Dear Editor,
Rafique et al.’s1 article, “Pre-operative GnRH agonist use and surgical outcomes in rectovaginal/colorectal endometriosis,” is a comprehensive, multicenter study that combines surgical outcomes and health-related quality of life data to examine patients’ experiences postsurgery. However, some methodological issues may necessitate further investigation.1
Firstly, gonadotrophin releasing hormone (GnRH) agonists produce hypoestrogenism, but their pharmacokinetics, formulations, and adverse effects vary. The study did not specify the type, dosage, and duration of GnRH therapy, which can affect hormonal suppression and tissue response. Extended use may make surgical dissection more challenging. The validity of the results is not compromised, but methodological challenges exist. Future research should focus on regimen-specific effects, despite the methodological challenges of stratifying large datasets by drug type and dosage.2
Secondly, the study, while controlling for variables, lacked information about the location, size, and depth of lesions, which are known to influence surgical risk. The use of terms like “surgical difficulty” or “procedure type” only provides a partial view. Standardized systems like ENZIAN could enhance future registry studies and improve risk assessment.3
Thirdly, the study provides valuable information on surgical risks and quality of life for women with severe endometriosis but does not evaluate fertility outcomes. Understanding the impact of major surgery and hormone therapy on fertility is crucial for family planning. However, the results are difficult to apply to real-life decisions. Future research should include information on pregnancy outcomes, whether natural or assisted, to be more beneficial for patients and clinicians.4
Lastly, the study, which includes 101 centers from six countries, offers diversity and strength but also introduces uncertainty due to the lack of standardization of surgeon experience, perioperative procedures, and surgical methods. Future research could consider this variability by reporting center-level practices or using random-effects models to reduce bias, as it represents real-world practice.5
Rafique et al.1 provide valuable insights into the function of GnRH analogue in endometriosis surgery, despite its limitations, and their findings may enhance future research.
