AAGL 2021 Classification and Surgical Complications in Women With Endometriosis

Endometriosis is a benign chronic inflammatory disease associated with pelvic pain and subfertility, characterised by endometrial tissue located outside the uterus. Deep endometriosis (deep infiltrating endometriosis, DIE), the most severe form of endometriosis, can be defined as the involvement of anatomical organs and tissues by endometriotic lesions, regardless of the depth of infiltration.

The first therapeutic approach for deep endometriosis is hormone therapy; surgery should be limited to patients who have not responded or have intolerance to medical therapy, infertile patients with failed attempts at assisted reproductive technologies, or patients with critical ureteral or intestinal stenosis. Although complete removal of the disease has proven effective in reducing pain and improving fertility results, surgical complications can occur in 3% to 22% of cases and can drastically reduce patients' quality of life.

Several intraoperative staging systems for endometriosis have been proposed. However, there is a lack of a scoring system that accurately describes the disease burden. Recently, the American Association of Gynecologic Laparoscopists (AAGL) has developed and validated an anatomy-based grading system for intraoperative scoring of surgical complexity, using a qualitative index scale as a reference that identifies a score and also allows the assignment of a surgical complexity stage.

There are no studies in the literature evaluating the association of these complications with aspects such as the technical difficulty of surgical removal of endometriosis in relation to the extent of the disease. The study of perioperative complications is imperative in endometriosis surgery, so having a classification system capable of predicting complications on the basis of surgical complexity could guide clinical practice and post-operative management of patients with DIE.

This study could provide useful elements not only to improve the post-operative outcome of operated patients but also to identify preoperatively those DIE pictures for which the surgeon will have to pay more attention because they have a higher risk of perioperative adverse events.

• Association between the AAGL score, ENZIAN classification, r-ASRM stage and the occurrence of peri-operative complications [Time frame: within 90 days from surgery]
• Occurrence of peri-operative complications in patients undergoing surgery for DIE compared to patients undergoing surgery for DIE with hysterectomy [Time frame: within 90 days from surgery]
• Occurrence of peri-operative complications in patients who underwent preoperative medical therapy compared to patients who did not [Time frame: within 90 days from surgery]
• Occurrence of peri-operative complications in patients who underwent peri-operative medical therapy compared to patients who discontinued medical therapy close to surgery [Time frame: within 90 days from surgery]
• Occurrence of clinical/radiological recurrence of disease at 24 months in patients who underwent peri-operative medical therapy compared to patients who discontinued medical therapy close to surgery [Time frame: 24 months after surgery]
• Association between AAGL score and achievement of pregnancy (spontaneous and non-spontaneous) [Time frame: At 3, 6, 9, 12, 24 and 36 months after surgery]