Posterior deep infiltrating endometriosis surgery: current status and mapping of care in France

Endometriosis is a frequent pathology affecting approximately 10% of the general population. Its diagnosis and management have improved in recent years. In France, a national strategy against endometriosis has been gradually developed, particularly through the establishment of regional referral networks to improve access to care. Regarding surgical management, the current trend is to define regional referral centers, although this process is still under development.

The primary objective of this study was to describe the characteristics of posterior deep infiltrating endometriosis (DIE) surgical activity in mainland France. The secondary objective was to describe patient characteristics and conditions of access to surgical care.

We performed a descriptive observational study using the French national medico-administrative database ((Program of Medicalization of Information Systems (PMSI) between January 1 and December 31, 2023. We identified all hospital stays involving posterior DIE surgery and recorded the number of procedures performed in each healthcare institution, their geographic location, and patients' sociodemographic and clinical characteristics.

In 2023, a total of 5364 hospital stays for posterior DIE surgery were recorded. We identified 339 distinct healthcare institutions that performed at least one hospital stay for posterior DIE surgery. The annual mean number of surgeries was 16.6 (±50.8 SD) per healthcare institution, but activity was highly concentrated, with fewer than 20% of healthcare institutions performing 80% of all surgeries nationwide. Mapping revealed that most surgeries were performed in major urban centers, leaving some regions with limited access. The average distance between patients' residence and treating healthcare institution was 46.5 km (±51.6), corresponding to an average driving time of 34.3 minutes (±31.6). Social deprivation markers (universal health insurance (UHI) (p=0,019) and complementary universal health insurance (UHIc) (p<0.0001)) and higher Charlson comorbidity score were significantly more frequent in patients treated in public or nonprofit private institutions compared to private institutions (p<0.0001).

Posterior DIE surgical activity in France is unevenly distributed both in volume and geography. A collective reorganization is needed to ensure equitable access while maintaining high-quality surgical care.