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Overview on surgical treatment of endometriosis
Abstract
Surgery in the context of endometriosis has a double indication. In the diagnosis of the disease, it is indicated when pain, infertility or an adnexal mass is present. In the treatment, it has a functional orientation: the objective is to solve the symptoms rather than eradicating the disease. A comprehensive evaluation of each case, assessing the type and intensity of symptoms, age, fertility desire and extent of lesions, allows good surgical selection and procedure planning in these cases. Laparoscopy is considered the gold standard in endometriosis surgical treatment. Most surgical procedures, even those complex ones associated with deep endometriosis, can be performed laparoscopically. For best results and lower complication rates in only one-step surgical procedure, it needs to be performed by expert surgeons and multidisciplinary teams.
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To compare robot assisted laparoscopic platform to standard laparoscopy for the treatment of endometriosis.
A retrospective cohort controlled study.
Tertiary referral center.
Seventy-eight reproductive aged women.
Robot assisted or standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009.
Operative time, estimated blood loss, hospitalization time, intraoperative and postoperative complications.
Seventy-eight patients underwent treatment of endometriosis, 40 by robot assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis, and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135-295 minutes) compared with 159 minutes (range 85-320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intraoperative or postoperative complications. There were no conversions to laparotomy.
Both robot assisted laparoscopic and standard laparoscopic treatment of endometriosis have excellent outcomes. The robotic technique required significantly longer surgical and anesthesia time, as well as larger trocars.
Endometriosis, defined by the development of endometrial tisue outside the uterus, is a benign disease responsible for infertility and pelvic pain. The diagnosis based on a detailed gynecological history and a careful clinical examination should be done as early as possible in order to treat patients correctly. Medical treatment is not appropriate in all cases and surgical treatment should be proposed but morbidity is related to the severity of the lesion. Ectopic implantation of endometrial cells needs complex interactions between host tissue and epithelial endometrial cells. The conditions for the development of endometriosis are estrogeno-dependent growth of endometrial cells, induction of angiogenesis and lymphangiogenesis. Principal cellular and molecular factors of angiogenesis, lymphangiogenesis and fibrosis should be identified in order to develop new therapeutic strategies of endometriosis.
Super-hard and elastic carbon nitride films have been synthesized by using an off-plane double-bend filtered cathodic vacuum
arc combined with a radio-frequency nitrogen-ion beam source. A nanoindenter was used to determine the micromechanical properties
of the deposited films. X-ray photoelectron spectroscopy was used to study the composition and bonding structure of the deposited
films. The influence of nitrogen ion energy on the structure and micromechanical properties of the deposited films was systematically
studied. As the nitrogen ion energy is increased, the microhardness, Young’s modulus and elastic recovery also increase, reaching
a maximum of 47GPa, 400GPa, and 87.5%, respectively, at a nitrogen ion energy of 100eV. Further increase in nitrogen ion
energy results in a decrease in microhardness, Young’s modulus and elastic recovery of the deposited films. The formation
of five-membered rings, as indicated by XPS, which causes bending of the basal planes and forms a three-dimensional rigid
covalent bond network, contributes to the super-hardness, Young’ s modulus and high elastic recovery of the films deposited
at a nitrogen ion energy of 100eV.
Endometriosis is a difficult problem for practicing gynecologists and is commonly associated with infertility. The diagnosis of endometriosis should only be made at the time of laparoscopy or laparotomy and should be confirmed with biopsy if possible. Once the diagnosis is made, it should be classified according to the revised AFS system. The treatment of infertility associated with endometriosis is controversial and usually consists of either medical therapy with hormonal manipulation designed to suppress the disease, surgical therapy designed to debulk the disease and repair anatomic distortion, or a combination of both.
Despite an abundance of research on the treatment of endometriosis, the pregnancy rate for patients with endometriosis remains lower than that of the normal population. The reasons for this are obscure. Endometriosis does not respond to hormonal changes the same way that normal endometrium does and has been shown to persist despite extensive medical therapy. The recurrence rate of the disease is impressively high after either medical or surgical therapy. Interestingly, expectant management of minimal or mild disease is associated with pregnancy rates equal to those of any other type of therapy. Only when the disease is more extensive does aggressive treatment appear to show improvement in pregnancy rates. Whether combination therapy of endometriosis is better than single agent therapy remains open to debate. Some of the best-designed studies using combination therapy have shown no difference in pregnancy rates. Yet, when taken as a whole, it would appear that if combination medical and surgical therapy is chosen, the medical therapy should be given preoperatively. The literature abounds with a wide variety of classification systems, methods of calculating pregnancy rates, and inclusion of control groups. Because of this disparity between studies, reliable conclusions cannot be drawn.
Our purpose was to evaluate the role of surgery in the treatment of endometriosis associated with infertility.
We used a prospective cohort analysis of pregnancy rates and variables affecting pregnancy rates for surgical, medical, and no treatment. Our studies were combined with those reported by Hughes et al. (Fertil Steril 1993; 59:963-70), and the meta-analysis was expanded to include additional comparisons. Treatment was performed by a single surgeon in a referral reproductive endocrinology and surgery private practice. Results from 579 women with endometriosis and infertility in our study and the meta-analysis of 25 studies by Hughes et al. were examined. Interventions consisted of no treatment, medical treatment, or surgical treatment by laparoscopy or laparotomy. The main outcome measure was pregnancy rates.
For minimal and mild disease, no treatment, laparoscopy, and laparotomy had equivalent 3-year estimated cumulative life-table pregnancy rates (67% +/- 12%, 68% +/- 4%, and 74% +/- 8%, respectively) that were higher than medical treatment pregnancy rates (Breslow p = 0.003). For moderate and severe disease, all but 11 patients were treated surgically. The 3-year estimated cumulative life-table pregnancy rates were 62% + 6% [corrected] for 120 laparoscopy cases and 44% + 6% [corrected] for 102 laparotomy cases (Breslow p = 0.054). For endometriomas, 48 laparoscopy patients had a 3-year estimated cumulative life-table pregnancy rate of 52% +/- 9% and 52 laparotomy patients had a 3-year estimated cumulative life-table pregnancy rate of 46% +/- 9% (Breslow p = 0.48). For 28 patients with complete cul-de-sac obliteration, the 3-year estimated cumulative life-table pregnancy rates were 30% +/- 14% after laparoscopy and 24% +/- 12% after laparotomy (Breslow p = 0.084). Comparison of our results with the expanded meta-analysis revealed deficiencies in the design of meta-analysis studies and the impact of our using life-table pregnancy rates controlled for factors influencing outcome (survival analysis with fixed covariates) rather than the simple pregnancy rates used in the meta-analysis. Benefits of sophisticated statistical techniques, including propensity scores, to adjust for noncomparability of groups in prospective cohort studies were identified.
Both our study and the meta-analysis show that either no treatment or surgery is superior to medical treatment for minimal and mild endometriosis associated with infertility. For moderate and severe disease, surgery is usually used. In these patients experienced surgeons utilizing good clinical judgment can achieve results at operative laparoscopy at least equivalent to those at laparotomy, even in cases involving endometriomas and complete cul-de-sac obliteration. Prospective randomized trials should be performed to confirm these findings.
To assess the usefulness of fat-saturated magnetic resonance (MR) imaging in detecting small endometrial implants, 258 pigmented lesions of endometriosis from 80 consecutive patients with histopathologically diagnosed pelvic endometriosis were compared using fat-saturated and conventional MR imaging. MR imaging was performed with a 1.5-tesla superconducting magnet with spin echo T1-, T2-, and fat-saturated T1-weighted images. Both conventional MR images and fat-saturated MR images permitted identification of almost all endometriomas > 10 mm in diameter. With conventional MR imaging, 29 endometrial implants measuring < 10 mm in diameter were detected. One hundred and seven lesions were detected by fat-saturated MR imaging. However, conventional MR images demonstrated only 4 lesions among these 111 small endometrial implants that measured < 5 mm in diameter. The addition of fat-saturated MR imaging increased the detection rate to 55 of 111 lesions. Fat-saturated MR imaging can, therefore, be useful in detecting small endometrial implants.
This study was undertaken to evaluate the effect that a patient's age at the time of hysterectomy for endometriosis-associated pain has on long-term improvement in symptoms.
An investigation of women who underwent hysterectomy for pelvic pain and endometriosis at <30 or >40 years of age was performed by means of medical records review and mailed questionnaires. Participants were asked to complete 2 standardized surveys, the Disruption of Functioning Index and the Beck Depression Inventory.
Sixteen women in the study group (<30 years old) and 27 women in the control group returned completed questionnaires. Although similar proportions reported overall alleviation of pain, the study group was significantly more likely to report residual symptoms, such as dyspareunia and dysuria. This younger group also more often reported a sense of loss after hysterectomy and reported more overall disruption in different aspects of life.
Women who undergo hysterectomy for pelvic pain and endometriosis at <30 years old are more likely than older women to have residual symptoms, to report a sense of loss, and to report more disruption from pain in different aspects of their lives.
We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis.
In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms.
Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months.
Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis.
To investigate the clinical value of the serum CA19-9 level in comparison with the serum CA125 level for diagnosing and determining the severity of endometriosis.
Retrospective study.
Department of Comprehensive Reproductive Medicine in a university hospital.
One hundred one women with endometriosis and 22 without endometriosis participated in this study.
Blood samples were collected before the operation (laparoscopy, oophrectomy, cystectomy, and/or hysterectomy), and tissue samples of ovarian chocolate cysts were collected during the operation.
The serum CA19-9 and CA125 levels and the localization of these antigens in ovarian chocolate cysts.
The mean serum CA19-9 levels in patients at all stages of endometriosis were significantly higher than those in patients without endometriosis, and serum CA19-9 levels significantly correlated with the Revised American Fertility Society classification scores. Intense staining of CA19-9 was observed in 15 of the 20 samples of ovarian chocolate cysts.
CA19-9 is a useful marker for determining the severity of endometriosis.
To analyse the frequency and the determinants of recurrence rate of clinically detectable endometriosis.
Prospective cohort multicenter study. Eligible for the study were all women observed for the first time during the period January-June 1998 at the participating centres with a laparoscopically confirmed first diagnosis of endometriosis. After diagnosis, patients were treated according to standard care of each centre and desire for pregnancy. The protocol required all women to be followed up at the centre each year for 2 years with a clinical examination, an ultrasound pelvic examination and a CA125 assay, unless pregnancy occurred. Second look laparoscopy was performed on a clinical basis.
A total of 311 women (median age 36 years) entered the study. The two-year recurrence rate was 5.7% among cases stage I-II and 14.4% among stage III-IV (chi(1)2 adjusted for indication for surgery, p < 0.05). The recurrence rates tended to increase with age, being 4.6% among women aged 20-30 and 13.1% among women aged >30, but this finding was not statistically significant.
The recurrence rate of clinically detectable endometriosis tends to be higher in older women with advanced stages of the disease and lower in women with infertility.
This article is a review of the efficacy of medical and surgical treatment of endometriosis-associated infertility and pelvic pain. Endometriosis is the cause of pelvic pain (dysmenorrhea, dyspareunia) and infertility in more than 35% of women of reproductive age. Complete resolution of endometriosis is not yet possible but therapy has essentially three main objectives: (1) to reduce pain; (2) to increase the possibility of pregnancy; (3) to delay recurrence for as long as possible. It could be concluded that a consensus will probably never be reached on minimal and mild endometriosis. Nevertheless, because the Canadian study reported a large number of cases, we strongly support the view that visible endometriosis must be removed at the time of surgery. In cases of moderate and severe endometriosis-associated infertility, the combined approach (operative laparoscopy with GnRH-a) must be considered as 'first-line' treatment. The mean pregnancy rate of 50% reported in the literature following surgery provides scientific proof that operative treatment should be undertaken first to give our patients the best chance of conceiving naturally.
To investigate the need for further surgery after laparoscopic excision of endometriosis or hysterectomy.
In this retrospective study, women who had surgery for endometriosis-associated pain at the Cleveland Clinic were assessed for requirement for subsequent surgery. One hundred twenty patients who underwent hysterectomy with or without oophorectomy for endometriosis and 120 patients who had laparoscopic excision of their endometriotic lesions only (local excision group) formed the study population. Estimates of reoperation-free survival at 2, 5, and 7 years were calculated using Kaplan-Meier methods, and estimates of risk (hazard ratios) were computed using Cox proportional hazards models. A significance level of .05 was assumed for all tests.
In women who underwent local excision with ovarian preservation, the surgery-free percentages were 79.4%, 53.3%, and 44.6%, respectively, at 2, 5, and 7 years. In women who underwent hysterectomy with ovarian preservation, the 2-, 5-, and 7-year reoperation-free percentages were 95.7%, 86.6%, and 77.0%, respectively. In women who underwent hysterectomy without ovarian preservation, the percentages were 96.0%, 91.7%, and 91.7%, respectively. However, in women between 30 and 39 years of age, removal of the ovaries did not significantly improve the surgery-free time.
Local excision of endometriosis is associated with good short-term outcomes but, on long-term follow-up, has a high reoperation rate. Hysterectomy is associated with a low reoperation rate. Preservation of the ovaries at the time of hysterectomy remains a viable option.
II.