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The significance of laparoscopy for the diagnosis and treatment of peritoneal endometriosis
Abstract
The diagnostic laparoscopy is the gold standard today to stage pelvic endometriosis and to prove it by biopsy and histology. Other diseases of the pelvic organs can be seen or excluded by differential diagnosis. Laparoscopic treatment of peritoneal implants is the treatment of choice, which is proven for pain and infertility with prospective randomised studies.
Endometriosis and infertility are frequently associated. There is controversy in the literature about the causal correlation. There is no doubt, that progressed disease causes infertility by mechanical disturbances of the reproductive organs. Mild and moderate endometriosis however is discussed to cause functional infertility by changes of the peritoneal fluid, by endocrine and immunological dysfunction. Ovulation, ovum transport, fertilisation and implantation has been shown to be negatively influenced in patients with endometriosis. Some randomised prospective clinical studies however have demonstrated, that pregnancy rates after medical or surgical treatment of endometriosis are not improved compared with no treatment of the disease. The morphological data of this study may explain these conflicting data of the past: inactive, not proliferative endometriosis is not a cause of infertility, but in contrast active proliferating disease reduces fertility and needs sufficient treatment.
In this series of patients, endometriosis does not involve more pelvic areas in older age groups. Exposure to pregnancy is associated with slightly less pelvic involvement, although this effect is inconstant when age groups are studied individually.
The diagnosis of nonpigmented endometrial lesions by simple laparoscopic visualization is difficult and often inaccurate. We therefore sought to establish a new and more accurate method to visualize these nonpigmented peritoneal changes caused by endometriosis.
A total of 37 patients received 30 mg 5-aminolevulinic acid/kg body weight 10 to 14 hs prior to surgery. Laparoscopy was then performed using a D-light system (Storz, Tuttlingen, Germany). The findings were evaluated first in the white-light mode; the D-light system was then activated, and all areas of fluorescence were documented. Multiple specimens were obtained by biopsy.
The sensitivity of the fluorescence diagnosis in detecting endometriosis in nonpigmented areas and normal-looking peritoneum is 100%, with a specificity of 75%. Diagnosis by simple visualization under white illumination has a sensitivity of only 69% and a specificity of 70%. Occult areas of endometriosis were discovered using fluorescence diagnosis.
Our findings suggest that fluorescence diagnosis using 5-aminolevulinic acid is feasible and can improve the diagnosis of endometriosis in nonpigmented and occult endometrial lesions. Fluorescence diagnosis is a promising new tool in the diagnosis of endometriosis.
In vitro studies demonstrated that implantation on membranes (peritoneum, amniotic membranes) can take place if there are defects on the surface of the membranes. If these mechanisms play a role for the development of endometriosis in vivo, then patients with surgical treatment of peritoneal endometriosis in the luteal phase must have a high recurrence rate.
Retrospective analysis of operation charts and follow-up data.
Department of gynecology, in a hospital-based endometriosis treatment center.
Two hundred twenty premenopausal women.
Laparoscopic treatment for peritoneal endometriosis, stage I and II by revised American Society for Reproductive Medicine guidelines.
During the follow-up period of 2 years, symptoms and gynecological and sonographic findings were documented. In case of suspected recurrence a repeat laparoscopy with biopsy was performed to prove the recurrent endometriosis macroscopically and histologically.
The total recurrence rate after 2 years was 9.6%. The recurrence rate of group III (15%) was twice as high as those of group I (7%) and group II (8%), as indicated by subjective complaints, clinical findings, macroscopy, and histology; no differences were found between groups I and II.
Endoscopic surgery for the treatment of peritoneal endometriosis should not be performed in the luteal phase.