Identification of predictors of success, in the radical laparoscopic excision of endometriosis, for chronic pelvic pain

Aims: Identification of parameters, predictive of symptomatic improvement in pelvic pain, for women undergoing radical laparoscopic excision of endometriosis. Design and Methods: Prospective observational study involving 108 women presenting to a tertiary pelvic pain clinic over twelve-month period. Detailed questionnaires, both preoperatively and eighteen months postoperatively were completed. They consisted of a ranked ordinate scale scoring for symptoms (dysmenorrhoea, dysparunia, dyschezia, non cyclical pelvic pain, exercise related pelvic pain and backache) quality of life measures using the EuroQoL, health, EQ-5D and depression score using the General Health Questionnaire (GHQ). All women requiring surgery underwent complete excision of all visible endometriosis lesions using monopolar diathermy and diagnosis was confirmed by histology. Intra-operative data including calculation of the revised American Fertility Society (rAFS) score were also entered into the analysis. All data was prospectively collected on a specifically designed database (Endostat™). Changes in symptom severity were compared to the preoperative and intra-operative variables with an a im to identify parameter s predictive of improvement. Results: Of the 88 (81.5%) women with a positive surgical diagnosis, 74 (68.5%) had intact gynaecological organs and were treated by radical laparoscopic excision of their endometriosis. Complete data sets were available on 44 (61%) women and used for analysis with data from women with a negative laparoscopy used as a control. The median rAFS score was 9 (range 1 to 74). Twenty-seven (61.4%) demonstrated improvement in their global symptom scores. Using the Mann Whitney test, there was a direct correlation between improvement and severity of presenting symptoms (p=0.003) and in particular dyschezia. There was also a correlation with the presence of uterosacral disease (p=0.008). Fatigue and total pain scores were directly related to level of psychological morbidity (p=0.001 and 0.002 respectively). The GHQ was related to the number of days of severe pain per month (p=0.002). The rAFS scores were not predictive of outcome unlike the type of lesion (p=0.09), whether superficial or deep. Conclusions: Women most likely to benefit from surgery are those with the higher pain scores, dyschezia or women with nodular and uterosacral disease. AFS scores were not however prognostic of outcome. There is a significant psychological morbidity but this does not improve significantly or correlate with change in symptom scores following surgery.