Impact of adenomyosis and endometriosis on chronic pelvic pain after niche repair

Objectives
To determine if the laparoscopic isthmocele repair in patients with endometriosis and/or adenomyosis (AD) has an impact on the post-operative outcomes on chronic pelvic pain (CPP).

Methods
A retrospective study was performed on 45 patients who underwent laparoscopic niche repair surgery between 2016 and 2021 in Liege University Hospital La Citadelle at the department of Obstetrics and Gynecology. Their preoperative ultrasonography was studied using the MUSA criteria in order to determine the presence of adenomyosis. The histology results were used to detect the presence of endometriosis. According to the clinical practice, all patients were seen in a post-operative period of 3 to 6 months and afterwards at their annual check-up. Data were collected from medical records.

Results:
Out of the 45 patients, 80% had adenomyosis, 40% endometriosis and 33% endometriosis and concomitant adenomyosis. Out of the 36 patients with AD, 67% had diffuse type, while 19% had anterior focal AD. On the 18 patients with endometriosis, 83% show concomitant adenomyosis.
In post-operative period (at 3 to 6 months), only 1 out of 18 patients (5%) with endometriosis, 5/21 (24%) with AD only, and 6/15 (40%) with both pathologies had CPP recurrence. There are more CPP recurrent patients in the group of endometriosis with concomitant AD compared to endometriosis only group (statistical significance p < 0,05).
In post-operative period (at 12 months), only 1 out of 18 patients (5%) with endometriosis only has CPP recurrence , with AD only 2/21 (9,5%), and both 8/15 (53%).
There are more CPP recurrent patients in the group with the presence of simultaneous pathologies compared to endometriosis (statistical significance p < 0,01) or AD only (statistical significance p < 0,02).

Conclusions:
Cesarean section has an important impact on adenomyosis development. In our case series, 80% of our patients treated for isthmocele present concomitant AD. Moreover, 86% of them show diffuse or anterior focal AD.
To our best knowledge, it is the first long term study on the CPP outcomes for patients who have been treated for niche repair. Our results demonstrate that there is an important CPP recurrency rate in patient with AD and concomitant endometriosis after 1 year.
Patients who undergo niche repair should be selected carefully as CPP does not seem to be a good indication for uterine scar repair in patients with concomitant adenomyosis and endometriosis.