AAGL 2021 Endometriosis Classification: Surgical Complexity Score PDF

Original Article AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score Mauricio S. Abrao, MD, Marina Paula Andres, MD, Charles E. Miller, MD, Julian A. Gingold, MD, PhD, Mariona Rius, MD, Joao Siufi Neto, MD, and Francisco Carmona, MD From the Gynecologic Division, BP-A...

Original Article AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score Mauricio S. Abrao, MD, Marina Paula Andres, MD, Charles E. Miller, MD, Julian A. Gingold, MD, PhD, Mariona Rius, MD, Joao Siufi Neto, MD, and Francisco Carmona, MD From the Gynecologic Division, BP-A Benefic^ encia Portuguesa de S~ao Paulo (Drs. Abrao, Andres, and Neto), Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of S~ ao Paulo (Drs. Abrao and Andres), S~ao Paulo, S~ ao Paulo, Brazil, Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller), Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold), Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clınic de Barcelona (Drs. Rius and Carmona), and Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain ABSTRACT Study Objective: To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility. Design: Multicenter study of patients treated at 3 recognized endometriosis centers. Setting: Three specialized endometriosis surgical centers in S~ao Paulo, Brazil and Barcelona, Spain. Patients: Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy under- went laparoscopic treatment of endometriosis. Interventions: Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Asso- ciation of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classifi- cation systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed. Measurements and Main Results: A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (k = 0.621), whereas the ASRM score dis- criminated between the complexity stages with poor reproducibility (k = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system. Conclusion: The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reli- ably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage. Journal of Minimally Invasive Gynecology (2021) 28, 1941−1950. © 2021 AAGL. All rights reserved. Keywords: Endometriosis; Infertility; Laparoscopy; Pelvic pain; Staging Multiple endometriosis classification systems have been 1985 and 1996 American Society for Reproductive Medi- proposed in the last 40 years [1−7]. The American Fertility cine (ASRM) classification systems [2,3], were motivated Society 1979 classification , subsequently revised as the by a desire to score the impact of endometriosis on fertility. Although the 1996 ASRM classification remains the most widely used endometriosis classification system, it The authors declare that they have no conflict of interest. does not address surgical skill and effort required for endo- Institutional review board approval numbers: Barcelona (HCB/2019/1152) and S~ao Paulo (3079709/2018 and 4232258/2020). metriosis removal. Because large lesions fully infiltrating Corresponding author: Mauricio S. Abrao, MD, Clinica Medicina da the rectum, ileum, ureter, vagina, or bladder receive compa- Mulher, Rua Colombia, 332, S~ao Paulo, SP 05403-000, Brazil. rable scores to a solitary 3-cm−deep lesion on the anterior E-mail: [email protected] peritoneum in ASRM classification, surgical complexity Submitted September 21, 2021, Accepted for publication September 21, seems poorly correlated to ASRM stage. The lack of a 2021. reliable surgical complexity score has complicated equita- Available at www.sciencedirect.com and www.jmig.org ble reimbursement [9−11]. The ASRM classification 1553-4650/$ — see front matter © 2021 AAGL. All rights reserved. https://doi.org/10.1016/j.jmig.2021.09.709 1942 Journal of Minimally Invasive Gynecology. Vol 28, No 11, November 2021 system also has limited correlation with pain symptoms. Materials and Methods Since 1996, additional endometriosis classification systems Development of the AAGL Endometriosis Classification have been developed, including the Endometriosis Fertility Score Index in 2010 , designed to predict pregnancy rates after surgical staging, and the Enzian classification system A survey was sent to 31 internationally recognized endo- [5,12], to facilitate classification of deep infiltrating endo- metriosis specialists (acknowledged at the end of the manu- metriosis without a points-based score. Surgeries for deep script) who were asked to estimate the complexity of infiltrating endometriosis, defined as endometriosis pene- surgical excision of endometriosis involving a series of ana- trating >5 mm beneath the peritoneal surface [13,14], are tomic sites (listed in Table 1) from 0 to 10 (0, not complex notable for their high complexity as well as high complica- at all to 10, most complex). Scores were linearly scaled and tion rate. normalized across surgeons, with the exclusion of individ- In 2010, the American Association of Gynecologic ual scores >2 standard deviations from the mean, before Laparoscopists (AAGL) Special Interest Group in Endo- computing an average “difficulty score” for each anatomic metriosis recognized the limitations of existing endome- site (Table 1). triosis classification systems and assigned a task force to A worksheet constructed from these component diffi- develop a new one. This article reports for the first time culty scores at each anatomic site was used to assign points the creation of the AAGL 2021 Endometriosis Classifi- to each patient during surgery (Fig. 1). The sum of the com- cation System stemming from the efforts of this task ponent scores across all anatomic sites defined the total force. score, which was used to determine the complexity stage The primary objective of this study was to develop an during surgery (described in later text) (Fig. 1). anatomy-based and user-friendly scoring system that corre- lates with surgical complexity. The secondary objective was to determine its correlation with preoperative pain Surgical Validation Cohort symptoms and infertility. In addition, we aimed to compare From February 2018 to 2020, patients with endometri- the performance of the new classification with the 1996 osis treated at 2 centers in S~ao Paulo, Brazil and 1 center in revised ASRM classification system. Barcelona, Spain (participating sites are listed at the end of Table 1 Mean surgical complexity rating for each site of endometriosis Site of endometriosis N of endometriosis specialist evaluations Mean Standard deviation Median p25 p75 Superficial