally, the laparoscopic radical excision group tended to have a higher rate of natural conception, indicating potential benefits for fertility in patients who have moderate and severe endometriosis with DE.

Limitations, reasons for caution
The main limitations were the small sample size and recall bias. But, additionally, the limited cases in the research group might have influenced the results and restricted the extrapolation of related conclusions. Further studies with larger sample sizes are needed in the future.

Wider implications of the findings
We believe that a standardized surgical technique outlining a step-by-step method to delineate all important structures and address altered planes as in endometriosis, with the aim of restoring normal pelvic anatomy, ensures the avoidance of high complication rates, leads to lower recurrence rates and positive impact on fertility outcomes.

Trial registration number
not applicable