JH u a z hongU n ivS c iT e c hno l[M e dS c i ] 34 ( 2 ) :2 13 21 9 , 2 01 4 DO I10 . 10 07 / s1 15 9 6 -0 14 -1 26 1 9 JH u a z hongU n ivS c iT e c hno l ［M e dS c i］ 34 (2 ) :2 01 4
21 3
R i skFa c to r sfo rR e cu r r en c eo fOva r i anEnd om e t r i om a sa f t e r * Su rg i ca lEx c i s ion M i n gYUAN(袁 明) ,W en -w en WANG( 汪雯雯) ,Y anL I( 栗 妍) ,L i n gGAO( 高 玲) ,T i an WANG( 王 恬) , # Sh i -xu an WANG(王世宣) D epa r tm en to fOb s t e t r i c sandG yn e co log y ,T ong j iHo sp i ta l ,T ong ji M ed i ca lCo l l eg e ,Hua zhongUn i v e r s i t yo fS c i en c eandT e chno lo g y , W uhan430030 ,Ch ina ©Hu a zhongUn iv e r s i tyo fS c i en c eandT e chno lo g y andSp r ing e r -V e r l agB e r l inH e id e lb e r g2014
Summa ry :Ov a r i anendom e t r iom ai sacomm onfo rmo fendom e t r io s i s , wh i ch m a yc au s ein f e r t i l i t y , d y sm eno r rh e aandp e lv i cp a inin wom eno fr ep r odu c t iv eag e .A l thoughsu r g e r yi sth et r e a tm en to f cho i c efo rendom e t r iom a s ,r e cu r r en c epo s e saf o rm id ab l ef ru s t r a t ion .Th i ss tud yinv e s t ig a t edp o t en t i a l r i skf a c to r so fendom e t r iom a sr e cu r r en c e ,a im in gtob e t t e rund e r s t andi t sp a thog en e s i s . Ato t a lo f307 p a t i en t sw i then dom e t r iom a sw e r efo l low edupf o ranav e r ag eo f28 .6 mon th san dth e1 ,2 -and3 y e a r cum u l a t iv er e cu r r en c er a t ew a s9 . 5% ,21 .9% ,and29 .2% ,r e s p e c t iv e l y .Tw en t y -on epo t en t i a lr i s kf a c to r s fo rendom e t r iom a sr e cu r r en c ew e r eev a lu a t edu s ingCox ’ sp ro po r t ion a lh a z a rd s mod e l s .T o t a lr ev i s ed Am e r i c anF e r t i l i tySo c i e ty( rAFS )s co r ew a ss ign i f i c an t lya s so c i a t edw i thh igh e rr e cu r r en c e(OR=1 .858 , 95%C I=1 .122– 3 .075 ,P=0 .016 ) ,a sw e l la syou ng e rag ea tsu r g e r y(OR=0 .953 ,95%C I=0 .915– 0 .992 , P=0 .020 ) .S em i r ad i c a lsu r g i c a lt r e a tm en tw a sd e f in eda ssu r g i c a lr em ov a lo fcy s tp lu sh y s t e r e c tomy w i thp r e s e rv a t io no fb i l a t e r a lo run i l a t e r a lov a r y ,and w a sas ign i f i c an tf a c to rth a tw a sa s s o c i a t ed w i th low e rr e cu r r en c eth anth econ s e r v a t iv esu r g e r y(OR=0 .318 ,95%C I=0 .107–0 .95 1 ,P=0 .040 ) .Po s top e r a t iv ep r egn an cy w a sf avo r ab l ef a c to r sfo rd i s e a s er e cu r r en c e(OR=0 .217 , 95% C I=0 .102– 0 .460 , P=0 .000 ) .Th er e su l t ssugg e s tth a tendom e t r iom ar e cu r r en c ei sin v e r s e lya s so c i a t edw i thag ea tsu r g e r y andpo s top e r a t iv ep r egn an cy ,andm ayco r r e l a t ew i thto t a lrAFSs co r eandcon s e rv a t iv esu r g e r ym e thod . K e ywo rd s :ov a r i anendom e t r iom a s ;r e cu r r en c e ;r i skf a c to r s ;su r g e r y
Endom e t r io s i s , a comm on and b en i gn gyn a e co log i c a ld i s o rd e r ,i sch a r a c t e r i z edbyth ep r e s e n c eo ffun c t i on a le nd om e t r i um l i k et i s s u eo u t s i d et h eu t e r i n e [1 ] . T h e m a i nc l i n i c a l m a n i f e s t a t ion si n c l ud e c a v i t y dy s p a r e u n i a ,d y sm e no r r h e a ,p e l v i cp a i na n di n f e r t i l i t y . O v a r i a ne nd om e t r i om ai st h em o s tc omm onf o rmo fe n dom e t r i o s i s .I na dd i t i o n ,i ti sd e em e da sa m a r k e rf o r u r op e a n g r e a t e rs e v e r i t yi ns ym p t om a t i cp a t i e n t s[2],andE So c i e t yo f Hum a n R e p r od u c t i o na n d Em b ry o l o gy (ESHRE )r e c omm e nd st h a th i s t o l ogysh o u l db eo b t a i n e d t oe x c l u d er a r ei n s t a n c e so fm a l i g n a n c yi nc a s eo fe nd o u r g i c a l m e t r i om ao fm o r et h a n 3cmi nd i am e t e r[3]. S t r e a tm e n ttoendom e t r iom am ayb ee f f e c t iv einr e l i ev ing a s s o c i a t e dp a i ns ym p t om sa ndim p ro v i n gi n f e r t i l i t y t ho ug ht h er e l i e fo fs ym p t om si sa s so c i a t ed w i tht h e [4 ] . Af r u s t r a t i ngi s s u e t r e a tm e n to fc on c om i t a n td i s e a s e fo rs u r g i c a lt r e a tm en ti spo s top e r a t iv er e c u r r en c e .R e cu r r en c ea n dr ep e a t eds u rg e r yin c r e a s ed m o rb id i tyand h e a l t hc a r ec o s t sa n d ,i no v ar i anen d om e t r i o s i s ,c ou l d c au s es ign i f i c an tov a r i and am ag eandr e du c eim p rov ed f e r t i l i t y .A c c o r d i ng l y ,a v o i d i ng d i s e a s er e c u r r e n c ei s M ingYUAN ,E -m a i l :yu an_7566 p ig@163 . com # Co r r e spond ingau tho r ,E -m a i l :s xw ang2012@ho tm a i l . com * Th i s p ro j e c t w a s suppo r t ed b y th e N a t ion a l S c i en c e Found a t ionfo rY oungS c i en t i s t so fCh in a(No .81 000240 ) .
p r e s e n t l yanu nm e tm e d i c a ln e edi nt h em a n ag em e n to f e nd om e t r i o s i s . T od a t e ,s e v e r a ls t ud i e sh a v eb e enc o nd u c t e dt oi n v e s t i g a t ep o t e n t i a lr i s kf a c t o r so fe nd om e t r i om a sr e c u r r en c ef o rb e t t e ru n d e r s t a nd i n gi t sp a t h og e n e s i s .How e v e r , th er e po r t edr i skf a c t o r sf o rr e c u r r e n c eb yd i f f e r e n ts t u d i e sa r eo f t e nc on f l i c t i ng .A sf o rp a t t e r n so fd i s e a s er e l a p s e ,l i t t l ea t t e n t i onh a sb e e nr e c e i v e d .T h e r e f o r e ,ou r kn ow l e d g ea b ou tt h er i s kf a c t o r sf o ra ndt h ep a t t e r n so f r e c u r r e n c eo fo v a r i a ne nd om e t r i om ai ss t i l lqu i t el im i t e d . H e r e ,w ec on d u c tafo l l ow -u ps t udyo f37 5p a t i e n t sw i t h e nd om e t r i om aa nda t t em p tt oi d e n t i fyp ro g n o s t i cf a c t o r s t h a tm i gh ti n f l u en c eb o t hr e c u r r en c er i s kan dp a t t e r n so f r e cu r r e n c ei nCh in e s ee n dom e t r iom ap a t i en t s . 1 MATER IALSAND METHODS W om e ni nr e p ro d u c t i v ea g e(1 5 –4 9y e a r so l d )w ho un d e rw e n tc o n s e r v a t i v eo rs em i r ad i c a l su r g e ry by l a p a r o s c o pyo rl a p a ro t om yfo ro v a r i a ne n d om e t r i om ai n T on g j i H o s p i t a l ,T on g j i M e d i c a lC o l l e g e , H u a z h o ng U n i v e r s i t yo fS c i e n c ea nd T e c h n o l o g y(HUST ,C h i n a ) f r omJ a n .1 ,2 01 0t oD e c .3 1 ,20 1 1p a r t i c i p a t e di nt h i s r e t r o s p e c t i v es t udy .C a s e si nw h i c hh i s t o l o g i c a l l yc on f i rm edendom e t r iom aw a sani n c i d e n t a lf i n d i n gw e r e a l soi n c l ud e d .A l ld i a gn o s e sw e r eco n f i rm e dh i s t o l o g i c a l l y .P a t i e n t sw e r ee x c l u d e di ft h e yh a d( 1 )p r e v i ou s
21 4
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s u r g e r yf o re n dom e t r i o s i s ;( 2 )d i a gn o s i so fg e n i t a lm a l fo rm a t ion ;(3 )a c com p an i ed w i thgyn e c o log i cm a l ign an t t um o r ;(4 )a g e> 45y e a r s .T h es t u dyw a sa p p ro v e dbyt h e M e d i c a lE t h i c sC omm i t t e eo fT o n g j iM e d i c a lC o l l e g e , HUST(C h i n a ) ,a ndi n f o rm edco n s e n tw a so b t a i n edf r om e a chp a r t i c ip a n t . Ina l lc a s e s ,t h esu r g i c a lp ro c edu r e sa im edtor e m ov ea l lv i s i b l eim p l an t so fe nd om e t r i o s i s .Th ec ho i c eo f l a p a r o s co pyo rl a p a r o t om yw a sm a d em a i n lybyt h ep a t i en t ,b e c au s el ap a ro s copyi sm o r eexp en s iv eth a nl ap a ro t om y .A sf o rm e t hodo fsu r g e ry ,i td e p e nd edo nc om p l ex i t yo fd i s e a s ean dp a t i e n t s ’d e s i r ef o rp r eg n a n cy . S em i r ad i c a lsu r g e ryi sd e f i n eda ss u r g i c a lr em ov a lo f cy s t sp l u shy s t e r e c t om yw i t hp r e s e rv a t i ono fb i l a t e r a lo r un i l a t e r a lo v a r y ,w h i l ec o n s e r v a t i v es u r g e r ya ss u r g i c a l r em ov a lo fc y s t sw i t hp r e s e r v a t i ono ff e r t i l i ty Du r i n gt h ef i r s tro un ds e l e c t i on ,at o t a lo f42 7p a t i e n t s w i t hh i s t o l o g i c a l l y con f i rm e d ov a r i an e n do m e t r iom aw e r eco l l e c t ed ,a n do fth e s e ,28c a s e sund e r w en tr a d i c a ls u r g e ry ,17c a s e sh adah i s t o r yo fe n dom e t r io s i s r e l a t edsu r g e ry ,3c a s e sh a dag e> 45y e a r sa ts u r g e rya nd2c a s e sw e r ea c co m p an i ed w i thgyn e c o log i c m a l i gn a n td i s e a s e s ,t h e nat o t a lo f3 7 7p a t i e n t sw e r ee l i g i b l efo rt h i ss t udy . Fo re a chp a t i e n t ,g en e r a lin fo rm a t ion w a sco l l e c t ed t h r ou g hr e a d i n gm e d i c a lr e co r d sa ndi nq u i r i n gp a t i e n t s by p h on e ,i n c l ud i n gd em og r ap h i cd a t a ,c om p l a i n to f dy sm e no r r h e ao ri n f e r t i l i t y ,d u r a t i o na n ds e v e r i t yo f dy sm e no r r h e a ,p r e v i o u se n d om e t r i o s i s r e l a t e ds u r g e r i e s , i fany ,t y p e sa ndd u r a t i o no fho rm on a lt h e r apyb e fo r eo r a f t e rs u r g e ry ,im p rov em en to fsym p tom a to logy ,p r eg n an cya f t e rs u r g e ryan dt im et or e c u r r e n c e .T y p e so f wo rkw e r ei n c l ud e di nt h e s etw oc a t e g o r i e s :p h y s i c a la nd m e n t a lw o r k .A sf o rc l i n i c o p atho log i c a lch a r a c t e r i s t i c so f e nd om e t r i om a ,d e t a i l e di n f o rm a t i on w a sr e c o r d e di no p e r a t i v en o t e .F o rt h ep r e s e n ts t udy ,t h ef o l l ow i ngd a t a w e r ee x t r a c t e d :l o c a l i z a t i on o fl e s i o n ,a n da dh e s i o n s , d e e pi n f i l t r a t i n gim p l a n t s ,c u l -d e s a co b l i t e r a t i on ,s i z eo f ov a r i a ne n d om e t r i om a s . A sac u s t om ,a l lp a t i e n t sw e r ec l i n i c a l l yf o l l ow e du p fo r3 ,6a nd12 m on t h sa f t e rs u r g e ryan dsu b s eq u en t l ya t l e a s ttw i c eay e a r .A te v e r yf o l l ow u pv i s i t ,as t a n d a r d gy n a e c o l o g i ce x am i n a t i ona n dat r a n s v a g i n a lu l t r a s ou n d s c an(TV -US )w e r ep e r fo rm ed .Sym p tom sandc l in i c a l d a t aw e r er e c o r d e d .D a t aa bo u tf e r t i l i t yp r o b l em sa nd p r e g n an c i e sfo rt h o s e wh od e s i r edt oco n c e i v ew e r ec o l l e c t ed .
R e cu r r en c eo fov a r i ane n dom e t r i om ai nt h i ss t u dy w a sd e f i n e da st h ep r e s en c eo f a hom og e n eo u s h y p o e c h o g e n i cc y s t sw i t hat yp i c a la s p e c td e t e c t e db y TV -US m o r eth an3cmind iam e t e randd idn ’ td i s a pp e a r f o l l ow i n gt h em e n s t r u a lc y c l e .S im i l a rd e f i n i t i on h a s b e enu s edino th e rs tud i e sb e c a u s eu l t r a s o n i cd e t e c t i o n cou l dp rov i d e >90% d i agno s t i ca c cu r a c y fo re n do – end i s e a s er e cu r r e n c eo c cu r r eddu r i ng m e t r i om a s[57]. Wh t h ef o l l ow u pp e r i od ,t h et im eb e tw e e ns u r g e r ya n dt h e on s e to fr e cu r r en c ew a sr e co rde da st im e to r e cu r r e n c e , i fn o t ,t h et im eb e tw e e ns u r g e rya ndt h el a s tm on t ho f fo l l ow u pw a sr e c o r d e da sc e n s o r e dt im etor e c u r r e n c e . Th es e v e r i tyo fd i s e a s ew a sev a lu a t e da tth et im eo fsu r g e rya n ds t ag e da c c o r d i n gt ot h er ev i s e d Am e r i c anF e r t i l i t yS o c i e t y( rAFS )c l a s s i f i c a t i on . S t a t i s t i c a lan a ly s i sw a sp e r fo rm edu s ingSPSS17 .0 so f tw a r e(SPSS , USA ) .T h ed i s t r ib u t io no fd a t aw a s t e s t ed by K o lm ogo r ov -Sm i rno vt e s t .C o n t i nuo u sv a r i ,wh e r e a sc a t ego r i cv a r i ab l e s ab l e sw e r ep r e s en t eda s ±s w e r ep r e s e n t e da sf r e qu e n c ya ndp e r c e n t a g e .Q u a n t i t a t iv ev a r i ab l e sw e r ec om p a r edbyS t ud en t ’ st t e s t s ,a n d qu a l i t a t i v ev a r i a b l e sw e r ea n a l y z e du s i ngF i s h e r ’ se x a c t t e s to rch i sq u a r et e s t s .Th eK ap l a n -M e i e rm e t hod w a s u s e dt oc a l c u l a t et h ec um u l a t i v ep r ob a b i l i t yo fe n do m e t r iom ar e cu r r en c e ,a n dC ox ’ sp ro p o r t i on a lh a z a rd s m od e l sw e r eu s e dtoe s t im a t eth ee f f e c to fs ev e r a lco v a r i a t e s . APv a l u e< 0 . 0 5w a sc o n s i d e r e dt ob es t a t i s t i c a l l ys i g n i f i c a n t . 2RESULTS O f3 77e l i g i b l ep a r t i c i p a n t s ,tw oc a s e sw e r ee x c lud e db e c au s eo fd i s e a s er e l a p s ed e t e c t e db yu l t r a s o u n d w i t h i n3 m on t h sa f t e rl a p a r o s c o p i ce x c i s i o n ,w h i c hw a s c on s i d e r e da ss u r g i c a lf a i l u r e s .U l t im a t e l y ,th ec h a r a c t e r i s t i c so f3 7 5p a t i e n t sw e r es umm a r i z e di nt a b l e1 .A sc a n b es e e nf romt h et a b l e ,ov e rh a l fo f( 57 . 3% )p a t i e n t s com p l a i n edo fdy sm eno r rh e a ,bu tt h ead n e x a lm a s sw a s t h em a jo rc a u s efo rs u r g e ry( i n2 4 6c a s e s ) . Am ong3 75 p a t i e n t s ,3 0 7( 81 . 9% )o ft h em w e r ef o l l ow e du pfo ra n av e r a g eo f28 . 6m on t h s( r a ng i ngf rom12 .8 – 38 .4 m on t h s ) . T h er e s tp a t i e n t sw e r em o s t l yl o s tt of o l l ow u p .T h e c h a r a c t e r i s t i c so fp a t i e n t sw h ol o s tt of o l l ow up w e r e summ a r i z ed( t ab l e2 ) . Nos t a t i s t i c a ld i f f e r en c ew a sob s e r v e di nt h e s ec h a r a c t e r i s t i c sb e tw e e np a t i e n t sw h ow e r e a ndw e r e n ’ tl o s tt of o l l ow up ,w h i c hs u g g e s t e dnos e l e c t i onb i a si no u rco ho r t .
T ab l e1Cha ra c t e r i s t i c so fpa t i en t sa F a c to r s Ag ea tm en a r ch e( y e a r s ) Ag ea tsu r g e r y( y e a r s ) In f e r t i l i ty P r im a r y S e cond a r y D y sm eno r rh e a rAFSs t ag i n g Ⅰ 0 Ⅱ 0 Ⅲ 217 Ⅳ 158
No .o fc a s e s(% )o r ±s 13 .2±1 .3 32 .4±7 .1 101(26 .9 ) 38(10 .1 ) 215(57 .3 )
(57 .9 ) (42 .1 )
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(T ob econ t inu ed ) Adn ex a lm a s s 246(65 .6 ) In f e r t i l i ty 68(18 .1 ) D y sm eno r rh e a 16(4 .3 ) C y s trup tu r e 3(0 .8 ) D IE 1(0 .3 ) Abdom in a lEm s 1(0 .3 ) M yom ao rAd enom yo s i s 31(8 .3 ) O th e rb en igng yn e co log i c a ld i s e a s e 9(2 .4 ) L a t e r a l i t y L e f ton ly 157(41 .9 ) R igh ton ly 107(28 .5 ) B i l a t e r a l 1 1 1(29 .6 ) Co ex i s t en c eo fo th e rtyp eEM s P e r i ton e a ll e s ion s 91(24 .3 ) D e epEm s 62(16 .5 ) Abdom in a lEM s 1(0 .3 ) Adh e s ion s M emb r anou sadh e s ion 156(41 .6 ) D en s eadh e s ion 125(33 .3 ) Cu ld es a cob l i t e r a t ion Ab s en t 313(83 .5 ) P a r t i a l 37(9 .9 ) Com p l e t e 25(6 .7 ) rAFS :r ev i s edAm e r i c anF e r t i l i tySo c i e ty ;D IE :d e epin f i l t r a t inge n d om e t r i o s i s ;Em s :endom e t r io s i s a V a lu e sa r eg iv e na snum b e r(p e r c en t ag e )o r ±s . T ab l e2Compa r i sono fcha ra c t e r i s t i c sb e tw e enr e c ru i t edpa t i en t sandpa t i en t slo s ttofo l low -up Cov a r i ab l e s R e c ru i t edp a t i en t s(n=307 ) P a t i en t slo s ttof o l low -up( n=68 ) Pv a lu e s Ag ea tsu r g e r y( y e a r s ) 32 .70±7 .13 30 .99±6 .85 0 .495 Ag ea tm en a r ch e( y e a r s ) 13 .22±1 .33 13 .25±1 .33 0 .792 rAFSs co r e 42 .79±24 .68 41 .59±22 .81 0 .1 16 rAFSs t ag ing 1 .000 Ⅲ 178(57 .98 ) 39(57 .35 ) Ⅳ 129(42 .02 ) 29(42 .65 ) O c cup a t ion 0 .220 Ph y s i c a l 234(76 .22 ) 47(69 .12 ) M en t a l 73(23 .78 ) 21(30 .88 ) Comp l a in to fd y sm eno r rh e a 0 .282 Y e s 180(58 .63 ) 35(51 .47 ) No 127(41 .37 ) 33(48 .53 ) P a r i ty 0 .278 P a rou s 132(43 .00 ) 24(35 .29 ) Nu l l ip a rou s 175(57 .00 ) 44(64 .71 ) Numb e ro fp r ev iou sindu c edabo r t ion s 0 .934 0 164(53 .42 ) 36(52 .94 ) 1 62(20 .00 ) 15(22 .06 ) 2 81(26 .38 ) 17(25 .00 ) L a t e r a l i ty 0 .538 L e f ton ly 128(41 .69 ) 29(42 .65 ) R igh ton ly 91(29 .64 ) 16(23 .53 ) B i l a t e r a l 88(28 .66 ) 23(33 .82 ) P r ev iou sabdom in a lsu r g e r y 0 .469 Y e s 97(31 .92 ) 18(26 .47 ) No 210(68 .08 ) 50(73 .53 ) Comb in a t ionw i thad enom yo s i s 0 .379 Y e s 56(18 .24 ) 9(13 .24 ) No 251(81 .76 ) 59(86 .76 ) Comb in a t ionw i th m yom a 0 .155 Y e s 75(24 .43 ) 1 1(16 .18 ) No 232(75 .57 ) 57(83 .82 ) M e thodo fsu r g e r y 0 .071
21 5
21 6 (T ob econ t inu ed ) S em i r ad i c a l Con s e rv a t iv e Mod eo fsu r g e r y L ap a ro tom y L ap a ro s cop y D a t aa r er ep r e s e n t eda s ±s ,o rn(% ) .
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55(17 .92 ) 252(82 .08 )
6(8 .82 ) 62(91 .18 )
59(19 .22 ) 248(80 .78 )
10(14 .71 ) 58(85 .29 )
F o rt h ee n t i r ec oh o r tf o l l ow e du pp e r i o d i c a l l y ,63 ( 2 0 . 5% )p a t i e n t sw e r ei d e n t i f i e da sr e c u r r e n c ebyTV -US . Th e1 ,2 -a n d3 -y e a rcum u l a t iv er e c u r r e n c er a t ew a s 9 . 5% ,21 .9% ,and29 .2% ,r e s p e c t i v e l y( f i g .1 ) .T h ee s t i m a t e dcum u l a t i v eh a z a rd w a sv i r t u a l l yco n s t a n td u r i n g t h ef i r s t2y e a r sp o s t o p e r a t i v e ly ,andt h en ,i td e c r e a s ed g r a d u a l l y . Ah i gh e rr i sko fr e cu r r en c ew a sfo un di nt h e f i r s t2y e a r s ,c om p a r edt oth efo l low i ngy e a r s .
F ig .1 Su rv iv a lcu rv eo fu l t r a so undr e cu r r en c einp a t i en t sw i th ov a r i anendom e t r iom a
T h ec h a r a c t e r i s t i c so fp a t i e n t sw i t ho rw i t ho u tr e c u r r e n c eo fo v a r i a ne n d om e t r i om aa ndt h er e s u l to fun i v a r i a t ean a ly s e sw e r el i s t edint ab l e3 .T h eun iv a r i a t e
0 .489
a n a l y s e sr e v e a l e dt h a ta g ea tm e n a r c h e ,bo d ym a s si nd e x (BM I ) ,t y p e so fw o r k(p hy s i c a lo rm e n t a l ) ,d y sm e no r rh e a , i n f e r t i l i t y ,p a r i t y ,num b e ro fp r e v i o u si nd u c e da bo r t i on s , l a t e r a l i t yo fe n dom e t r i om a ,adh e s i o n s ,C u ld es a co b l i t e r a t ion ,p r e s en c eo fad e n om y o s i so rm y om a ,p r e v i ou s h i s t o ryo fab d om i n a lsu r g e ry ,a nd m od eo fs u r g e ryd i d no ts i gn i f i c a n t l yi n f l u e n c er e c u r r en c er i s k .Ag ea tsu r g e ry , l a r g e s tc y s td i am e t e r( cm ) ,rAFSs c o r e ,rAFSs t a g e , m e t hod o fs u r g e rya nd po s t op e r a t i v ep r e g n an cy w e r e con s id e r e da sr i skf a c to r sfo rr e c u r r e n c eo fov a r i ane n dom e t r i om a s( t ab l e3 ) .H ow e v e r ,p o s t op e r a t i v em ed i c a t i on(G nRH a )d i dn o ts e emt oi n f l u e n c et h ee nd o m e t r iom ar e cu r r en c er a t e . A c co r d i n gt oab a c kw a r de l im i n a t i onp r o c edu r eo f v a r i a b l es e l e c t i on ,s i xv a r i a b l e s[ ag ea tsu r g e ry ,l a r g e s t cy s td i am e t e r( cm ) ,rAFSs c o r e ,rAFSs t a g e ,m e t hodo f s u r g e rya n dp o s t o p e r a t i v ep r e gn a n c y ]w e r es e l e c t e df o r m u l t i v a r i a b l es u r v i v a la n a l y s i su s i ng C o xp r o p o r t i o n a l H a z a rd m od e l .S ign i f i c an tf ac to r sth a tw e r eind e p end e n t l ya s s o c i a t e dw i t hl ow e rr e cu r r en c ew e r eag ea ts u r g e ry (OR= 0 . 95 3 , 9 5% C I=0 . 9 15 – 0 . 99 2 , P= 0 . 0 20 ) , m e t hod o fs u r g e ry(OR= 0 . 31 8 ,9 5% C I=0 . 10 7 –0 .9 5 1 , P=0 . 0 40 )an dpo s t o p e r a t i v ep r e g n an cy(OR= 0 . 21 7 ,95% C I= 0 . 1 02 – 0 . 46 0 , P< 0 . 00 1 ) .I n t e r e s t i n g l y ,n e i t h e rl a r g e r d i am e t e ro fth el a r g e s tcy s tno ra d v an c e drAFSs t ag ew a s s ign i f i c a n t lya s so c i a t edw i thr e cu r r en c e ,bu th igh e rrAFS s co r ew a ss ign i f i c an t lya s so c i a t edw i thh igh e rr e cu r r e n c e (OR= 1 . 85 8 ,9 5%C I= 1 . 12 2 –3 . 0 75 ,P= 0 . 0 16 )( t ab l e4 ) .
T ab l e3Ch a ra c t e r i s t i c so fp a t i en t sw i thandw i th ou tr e cu r r en c eo fova r ianend om e t r ioma sandPva lu e sf r omun iva r ia t eCox r eg r e s s ionana ly s i s Cov a r i ab l e s Non r e cu r r en t( n =244 ) R e cu r r en t( n =63 ) Pv a lu e s Ag ea tsu r g e r y( y e a r s ) 33 .4±7 .3 30 .1±5 .8 0 .003 Ag ea tm en a r ch e( y e a r s ) 13 .3±1 .4 13 .1±1 .2 0 .837 BM I 21 .4±3 .0 23 .18±4 .1 0 .080 L a r g e s tcy s td i am e t e r( cm ) 5 .6±2 .8 6 .7±2 .5 0 .005 rAFSs co r e 41 .0±24 .0 49 .8±26 .3 0 .002 rAFSs t ag ing 0 .003 Ⅲ 150(61 .5 ) 28(44 .4 ) Ⅳ 94(38 .5 ) 35(55 .6 ) T yp e so fwo rk 0 .281 Ph y s i c a l 190(77 .9 ) 44(69 .8 ) M en t a l 54(22 .1 ) 19(30 .2 ) Comp l a in to fd y sm eno r rh e a 0 .883 Y e s 140(57 .4 ) 40(63 .5 ) No 104(42 .6 ) 23(36 .5 ) In f e r t i l i ty(p r im a r yands e cond a r y ) 0 .324 Y e s 86(35 .3 ) 28(44 .4 ) No 158(64 .7 ) 35(55 .6 ) P a r i ty 0 .279 P a rou s 1 1 1(45 .5 ) 21(33 .3 ) Nu l l ip a rou s 133(54 .5 ) 42(66 .7 )
21 7
JH u a z hongU n ivS c iT e c hno l ［M e dS c i］ 34 (2 ) :2 01 4
(T ob econ t inu ed ) Numb e ro fp r ev iou sindu c edabo r t ion s 0 126(51 .6 ) 1 54(22 .1 ) 2 64(26 .2 ) L a t e r a l i ty L e f ton ly 107(43 .9 ) R igh ton ly 73(29 .9 ) B i l a t e r a l 64(26 .2 ) Adh e s ion s Ab s en t 31(12 .7 ) M emb r anou s 1 17(48 .0 ) D en s e 96(39 .3 ) Cu l -d e s a cob l i t e r a t ion Ab s en t 199(81 .6 ) P a r t i a l 27(1 1 .1 ) Comp l e t e 18(7 .4 ) Comb in a t ionw i thad enom yo s i s Y e s 44(18 .0 ) No 200(82 .0 ) Comb in a t ionw i th m yom a Y e s 62(25 .4 ) No 182(74 .6 ) P r ev iou sabdom in a lsu r g e r y Y e s 76(31 .2 ) No 168(68 .8 ) M e thodo fsu r g e r y Con s e rv a t iv e 193(79 .1 ) S em i r ad i c a l 51(20 .9 ) Mod eo fsu r g e r y L ap a ro tom y 49(20 .1 ) L ap a ro s cop y 195(79 .9 ) Po s top e r a t iv ep r egn an cy Y e s 87(35 .7 ) No 157(64 .3 ) Po s top e r a t iv em ed i c a t ion GnRHagon i s t 109 Non e 124 BM I :bod ym a s sind ex .D a t aa r er ep r e s en t eda s ±s ,o rn(% ) .
38(60 .3 ) 8(12 .7 ) 17(27 .0 ) 21(33 .3 ) 18(28 .6 ) 24(38 .1 ) 7(1 1 .1 ) 31(49 .2 ) 25(39 .7 ) 48(76 .2 ) 8(12 .7 ) 7(1 1 .1 ) 12(19 .1 ) 51(80 .9 ) 13(20 .6 ) 50(79 .4 ) 21(33 .3 ) 42(66 .7 ) 59(93 .6 ) 4(6 .4 ) 10(15 .9 ) 53(84 .1 ) 8(12 .7 ) 55(87 .3 ) 23 38
0 .189
0 .066
0 .798
0 .713
0 .194 0 .957 0 .565 0 .017 0 .577 0 .001 0 .195
T ab l e4 Mu l t iv a r iab l e Coxp r opo r t iona l Ha z a rd mod e l so fr i skfa c to r sa s s o c ia t ed w i thr e cu r r en c eo fend om e t r iomaa f t e r su rg e ry Cov a r i ab l e s Exp() 95%C I Pv a lu e s Ag ea tsu r g e r y( y e a r s ) 0 .953 0 .915–0 .992 0 .020 rAFSs co r e 1 .858 1 .122–3 .075 0 .016 M e thodo fsu r g e r y 0 .318 0 .107–0 .951 0 .040 Po s top e r a t iv ep r egn an cy 0 .217 0 .102–0 .460
21 3
R i skFa c to r sfo rR e cu r r en c eo fOva r i anEnd om e t r i om a sa f t e r * Su rg i ca lEx c i s ion M i n gYUAN(袁 明) ,W en -w en WANG( 汪雯雯) ,Y anL I( 栗 妍) ,L i n gGAO( 高 玲) ,T i an WANG( 王 恬) , # Sh i -xu an WANG(王世宣) D epa r tm en to fOb s t e t r i c sandG yn e co log y ,T ong j iHo sp i ta l ,T ong ji M ed i ca lCo l l eg e ,Hua zhongUn i v e r s i t yo fS c i en c eandT e chno lo g y , W uhan430030 ,Ch ina ©Hu a zhongUn iv e r s i tyo fS c i en c eandT e chno lo g y andSp r ing e r -V e r l agB e r l inH e id e lb e r g2014
Summa ry :Ov a r i anendom e t r iom ai sacomm onfo rmo fendom e t r io s i s , wh i ch m a yc au s ein f e r t i l i t y , d y sm eno r rh e aandp e lv i cp a inin wom eno fr ep r odu c t iv eag e .A l thoughsu r g e r yi sth et r e a tm en to f cho i c efo rendom e t r iom a s ,r e cu r r en c epo s e saf o rm id ab l ef ru s t r a t ion .Th i ss tud yinv e s t ig a t edp o t en t i a l r i skf a c to r so fendom e t r iom a sr e cu r r en c e ,a im in gtob e t t e rund e r s t andi t sp a thog en e s i s . Ato t a lo f307 p a t i en t sw i then dom e t r iom a sw e r efo l low edupf o ranav e r ag eo f28 .6 mon th san dth e1 ,2 -and3 y e a r cum u l a t iv er e cu r r en c er a t ew a s9 . 5% ,21 .9% ,and29 .2% ,r e s p e c t iv e l y .Tw en t y -on epo t en t i a lr i s kf a c to r s fo rendom e t r iom a sr e cu r r en c ew e r eev a lu a t edu s ingCox ’ sp ro po r t ion a lh a z a rd s mod e l s .T o t a lr ev i s ed Am e r i c anF e r t i l i tySo c i e ty( rAFS )s co r ew a ss ign i f i c an t lya s so c i a t edw i thh igh e rr e cu r r en c e(OR=1 .858 , 95%C I=1 .122– 3 .075 ,P=0 .016 ) ,a sw e l la syou ng e rag ea tsu r g e r y(OR=0 .953 ,95%C I=0 .915– 0 .992 , P=0 .020 ) .S em i r ad i c a lsu r g i c a lt r e a tm en tw a sd e f in eda ssu r g i c a lr em ov a lo fcy s tp lu sh y s t e r e c tomy w i thp r e s e rv a t io no fb i l a t e r a lo run i l a t e r a lov a r y ,and w a sas ign i f i c an tf a c to rth a tw a sa s s o c i a t ed w i th low e rr e cu r r en c eth anth econ s e r v a t iv esu r g e r y(OR=0 .318 ,95%C I=0 .107–0 .95 1 ,P=0 .040 ) .Po s top e r a t iv ep r egn an cy w a sf avo r ab l ef a c to r sfo rd i s e a s er e cu r r en c e(OR=0 .217 , 95% C I=0 .102– 0 .460 , P=0 .000 ) .Th er e su l t ssugg e s tth a tendom e t r iom ar e cu r r en c ei sin v e r s e lya s so c i a t edw i thag ea tsu r g e r y andpo s top e r a t iv ep r egn an cy ,andm ayco r r e l a t ew i thto t a lrAFSs co r eandcon s e rv a t iv esu r g e r ym e thod . K e ywo rd s :ov a r i anendom e t r iom a s ;r e cu r r en c e ;r i skf a c to r s ;su r g e r y
Endom e t r io s i s , a comm on and b en i gn gyn a e co log i c a ld i s o rd e r ,i sch a r a c t e r i z edbyth ep r e s e n c eo ffun c t i on a le nd om e t r i um l i k et i s s u eo u t s i d et h eu t e r i n e [1 ] . T h e m a i nc l i n i c a l m a n i f e s t a t ion si n c l ud e c a v i t y dy s p a r e u n i a ,d y sm e no r r h e a ,p e l v i cp a i na n di n f e r t i l i t y . O v a r i a ne nd om e t r i om ai st h em o s tc omm onf o rmo fe n dom e t r i o s i s .I na dd i t i o n ,i ti sd e em e da sa m a r k e rf o r u r op e a n g r e a t e rs e v e r i t yi ns ym p t om a t i cp a t i e n t s[2],andE So c i e t yo f Hum a n R e p r od u c t i o na n d Em b ry o l o gy (ESHRE )r e c omm e nd st h a th i s t o l ogysh o u l db eo b t a i n e d t oe x c l u d er a r ei n s t a n c e so fm a l i g n a n c yi nc a s eo fe nd o u r g i c a l m e t r i om ao fm o r et h a n 3cmi nd i am e t e r[3]. S t r e a tm e n ttoendom e t r iom am ayb ee f f e c t iv einr e l i ev ing a s s o c i a t e dp a i ns ym p t om sa ndim p ro v i n gi n f e r t i l i t y t ho ug ht h er e l i e fo fs ym p t om si sa s so c i a t ed w i tht h e [4 ] . Af r u s t r a t i ngi s s u e t r e a tm e n to fc on c om i t a n td i s e a s e fo rs u r g i c a lt r e a tm en ti spo s top e r a t iv er e c u r r en c e .R e cu r r en c ea n dr ep e a t eds u rg e r yin c r e a s ed m o rb id i tyand h e a l t hc a r ec o s t sa n d ,i no v ar i anen d om e t r i o s i s ,c ou l d c au s es ign i f i c an tov a r i and am ag eandr e du c eim p rov ed f e r t i l i t y .A c c o r d i ng l y ,a v o i d i ng d i s e a s er e c u r r e n c ei s M ingYUAN ,E -m a i l :yu an_7566 p ig@163 . com # Co r r e spond ingau tho r ,E -m a i l :s xw ang2012@ho tm a i l . com * Th i s p ro j e c t w a s suppo r t ed b y th e N a t ion a l S c i en c e Found a t ionfo rY oungS c i en t i s t so fCh in a(No .81 000240 ) .
p r e s e n t l yanu nm e tm e d i c a ln e edi nt h em a n ag em e n to f e nd om e t r i o s i s . T od a t e ,s e v e r a ls t ud i e sh a v eb e enc o nd u c t e dt oi n v e s t i g a t ep o t e n t i a lr i s kf a c t o r so fe nd om e t r i om a sr e c u r r en c ef o rb e t t e ru n d e r s t a nd i n gi t sp a t h og e n e s i s .How e v e r , th er e po r t edr i skf a c t o r sf o rr e c u r r e n c eb yd i f f e r e n ts t u d i e sa r eo f t e nc on f l i c t i ng .A sf o rp a t t e r n so fd i s e a s er e l a p s e ,l i t t l ea t t e n t i onh a sb e e nr e c e i v e d .T h e r e f o r e ,ou r kn ow l e d g ea b ou tt h er i s kf a c t o r sf o ra ndt h ep a t t e r n so f r e c u r r e n c eo fo v a r i a ne nd om e t r i om ai ss t i l lqu i t el im i t e d . H e r e ,w ec on d u c tafo l l ow -u ps t udyo f37 5p a t i e n t sw i t h e nd om e t r i om aa nda t t em p tt oi d e n t i fyp ro g n o s t i cf a c t o r s t h a tm i gh ti n f l u en c eb o t hr e c u r r en c er i s kan dp a t t e r n so f r e cu r r e n c ei nCh in e s ee n dom e t r iom ap a t i en t s . 1 MATER IALSAND METHODS W om e ni nr e p ro d u c t i v ea g e(1 5 –4 9y e a r so l d )w ho un d e rw e n tc o n s e r v a t i v eo rs em i r ad i c a l su r g e ry by l a p a r o s c o pyo rl a p a ro t om yfo ro v a r i a ne n d om e t r i om ai n T on g j i H o s p i t a l ,T on g j i M e d i c a lC o l l e g e , H u a z h o ng U n i v e r s i t yo fS c i e n c ea nd T e c h n o l o g y(HUST ,C h i n a ) f r omJ a n .1 ,2 01 0t oD e c .3 1 ,20 1 1p a r t i c i p a t e di nt h i s r e t r o s p e c t i v es t udy .C a s e si nw h i c hh i s t o l o g i c a l l yc on f i rm edendom e t r iom aw a sani n c i d e n t a lf i n d i n gw e r e a l soi n c l ud e d .A l ld i a gn o s e sw e r eco n f i rm e dh i s t o l o g i c a l l y .P a t i e n t sw e r ee x c l u d e di ft h e yh a d( 1 )p r e v i ou s
21 4
JH u a z hongU n ivS c iT e c hno l ［M e dS c i］ 34 (2 ) :2 01 4
s u r g e r yf o re n dom e t r i o s i s ;( 2 )d i a gn o s i so fg e n i t a lm a l fo rm a t ion ;(3 )a c com p an i ed w i thgyn e c o log i cm a l ign an t t um o r ;(4 )a g e> 45y e a r s .T h es t u dyw a sa p p ro v e dbyt h e M e d i c a lE t h i c sC omm i t t e eo fT o n g j iM e d i c a lC o l l e g e , HUST(C h i n a ) ,a ndi n f o rm edco n s e n tw a so b t a i n edf r om e a chp a r t i c ip a n t . Ina l lc a s e s ,t h esu r g i c a lp ro c edu r e sa im edtor e m ov ea l lv i s i b l eim p l an t so fe nd om e t r i o s i s .Th ec ho i c eo f l a p a r o s co pyo rl a p a r o t om yw a sm a d em a i n lybyt h ep a t i en t ,b e c au s el ap a ro s copyi sm o r eexp en s iv eth a nl ap a ro t om y .A sf o rm e t hodo fsu r g e ry ,i td e p e nd edo nc om p l ex i t yo fd i s e a s ean dp a t i e n t s ’d e s i r ef o rp r eg n a n cy . S em i r ad i c a lsu r g e ryi sd e f i n eda ss u r g i c a lr em ov a lo f cy s t sp l u shy s t e r e c t om yw i t hp r e s e rv a t i ono fb i l a t e r a lo r un i l a t e r a lo v a r y ,w h i l ec o n s e r v a t i v es u r g e r ya ss u r g i c a l r em ov a lo fc y s t sw i t hp r e s e r v a t i ono ff e r t i l i ty Du r i n gt h ef i r s tro un ds e l e c t i on ,at o t a lo f42 7p a t i e n t s w i t hh i s t o l o g i c a l l y con f i rm e d ov a r i an e n do m e t r iom aw e r eco l l e c t ed ,a n do fth e s e ,28c a s e sund e r w en tr a d i c a ls u r g e ry ,17c a s e sh adah i s t o r yo fe n dom e t r io s i s r e l a t edsu r g e ry ,3c a s e sh a dag e> 45y e a r sa ts u r g e rya nd2c a s e sw e r ea c co m p an i ed w i thgyn e c o log i c m a l i gn a n td i s e a s e s ,t h e nat o t a lo f3 7 7p a t i e n t sw e r ee l i g i b l efo rt h i ss t udy . Fo re a chp a t i e n t ,g en e r a lin fo rm a t ion w a sco l l e c t ed t h r ou g hr e a d i n gm e d i c a lr e co r d sa ndi nq u i r i n gp a t i e n t s by p h on e ,i n c l ud i n gd em og r ap h i cd a t a ,c om p l a i n to f dy sm e no r r h e ao ri n f e r t i l i t y ,d u r a t i o na n ds e v e r i t yo f dy sm e no r r h e a ,p r e v i o u se n d om e t r i o s i s r e l a t e ds u r g e r i e s , i fany ,t y p e sa ndd u r a t i o no fho rm on a lt h e r apyb e fo r eo r a f t e rs u r g e ry ,im p rov em en to fsym p tom a to logy ,p r eg n an cya f t e rs u r g e ryan dt im et or e c u r r e n c e .T y p e so f wo rkw e r ei n c l ud e di nt h e s etw oc a t e g o r i e s :p h y s i c a la nd m e n t a lw o r k .A sf o rc l i n i c o p atho log i c a lch a r a c t e r i s t i c so f e nd om e t r i om a ,d e t a i l e di n f o rm a t i on w a sr e c o r d e di no p e r a t i v en o t e .F o rt h ep r e s e n ts t udy ,t h ef o l l ow i ngd a t a w e r ee x t r a c t e d :l o c a l i z a t i on o fl e s i o n ,a n da dh e s i o n s , d e e pi n f i l t r a t i n gim p l a n t s ,c u l -d e s a co b l i t e r a t i on ,s i z eo f ov a r i a ne n d om e t r i om a s . A sac u s t om ,a l lp a t i e n t sw e r ec l i n i c a l l yf o l l ow e du p fo r3 ,6a nd12 m on t h sa f t e rs u r g e ryan dsu b s eq u en t l ya t l e a s ttw i c eay e a r .A te v e r yf o l l ow u pv i s i t ,as t a n d a r d gy n a e c o l o g i ce x am i n a t i ona n dat r a n s v a g i n a lu l t r a s ou n d s c an(TV -US )w e r ep e r fo rm ed .Sym p tom sandc l in i c a l d a t aw e r er e c o r d e d .D a t aa bo u tf e r t i l i t yp r o b l em sa nd p r e g n an c i e sfo rt h o s e wh od e s i r edt oco n c e i v ew e r ec o l l e c t ed .
R e cu r r en c eo fov a r i ane n dom e t r i om ai nt h i ss t u dy w a sd e f i n e da st h ep r e s en c eo f a hom og e n eo u s h y p o e c h o g e n i cc y s t sw i t hat yp i c a la s p e c td e t e c t e db y TV -US m o r eth an3cmind iam e t e randd idn ’ td i s a pp e a r f o l l ow i n gt h em e n s t r u a lc y c l e .S im i l a rd e f i n i t i on h a s b e enu s edino th e rs tud i e sb e c a u s eu l t r a s o n i cd e t e c t i o n cou l dp rov i d e >90% d i agno s t i ca c cu r a c y fo re n do – end i s e a s er e cu r r e n c eo c cu r r eddu r i ng m e t r i om a s[57]. Wh t h ef o l l ow u pp e r i od ,t h et im eb e tw e e ns u r g e r ya n dt h e on s e to fr e cu r r en c ew a sr e co rde da st im e to r e cu r r e n c e , i fn o t ,t h et im eb e tw e e ns u r g e rya ndt h el a s tm on t ho f fo l l ow u pw a sr e c o r d e da sc e n s o r e dt im etor e c u r r e n c e . Th es e v e r i tyo fd i s e a s ew a sev a lu a t e da tth et im eo fsu r g e rya n ds t ag e da c c o r d i n gt ot h er ev i s e d Am e r i c anF e r t i l i t yS o c i e t y( rAFS )c l a s s i f i c a t i on . S t a t i s t i c a lan a ly s i sw a sp e r fo rm edu s ingSPSS17 .0 so f tw a r e(SPSS , USA ) .T h ed i s t r ib u t io no fd a t aw a s t e s t ed by K o lm ogo r ov -Sm i rno vt e s t .C o n t i nuo u sv a r i ,wh e r e a sc a t ego r i cv a r i ab l e s ab l e sw e r ep r e s en t eda s ±s w e r ep r e s e n t e da sf r e qu e n c ya ndp e r c e n t a g e .Q u a n t i t a t iv ev a r i ab l e sw e r ec om p a r edbyS t ud en t ’ st t e s t s ,a n d qu a l i t a t i v ev a r i a b l e sw e r ea n a l y z e du s i ngF i s h e r ’ se x a c t t e s to rch i sq u a r et e s t s .Th eK ap l a n -M e i e rm e t hod w a s u s e dt oc a l c u l a t et h ec um u l a t i v ep r ob a b i l i t yo fe n do m e t r iom ar e cu r r en c e ,a n dC ox ’ sp ro p o r t i on a lh a z a rd s m od e l sw e r eu s e dtoe s t im a t eth ee f f e c to fs ev e r a lco v a r i a t e s . APv a l u e< 0 . 0 5w a sc o n s i d e r e dt ob es t a t i s t i c a l l ys i g n i f i c a n t . 2RESULTS O f3 77e l i g i b l ep a r t i c i p a n t s ,tw oc a s e sw e r ee x c lud e db e c au s eo fd i s e a s er e l a p s ed e t e c t e db yu l t r a s o u n d w i t h i n3 m on t h sa f t e rl a p a r o s c o p i ce x c i s i o n ,w h i c hw a s c on s i d e r e da ss u r g i c a lf a i l u r e s .U l t im a t e l y ,th ec h a r a c t e r i s t i c so f3 7 5p a t i e n t sw e r es umm a r i z e di nt a b l e1 .A sc a n b es e e nf romt h et a b l e ,ov e rh a l fo f( 57 . 3% )p a t i e n t s com p l a i n edo fdy sm eno r rh e a ,bu tt h ead n e x a lm a s sw a s t h em a jo rc a u s efo rs u r g e ry( i n2 4 6c a s e s ) . Am ong3 75 p a t i e n t s ,3 0 7( 81 . 9% )o ft h em w e r ef o l l ow e du pfo ra n av e r a g eo f28 . 6m on t h s( r a ng i ngf rom12 .8 – 38 .4 m on t h s ) . T h er e s tp a t i e n t sw e r em o s t l yl o s tt of o l l ow u p .T h e c h a r a c t e r i s t i c so fp a t i e n t sw h ol o s tt of o l l ow up w e r e summ a r i z ed( t ab l e2 ) . Nos t a t i s t i c a ld i f f e r en c ew a sob s e r v e di nt h e s ec h a r a c t e r i s t i c sb e tw e e np a t i e n t sw h ow e r e a ndw e r e n ’ tl o s tt of o l l ow up ,w h i c hs u g g e s t e dnos e l e c t i onb i a si no u rco ho r t .
T ab l e1Cha ra c t e r i s t i c so fpa t i en t sa F a c to r s Ag ea tm en a r ch e( y e a r s ) Ag ea tsu r g e r y( y e a r s ) In f e r t i l i ty P r im a r y S e cond a r y D y sm eno r rh e a rAFSs t ag i n g Ⅰ 0 Ⅱ 0 Ⅲ 217 Ⅳ 158
No .o fc a s e s(% )o r ±s 13 .2±1 .3 32 .4±7 .1 101(26 .9 ) 38(10 .1 ) 215(57 .3 )
(57 .9 ) (42 .1 )
JH u a z hongU n ivS c iT e c hno l ［M e dS c i］ 34 (2 ) :2 01 4
(T ob econ t inu ed ) Adn ex a lm a s s 246(65 .6 ) In f e r t i l i ty 68(18 .1 ) D y sm eno r rh e a 16(4 .3 ) C y s trup tu r e 3(0 .8 ) D IE 1(0 .3 ) Abdom in a lEm s 1(0 .3 ) M yom ao rAd enom yo s i s 31(8 .3 ) O th e rb en igng yn e co log i c a ld i s e a s e 9(2 .4 ) L a t e r a l i t y L e f ton ly 157(41 .9 ) R igh ton ly 107(28 .5 ) B i l a t e r a l 1 1 1(29 .6 ) Co ex i s t en c eo fo th e rtyp eEM s P e r i ton e a ll e s ion s 91(24 .3 ) D e epEm s 62(16 .5 ) Abdom in a lEM s 1(0 .3 ) Adh e s ion s M emb r anou sadh e s ion 156(41 .6 ) D en s eadh e s ion 125(33 .3 ) Cu ld es a cob l i t e r a t ion Ab s en t 313(83 .5 ) P a r t i a l 37(9 .9 ) Com p l e t e 25(6 .7 ) rAFS :r ev i s edAm e r i c anF e r t i l i tySo c i e ty ;D IE :d e epin f i l t r a t inge n d om e t r i o s i s ;Em s :endom e t r io s i s a V a lu e sa r eg iv e na snum b e r(p e r c en t ag e )o r ±s . T ab l e2Compa r i sono fcha ra c t e r i s t i c sb e tw e enr e c ru i t edpa t i en t sandpa t i en t slo s ttofo l low -up Cov a r i ab l e s R e c ru i t edp a t i en t s(n=307 ) P a t i en t slo s ttof o l low -up( n=68 ) Pv a lu e s Ag ea tsu r g e r y( y e a r s ) 32 .70±7 .13 30 .99±6 .85 0 .495 Ag ea tm en a r ch e( y e a r s ) 13 .22±1 .33 13 .25±1 .33 0 .792 rAFSs co r e 42 .79±24 .68 41 .59±22 .81 0 .1 16 rAFSs t ag ing 1 .000 Ⅲ 178(57 .98 ) 39(57 .35 ) Ⅳ 129(42 .02 ) 29(42 .65 ) O c cup a t ion 0 .220 Ph y s i c a l 234(76 .22 ) 47(69 .12 ) M en t a l 73(23 .78 ) 21(30 .88 ) Comp l a in to fd y sm eno r rh e a 0 .282 Y e s 180(58 .63 ) 35(51 .47 ) No 127(41 .37 ) 33(48 .53 ) P a r i ty 0 .278 P a rou s 132(43 .00 ) 24(35 .29 ) Nu l l ip a rou s 175(57 .00 ) 44(64 .71 ) Numb e ro fp r ev iou sindu c edabo r t ion s 0 .934 0 164(53 .42 ) 36(52 .94 ) 1 62(20 .00 ) 15(22 .06 ) 2 81(26 .38 ) 17(25 .00 ) L a t e r a l i ty 0 .538 L e f ton ly 128(41 .69 ) 29(42 .65 ) R igh ton ly 91(29 .64 ) 16(23 .53 ) B i l a t e r a l 88(28 .66 ) 23(33 .82 ) P r ev iou sabdom in a lsu r g e r y 0 .469 Y e s 97(31 .92 ) 18(26 .47 ) No 210(68 .08 ) 50(73 .53 ) Comb in a t ionw i thad enom yo s i s 0 .379 Y e s 56(18 .24 ) 9(13 .24 ) No 251(81 .76 ) 59(86 .76 ) Comb in a t ionw i th m yom a 0 .155 Y e s 75(24 .43 ) 1 1(16 .18 ) No 232(75 .57 ) 57(83 .82 ) M e thodo fsu r g e r y 0 .071
21 5
21 6 (T ob econ t inu ed ) S em i r ad i c a l Con s e rv a t iv e Mod eo fsu r g e r y L ap a ro tom y L ap a ro s cop y D a t aa r er ep r e s e n t eda s ±s ,o rn(% ) .
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55(17 .92 ) 252(82 .08 )
6(8 .82 ) 62(91 .18 )
59(19 .22 ) 248(80 .78 )
10(14 .71 ) 58(85 .29 )
F o rt h ee n t i r ec oh o r tf o l l ow e du pp e r i o d i c a l l y ,63 ( 2 0 . 5% )p a t i e n t sw e r ei d e n t i f i e da sr e c u r r e n c ebyTV -US . Th e1 ,2 -a n d3 -y e a rcum u l a t iv er e c u r r e n c er a t ew a s 9 . 5% ,21 .9% ,and29 .2% ,r e s p e c t i v e l y( f i g .1 ) .T h ee s t i m a t e dcum u l a t i v eh a z a rd w a sv i r t u a l l yco n s t a n td u r i n g t h ef i r s t2y e a r sp o s t o p e r a t i v e ly ,andt h en ,i td e c r e a s ed g r a d u a l l y . Ah i gh e rr i sko fr e cu r r en c ew a sfo un di nt h e f i r s t2y e a r s ,c om p a r edt oth efo l low i ngy e a r s .
F ig .1 Su rv iv a lcu rv eo fu l t r a so undr e cu r r en c einp a t i en t sw i th ov a r i anendom e t r iom a
T h ec h a r a c t e r i s t i c so fp a t i e n t sw i t ho rw i t ho u tr e c u r r e n c eo fo v a r i a ne n d om e t r i om aa ndt h er e s u l to fun i v a r i a t ean a ly s e sw e r el i s t edint ab l e3 .T h eun iv a r i a t e
0 .489
a n a l y s e sr e v e a l e dt h a ta g ea tm e n a r c h e ,bo d ym a s si nd e x (BM I ) ,t y p e so fw o r k(p hy s i c a lo rm e n t a l ) ,d y sm e no r rh e a , i n f e r t i l i t y ,p a r i t y ,num b e ro fp r e v i o u si nd u c e da bo r t i on s , l a t e r a l i t yo fe n dom e t r i om a ,adh e s i o n s ,C u ld es a co b l i t e r a t ion ,p r e s en c eo fad e n om y o s i so rm y om a ,p r e v i ou s h i s t o ryo fab d om i n a lsu r g e ry ,a nd m od eo fs u r g e ryd i d no ts i gn i f i c a n t l yi n f l u e n c er e c u r r en c er i s k .Ag ea tsu r g e ry , l a r g e s tc y s td i am e t e r( cm ) ,rAFSs c o r e ,rAFSs t a g e , m e t hod o fs u r g e rya nd po s t op e r a t i v ep r e g n an cy w e r e con s id e r e da sr i skf a c to r sfo rr e c u r r e n c eo fov a r i ane n dom e t r i om a s( t ab l e3 ) .H ow e v e r ,p o s t op e r a t i v em ed i c a t i on(G nRH a )d i dn o ts e emt oi n f l u e n c et h ee nd o m e t r iom ar e cu r r en c er a t e . A c co r d i n gt oab a c kw a r de l im i n a t i onp r o c edu r eo f v a r i a b l es e l e c t i on ,s i xv a r i a b l e s[ ag ea tsu r g e ry ,l a r g e s t cy s td i am e t e r( cm ) ,rAFSs c o r e ,rAFSs t a g e ,m e t hodo f s u r g e rya n dp o s t o p e r a t i v ep r e gn a n c y ]w e r es e l e c t e df o r m u l t i v a r i a b l es u r v i v a la n a l y s i su s i ng C o xp r o p o r t i o n a l H a z a rd m od e l .S ign i f i c an tf ac to r sth a tw e r eind e p end e n t l ya s s o c i a t e dw i t hl ow e rr e cu r r en c ew e r eag ea ts u r g e ry (OR= 0 . 95 3 , 9 5% C I=0 . 9 15 – 0 . 99 2 , P= 0 . 0 20 ) , m e t hod o fs u r g e ry(OR= 0 . 31 8 ,9 5% C I=0 . 10 7 –0 .9 5 1 , P=0 . 0 40 )an dpo s t o p e r a t i v ep r e g n an cy(OR= 0 . 21 7 ,95% C I= 0 . 1 02 – 0 . 46 0 , P< 0 . 00 1 ) .I n t e r e s t i n g l y ,n e i t h e rl a r g e r d i am e t e ro fth el a r g e s tcy s tno ra d v an c e drAFSs t ag ew a s s ign i f i c a n t lya s so c i a t edw i thr e cu r r en c e ,bu th igh e rrAFS s co r ew a ss ign i f i c an t lya s so c i a t edw i thh igh e rr e cu r r e n c e (OR= 1 . 85 8 ,9 5%C I= 1 . 12 2 –3 . 0 75 ,P= 0 . 0 16 )( t ab l e4 ) .
T ab l e3Ch a ra c t e r i s t i c so fp a t i en t sw i thandw i th ou tr e cu r r en c eo fova r ianend om e t r ioma sandPva lu e sf r omun iva r ia t eCox r eg r e s s ionana ly s i s Cov a r i ab l e s Non r e cu r r en t( n =244 ) R e cu r r en t( n =63 ) Pv a lu e s Ag ea tsu r g e r y( y e a r s ) 33 .4±7 .3 30 .1±5 .8 0 .003 Ag ea tm en a r ch e( y e a r s ) 13 .3±1 .4 13 .1±1 .2 0 .837 BM I 21 .4±3 .0 23 .18±4 .1 0 .080 L a r g e s tcy s td i am e t e r( cm ) 5 .6±2 .8 6 .7±2 .5 0 .005 rAFSs co r e 41 .0±24 .0 49 .8±26 .3 0 .002 rAFSs t ag ing 0 .003 Ⅲ 150(61 .5 ) 28(44 .4 ) Ⅳ 94(38 .5 ) 35(55 .6 ) T yp e so fwo rk 0 .281 Ph y s i c a l 190(77 .9 ) 44(69 .8 ) M en t a l 54(22 .1 ) 19(30 .2 ) Comp l a in to fd y sm eno r rh e a 0 .883 Y e s 140(57 .4 ) 40(63 .5 ) No 104(42 .6 ) 23(36 .5 ) In f e r t i l i ty(p r im a r yands e cond a r y ) 0 .324 Y e s 86(35 .3 ) 28(44 .4 ) No 158(64 .7 ) 35(55 .6 ) P a r i ty 0 .279 P a rou s 1 1 1(45 .5 ) 21(33 .3 ) Nu l l ip a rou s 133(54 .5 ) 42(66 .7 )
21 7
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(T ob econ t inu ed ) Numb e ro fp r ev iou sindu c edabo r t ion s 0 126(51 .6 ) 1 54(22 .1 ) 2 64(26 .2 ) L a t e r a l i ty L e f ton ly 107(43 .9 ) R igh ton ly 73(29 .9 ) B i l a t e r a l 64(26 .2 ) Adh e s ion s Ab s en t 31(12 .7 ) M emb r anou s 1 17(48 .0 ) D en s e 96(39 .3 ) Cu l -d e s a cob l i t e r a t ion Ab s en t 199(81 .6 ) P a r t i a l 27(1 1 .1 ) Comp l e t e 18(7 .4 ) Comb in a t ionw i thad enom yo s i s Y e s 44(18 .0 ) No 200(82 .0 ) Comb in a t ionw i th m yom a Y e s 62(25 .4 ) No 182(74 .6 ) P r ev iou sabdom in a lsu r g e r y Y e s 76(31 .2 ) No 168(68 .8 ) M e thodo fsu r g e r y Con s e rv a t iv e 193(79 .1 ) S em i r ad i c a l 51(20 .9 ) Mod eo fsu r g e r y L ap a ro tom y 49(20 .1 ) L ap a ro s cop y 195(79 .9 ) Po s top e r a t iv ep r egn an cy Y e s 87(35 .7 ) No 157(64 .3 ) Po s top e r a t iv em ed i c a t ion GnRHagon i s t 109 Non e 124 BM I :bod ym a s sind ex .D a t aa r er ep r e s en t eda s ±s ,o rn(% ) .
38(60 .3 ) 8(12 .7 ) 17(27 .0 ) 21(33 .3 ) 18(28 .6 ) 24(38 .1 ) 7(1 1 .1 ) 31(49 .2 ) 25(39 .7 ) 48(76 .2 ) 8(12 .7 ) 7(1 1 .1 ) 12(19 .1 ) 51(80 .9 ) 13(20 .6 ) 50(79 .4 ) 21(33 .3 ) 42(66 .7 ) 59(93 .6 ) 4(6 .4 ) 10(15 .9 ) 53(84 .1 ) 8(12 .7 ) 55(87 .3 ) 23 38
0 .189
0 .066
0 .798
0 .713
0 .194 0 .957 0 .565 0 .017 0 .577 0 .001 0 .195
T ab l e4 Mu l t iv a r iab l e Coxp r opo r t iona l Ha z a rd mod e l so fr i skfa c to r sa s s o c ia t ed w i thr e cu r r en c eo fend om e t r iomaa f t e r su rg e ry Cov a r i ab l e s Exp() 95%C I Pv a lu e s Ag ea tsu r g e r y( y e a r s ) 0 .953 0 .915–0 .992 0 .020 rAFSs co r e 1 .858 1 .122–3 .075 0 .016 M e thodo fsu r g e r y 0 .318 0 .107–0 .951 0 .040 Po s top e r a t iv ep r egn an cy 0 .217 0 .102–0 .460
