Predicting disease recurrence in patients with endometriosis: an observational study.

BACKGROUND: Despite surgical and pharmacological interventions, endometriosis can recur. Reliable information regarding risk of recurrence following a first diagnosis is scant. The aim of this study was to examine clinical and survey data in the setting of disease recurrence to identify predictors of risk of endometriosis recurrence. METHODS: This observational study reviewed data from 794 patients having surgery for pelvic pain or endometriosis. Patients were stratified into two analytic groups based on self-reported or surgically confirmed recurrent endometriosis. Statistical analyses included univariate, followed by multivariate logistic regression to identify risk factors of recurrence, with least absolute shrinkage and selection operator (Lasso) regularisation. Risk-calibrated Supersparse Linear Integer Models (RiskSLIM) and survival analyses (with Lasso) were undertaken to identify predictive features of recurrence. RESULTS: Several significant features were repeatedly identified in association with recurrence, including adhesions, high rASRM score, deep disease, bowel lesions, adenomyosis, emergency room attendance for pelvic pain, younger age at menarche, higher gravidity, high blood pressure and older age. In the surgically confirmed group, with a score of 5, the RiskSLIM method was able to predict the risk of recurrence (compared to a single diagnosis) at 95.3% and included adenomyosis and adhesions in the model. Survival analysis further highlighted bowel lesions, adhesions and adenomyosis. CONCLUSIONS: Following an initial diagnosis of endometriosis, clinical decision-making regarding disease management should take into consideration the presence of bowel lesions, adhesions and adenomyosis, which increase the risk of endometriosis recurrence.

The impact of age and parity on the experience of relief and regret in women who have undergone hysterectomy for benign disease: A cross sectional survey.

OBJECTIVE: To investigate the impact of age and parity on the experience on relief and regret following elective hysterectomy for benign disease, and to explore the factors that impact relief and regret. DESIGN: Retrospective cross-sectional survey of a cohort. SETTING: Single-centre tertiary hospital in Melbourne, Australia. POPULATION: Patients who underwent elective hysterectomy for benign indications from 01 January 2008 - 31 July 2015 (inclusive) with age <51 years at time of admission. METHODS: Eligible participants completed a retrospective survey regarding their experience of relief and regret following hysterectomy. MAIN OUTCOME MEASURES: Regret was defined as a positive response to "Do you regret the decision to have a hysterectomy?". Relief was defined as responding "agree/strongly agree" to "I feel relieved I had a hysterectomy". RESULTS: 268 of 1285 (21%) eligible participants completed the study questionnaire. Of these, 29 were aged <36 years at the time of hysterectomy. Seven percent (n=18/262) reported regretting having a hysterectomy and 88% (n=230/262) reported experiencing relief. We did not observe associations between age at hysterectomy and regret (aOR 0.93; 95% CI 0.85, 1.03), age at hysterectomy and relief (aOR 1.01; 95% CI 0.93, 1.09), nulliparity and regret (aOR 0.32; 95% CI 0.06, 1.59) or nulliparity and relief (aOR 2.37; 95% CI 0.75, 7.51). Desire for future pregnancy at the time of hysterectomy was more frequently reported in those who experienced regret vs no regret (46.7% vs 12.1%, OR: 6.33; 95% CI: 2.12, 18.90; p=0.001). CONCLUSIONS: Age and parity are not associated with relief nor regret following elective hysterectomy for benign disease.

Constipation After Elective Laparoscopy for Benign Gynecological Indications-A Prospective Observational Study.

STUDY OBJECTIVE: Discover the rate of post-operative constipation in participants undergoing elective laparoscopy for benign gynecological indications DESIGN: Prospective observational study SETTING: Single site, tertiary level gynecology unit with a focus on pelvic pain and endometriosis. PATIENTS: Recruited participants were patients of the institution over the age of 18 who had planned to undergo an elective laparoscopy for benign gynecological indications prior to enrolment in the study. Participants were excluded if they were not English speaking, had a chronic bowel condition (with the exception of irritable bowel syndrome), were planned to have bowel surgery, hysterectomy, or converted to laparotomy. INTERVENTION: In this prospective study, participants completed 3 consecutive surveys. One prior to surgery, one a week post-surgery, and a third 3 months post-surgery. The surveys collected data regarding the participant's bowel habits, pain relief used, laxatives used, and the distress or bother caused by their bowels. MEASUREMENT AND MAIN RESULTS: Constipation was defined by a modified ROME IV criteria. Opiate use and laxative use were defined by patient-reported tablet counts. The level of distress was measured as a continuously variable scale from 0 to 100. Variables adjusted for included subject's demographics, pre-operative constipation, indication for surgery, duration of surgery, estimated blood loss, opiate use (preoperative, peri-operative, and post-operative), laxative use, and length of stay. A total of 153 participants were recruited, of which 103 completed both the pre-operative and post-operative survey. Post-operative constipation was present in 70% of participants. The mean length of time to first bowel motion was 3 days, with 32% of participants having their first bowel motion after the third post-operative day. The level of bother caused by their bowel habit was higher in the constipation group compared to those without constipation. Post-operatively opiates were used in 84.9% of participants, and laxatives were used in 47.1%. Visits to the general practitioner for constipation occurred in 5.8% of participants. CONCLUSION: Post-operative constipation is common and bothersome in participants who undergo elective laparoscopy for benign gynecological indications. Analysis of individual variables failed to identify any factors that influenced the rate of constipation.

Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study.

BACKGROUND: Deep endometriosis (DE) may significantly affect women's quality of life. Limited data exists on the effect of surgery on the several domains of sexual function. AIM: To prospectively compare various domains of sexual function before and after laparoscopic surgery for DE. METHODS: A prospective observational cohort study in a tertiary university-affiliated referral center. Patients with suspected DE who were planned to undergo laparoscopic surgery completed the Female Sexual Function Index questionnaire before surgery. The same questionnaire was completed by the participants 6 weeks, 6 months, and 12 months after surgery. Rate of sexual dysfunction over time was compared using multilevel logistic regression. Summary scores were then compared at each time point to the corresponding score before surgery using multilevel linear regression. Multivariable analysis was performed of potential confounders. OUTCOMES: Change in desire, arousal, orgasm, lubrication, satisfaction and pain summary scores as well as in the full-scale score between before and after surgery. RESULTS: We followed 149 patients with surgically confirmed DE. Sexual dysfunction rate as per the full-scale score was 75.5% before surgery and remained over 60% to 12 months after. The full-scale sexual function score improved at 6 (change in score = 2.8 ± 9.5, P = .004) and 12 months (change in score = 2.1 ± 9.9, P = .03). None of the summary scores improved at 6 weeks. Desire score (P < .001), arousal score (P = .02), and pain score (P = .01) improved at 6 months. Desire score (P = .03) and pain score (P = .01) also improved at 12 months, as compared to before surgery. On multivariable multilevel analysis, scores before surgery significantly contributed to the scores after surgery (P < .001). CLINICAL TRANSLATION: While sexual function improved after surgery, dysfunction rate remained substantial. Proper preoperative counseling should address sexual function measures and clinical and research attention should be given to seek ways to further reduce sexual dysfunction. STRENGTHS AND LIMITATIONS: The main strengths of our study are the prospective design, the relatively long follow-up and the use of a detailed validated questionnaire allowing assessment of a large variety of clinically relevant sexual function domains and scores as well as a full-scale score. Among our limitations are the lower response rate at 12 months and the limited generalizability as this is a single center study. CONCLUSION: Sexual function is a major and often under reported domain of quality of life. Further research is needed to identify the specific populations who may improve, not change or experience deterioration in their sexual functioning after surgery. Dior UP, Reddington C, Cheng C, et al. Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study. J Sex Med 2022;19:280-289.

Urinary Function after Surgery for Deep Endometriosis: A Prospective Study.

STUDY OBJECTIVE: To compare urinary function before and after surgery in patients undergoing laparoscopy for deep endometriosis and to measure the rate of postoperative deterioration in urinary function after surgery. DESIGN: Prospective questionnaire-based observational cohort study. SETTING: Tertiary university-affiliated hospital. PATIENTS: Included were 149 women who underwent surgery for deep endometriosis. INTERVENTIONS: Participants completed the international consultation on incontinence female lower urinary tract symptoms long-form questionnaire before surgery and 6 weeks, 6 months, and 12 months after surgery. MEASUREMENTS AND MAIN RESULTS: Bladder filling, voiding, and urinary incontinence summary scores were compared before and after surgery with mixed-effects linear regression analysis (correlated observations). Individual domains comprising the summary scores and their bother scores were also compared before and after surgery. Filling score at 6 weeks (3.7 ± 2.6), 6 months (3.2 ± 2.2), and 12 months (3.4 ± 2.2) improved from presurgery scores (4.2 ± 2.6) (p-value for the difference between before and after surgery: p <.001, p = .009, and p = .02 for 6 weeks, 6 months, and 12 months, respectively). No change was observed after surgery in bladder voiding score. Incontinence score improved at 6 weeks after surgery (presurgery and 6-week scores: 2.5 ± 3.3 and 1.6 ± 2.2, respectively, p <.001) but not thereafter. Patients with low preoperative summary scores had higher summary scores (worse function) after surgery, and patients with high preoperative scores had lower summary scores (improved function) after surgery. CONCLUSION: Urinary function improved after laparoscopy for deep endometriosis. Greatest improvement was found in patients with worse preoperative function, whereas postoperative deterioration in urinary function was found for patients with initially normal function. More research is needed to better identify the subpopulations in whom surgical intervention provides symptomatic benefit or deterioration.

Central sensitisation in pelvic pain: A cohort study.

BACKGROUND: Central sensitisation (CS) leads to pain amplification and impacts on the management of pelvic pain (PP). Identification of CS in patients with PP may provide additional treatment pathways and improve patient outcomes. AIMS: The aims are to quantify the prevalence of questionnaire-predicted CS (QPCS) in patients presenting with PP and investigate associations between QPCS and clinical variables. MATERIALS AND METHODS: This was an observational, cross-sectional study. Subjects with PP completed a questionnaire comprising four validated tools: the Central Sensitisation Inventory (CSI) for QPCS, Pain Catastrophising Scale for Catastrophising Trait, Bladder Pain/Interstitial Cystitis Symptom Score for bladder pain syndrome (BPS) and the Rome IV criteria for irritable bowel syndrome (IBS). RESULTS: One hundred and eleven women were enrolled in the study; 74.8% (n = 83) had a CSI score of >40, indicating the presence of QPCS. Subjects with QPCS were more likely to screen positive for catastrophising trait (odds ratio (OR) 3.57, 95% CI 1.19-10.76, P = 0.02), BPS (OR 11.77, 95% CI 2.13-64.89, P = 0.005) and IBS (OR 2.6, 95% CI 1.05-6.43, P = 0.04). They were more likely to experience pain for more than two years (OR 4.98, 95% CI 1.94-12.82, P = 0.001) and other pain symptoms involving bladder (OR 9.87, 95% CI 2.52-38.67, P = 0.001), bowel (OR 3.13, 95% CI 1.31-7.48, P = 0.01), back (OR 4.17, 95% CI 1.66-10.51, P = 0.002) and vulva (OR 3.61, 95% CI 1.21-10.82, P = 0.02). They also had higher previous diagnoses of mental health disorder (OR 3.5, 95% CI 1.5-8.4, P = 0.005) or IBS (OR 8.9, 95% CI 1.6-49.1, P = 0.01). CONCLUSIONS: QPCS occurs frequently in patients with PP, and subjects with QPCS experience more prolonged and complex pain.

Oophorectomy for ovarian torsion - should this be abandoned?

BACKGROUND: Management of ovarian torsion ranges from de-torsion to oophorectomy and is dependent on various factors. Oophorectomy can have significant implications for fertility and general health, thus requiring careful consideration. AIMS: We evaluate the management of ovarian torsion at a tertiary hospital over a ten-year period and identify the predictors of oophorectomy in ovarian torsion cases. MATERIALS AND METHODS: Inpatient notes of patients who underwent surgical management for acute ovarian torsion at a tertiary hospital in Victoria, Australia, were reviewed, from January 2008 to June 2018. We reported the incidence and predictors of oophorectomy and ovarian ischaemia and current practices in oophoropexy. RESULTS: Our analysis included 159 patients. The incidence of oophorectomy was 47%. After confounders were adjusted, increasing age was the only significant predictor for oophorectomy. The adjusted odds ratio of having an oophorectomy based on age alone was 1.10 for each year increase in age between the ages of 15 and 68 (P = 0.001, 95% confidence interval 1.04-1.16). Of those with oophorectomy, 57% had ischaemia confirmed histologically. There were no significant predictors for ischaemia. CONCLUSION: The incidence of oophorectomy in this audit is comparable to reported incidences in current literature. However, with increasing evidence to support ongoing ovarian function even in cases where ischaemia is histologically confirmed, this incidence could be lowered. Age was the only variable that was found to have a significant effect on the incidence of oophorectomy.

The role of social media in management of individuals with endometriosis: A cross-sectional study.

BACKGROUND: To better understand the potential role of social media (SM) as a self-management tool for individuals with endometriosis and to assess its current use by endometriosis patients. AIMS: The primary outcome was use of SM for health in patients with endometriosis. Secondary outcomes included preferred SM platforms for health information sharing and factors that influenced use, positive and negative experiences and reported impacts on health. MATERIALS AND METHODS: A single-centre, cross-sectional study performed within benign gynaecology units at a tertiary hospital in Melbourne, Australia. One hundred patients with a confirmed diagnosis of endometriosis participated. Individuals did not have to be users of SM. Data were collected through an electronic third-party survey tool (SurveyMonkey® ). Analysis methods included descriptive statistical analysis, frequency counts, as well as cross-tabulation to examine statistical association between variables. Free-text responses were qualitatively analysed using deductive-inductive semantic thematic analysis. RESULTS: Social media was used for health by 76% of patients with endometriosis in this study. SM users were younger, had pelvic pain for more than six months and reported higher rates of psychosocial impact and symptoms from endometriosis. Respondents reported overall positive impacts on psychological, social and cognitive health outcomes (76%) from SM use. CONCLUSION: In our cohort, a high number of people with endometriosis are using SM for health. These individuals are more likely to suffer both physical and psychosocial impacts from endometriosis. Hospitals and health organisations may consider support of the endometriosis community through SM.

Risk Factors and Outcomes of Conversion to Open Surgery in Benign Gynecologic Laparoscopies: A Case-Control Study.

STUDY OBJECTIVE: To describe cases of conversion from gynecologic laparoscopy to open surgery and to assess risk factors for conversion and conversion outcomes. DESIGN: A retrospective case-control study. SETTING: Tertiary referral hospital in Melbourne, Australia. PATIENTS: Eighty-five cases of conversion from laparoscopy to laparotomy and 170 controls matched by age, surgical date, and gynecologic unit from 2006 to 2017. INTERVENTIONS: Demographic, clinical, and surgical data were collected and compared between the study groups. Logistic regression was performed to identify preoperative and intraoperative risk factors for conversion. MEASUREMENTS AND MAIN RESULTS: Rate of conversion during the study period was 0.7%. The most common indication for conversion was unexpected surgical complexity (67% of cases), which included severe adhesive disease, specimen size, severe pathology, and inadequate views. Factors that were significantly associated with risk of conversion in multivariate analysis were previous pelvic inflammatory disease (adjusted odds ratio [aOR] 5.16; 95% confidence interval [CI], 1.35-19.71; p = .02), previous open surgery (aOR 3.62; 95% CI, 1.52-8.58; p <.01), history of endometriosis (aOR 2.96; 95% CI, 1.17-7.50; p = .02), and elevated body mass index (aOR 1.07; 95% CI, 1.01-1.13; p = .02). As compared with current surgery for endometriosis, odds of conversion were higher in surgeries for emergency indications (aOR 5.40; 95% CI, 1.53-18.98; p <.01), uterine pathologies (aOR 3.34; 95% CI, 1.10-10.12; p = .03), and adnexal pathologies (aOR 2.76; 95% CI, 1.19-6.40; p = .02). With the inclusion of intraoperative factors, surgical adhesions were also found to be associated with conversion (aOR 3.19; 95% CI, 1.30-7.85; p = .01). Most skilled laparoscopic surgeon level as defined by the Australasian Gynaecological Endoscopy and Surgery Society was not associated with conversion risk. Conversion to laparotomy was associated with a higher rate of intraoperative and postoperative complications and prolonged length of stay. CONCLUSION: Conversion to laparotomy is a rare but very important clinical outcome measure of laparoscopic surgery. Understanding the factors contributing to conversion and perioperative outcomes may help clinicians to identify and counsel patients before surgery and to reduce surgical morbidity.

Lower gastrointestinal function after surgery for deep endometriosis: A prospective cohort study.

OBJECTIVE: To prospectively compare long-term lower gastrointestinal function before and after laparoscopic surgery for deep endometriosis (DE). METHODS: In this prospective observational study we followed 149 patients with confirmed DE who were treated surgically. Patients completed the International Consultation on Incontinence Questionnaire Anal Incontinence Symptoms and Quality of Life Module (ICIQ-B) before surgery, and 6 weeks, 6 months, and 12 months after surgery. Bowel pattern, bowel control, and bowel impact on quality of life summary scores were compared before and after surgery. RESULTS: Bowel pattern score showed an increasing improvement at all time points after surgery, from a mean pre-operation score of 4.8 ± 2.0 to 4.4 ± 1.8 at 6 weeks, 4.2 ± 1.8 at 6 months, and 4.2 ± 1.2 at 12 months. Bowel impact on quality of life significantly improved from pre-surgery mean score of 5.5 ± 6.0 to 4.2 ± 5.5 at 6 weeks and 4.4 ± 5.4 at 6 months. Direct lower gastrointestinal endometriosis involvement and worse initial function were associated with larger improvements in scores following surgery. CONCLUSIONS: Lower gastrointestinal function significantly improved after surgical treatment of DE. Further research is needed to confirm our findings and to better characterize the sub-groups of patients for whom surgery will have a beneficial effect on their bowel function.

Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes.

Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.

Effect of Surgical Skin Antisepsis on Surgical Site Infections in Patients Undergoing Gynecological Laparoscopic Surgery: A Double-Blind Randomized Clinical Trial.

Importance: Gynecological laparoscopies are one of the most common surgical procedures worldwide. Limited evidence exists on rates of surgical site infections in patients undergoing gynecological laparoscopies and strategies to prevent these infections. Objective: To compare rates of port-site infections, organ or space infections, and any type of surgical site infections among patients who underwent gynecological laparoscopies and received 1 of 3 types of skin preparation solutions. Design, Setting, and Participants: A double-blind randomized clinical trial was conducted between February 28, 2017, and November 26, 2018, at a tertiary university-affiliated referral center. A total of 661 patients 18 years or older who underwent an elective operative laparoscopy for treatment of nonmalignant gynecological disorders were randomly assigned in a 1:1:1 ratio to have their skin cleaned before surgery with alcohol-based chlorhexidine, alcohol-based povidone-iodine, or water-based povidone-iodine. Statistical analysis was performed from February 28, 2017, to November 26, 2018. Analyses were performed on a modified intention-to-treat basis. Interventions: A total of 221 patients were randomized to have their skin prepared preoperatively with water-based povidone-iodine, 220 were randomized to alcohol-based povidone-iodine, and 220 were randomized to alcohol-based chlorhexidine. The patients were blinded to the solution used to clean their skin. Patients were followed up 1 and 4 weeks after surgery by a physician who was blinded to the skin preparation solution used at surgery. Evidence of infection according to Centers for Disease Control and Prevention criteria were documented. Main Outcomes and Measures: The primary outcome of this study was port-site infection 30 days after surgery. Secondary outcomes were organ or space infections and any type of surgical site infections; the study also aimed to prospectively describe rates of surgical site infections in gynecological laparoscopies. Results: Of the 661 patients, 640 (96.8%; mean [SD] age, 36.2 [10.6] years) were examined after surgery by a physician at the study site and were included in the modified intention-to-treat analysis. The overall rate of port-site infection was 10.2% (65 of 640), rate of organ or space infection was 6.6% (42 of 640), and rate of any surgical site infection was 16.3% (104 of 640). The odds ratio for port-site infection for alcohol-based chlorhexidine vs water-based povidone-iodine was 1.13 (95% CI, 0.61-2.08), for alcohol-based chlorhexidine vs alcohol-based povidone-iodine was 1.34 (95% CI, 0.71-2.52), and for water-based povidone-iodine vs alcohol-based povidone-iodine was 1.19 (95% 0.62-2.27). Conclusions and Relevance: Surgical site infections were more common than expected among patients who underwent gynecological laparoscopies. No skin preparation solution provided an advantage compared with the other solutions in reducing infection rates. Trial Registration: http://anzctr.org.au Identifier: ACTRN12617000475347.

Lung function in adult survivors of very low birth weight, with and without bronchopulmonary dysplasia.

INTRODUCTION: The lung function outcome of cohorts of very low birth weight (VLBW; birth weight <1501 g) survivors born in the late 1970s or early 1980s into adulthood at an age when lung growth would be expected to have ceased is not well described. The aim of this study was to report lung function data in adulthood of VLBW survivors compared with normal birth weight controls (>2499 g), and in those who had bronchopulmonary dysplasia (BPD) compared with those without BPD. MATERIALS AND METHODS: Spirometry and lung volumes were measured according to standard guidelines when subjects were in their mid-20s; there were 47 survivors of birth weight <1000 g, 40 of birth weight 1000-1500 g, and 20 controls of birth weight >2499 g. Results were converted to z-scores. RESULTS: Both subgroups with birth weight <1501 g had significant reductions in airflow compared with controls, but not compared with each other. There were no significant differences between groups in variables reflecting air trapping. Within the VLBW cohort, those with BPD (n = 24) had reductions in airflow, including the z-score for the forced expired volume in 1 sec (FEV1 ), compared with those without BPD (n = 63). Within the VLBW cohort, there were positive relationships between FEV1 measurements earlier in childhood with those obtained at 25 years of age; these relationships were stronger in those who had BPD in the newborn period, and increased over time. CONCLUSIONS: VLBW survivors continue to have airways obstruction in their mid-20s compared with controls, particularly those who had BPD in the newborn period.