Surgical Techniques

Strategies and steps for the surgical management of endometriosis

OBG Manag. 2011 November;23(11):34-50

References

1. Bulun S E. Endometriosis. N Engl J Med. 2009;360(3):268-279.

2. Gao X, Outley J, Botteman M, Spalding J, Simon JA, Pashos CL. Economic burden of endometriosis. Fertil Steril. 2006;86(6):1561-1572.

3. Laufer MR, Goitein L, Bush M, Cramer DW, Emans SJ. Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding conventional therapy. J Pediatr Adolesc Gynecol. 1997;10(4):199-202.

4. Gruppo Italiano per lo studio dell’endometriosi. Prevalence and anatomic distribution of endometriosis in women with selected gynaecological conditions: results from a multicenter Italian study. Hum Reprod. 1994;9(6):1158-1162.

5. Redwine DB. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril. 1999;72(2):319-315.

6. Muzii L, Marana R, Caruana P, Catalano GF, Mancuso S. Laparoscopic findings after transvaginal ultrasound-guided aspiration of ovarian endometriomas. Hum Reprod. 1995;10(11):2902-2903

7. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatment of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril. 1998;70(6):1176-1180

8. Alborzi S, Momtahan M, Paranezhad ME, Dehbashi S, Zolghadri J, Alborzi S. A prospective randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82(6):1633-1637

9. Hart RJ, Hickey M, Maouris P, Buckett W, Garry R. Excisional surgery versus ablative surgery for ovarian endometriomas. Cochrane Database Syst Rev. 2005;(3):CD004992.-

10. Chang HJ, Sang HH, Jung RL, et al. Impact of laparoscopic cystectomy on ovarian reserve: serial changes of serum anti-Müllerian hormone levels. Fertil Steril. 2010;94(1):343-349.

11. Muzii L. Bianchi A Crocè C, Manci N, Panici PB. Laparoscopic excision of ovarian cysts: is the stripping technique a tissue sparing procedure? Fertil Steril. 2002;77(3):609-614.

12. Hachisuga T, Kawarabyashi T. Histopathological analysis of laparoscopically treated ovarian endometriotic cysts with special reference to loss of follicles. Hum Reprod. 2002;17(2):432-435.

13. Busacca M, Riparini J Somigliana E, et al. Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol. 2006;195(2):421-425.

14. Nawroth F, Rahimi G, Nawroth C, Foth D, Ludwig M, Schmidt T. Is there an association between septate uterus and endometriosis? Hum Reprod. 2006;21(2):542-546.

15. Matalliotakis IM, Goumenou AG, Matalliotakis M, Arici A. Uterine anomalies in women with endometriosis. J Endometriosis. 2010;2(4):213-217.

16. Li CZ, Liu B, Wen ZQ, Sun Q. The impact of electrocoagulation on ovarian reserve after laparoscopic excision of ovarian cyst: a prospective clinical study of 191 patients. Fertil Steril. 2009;92(4):1428-1435.

17. Luciano DE, Roy G, Luciano AA. Adhesion reformation after laparoscopic adhesiolysis: where what type, and in whom are they most likely to recur. J Minim Invasive Gynecol. 2008;15(1):44-48.

18. Colin CB, Luciano AA, Martin D, et al. Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study. Fertil Steril. 2007;88(5):1413-1426.

19. Wright J, Lotfallah H, Jones K, Lovell D. A randomized study of excision vs ablation for mild endometriosis. Fertil Steril. 2004;83(6):1830-1836.

20. Cheong Y, Tay P, Luk F, Gan HC, Li TC, Cooke I. Laparoscopic surgery for endometriosis: How often do we need to re-operate? J Obstet Gynaecol. 2008;28(1):82-85.

21. Liu X, Yuan L, Shen F, Zhu Z, Jiang H, Guo SW. Patterns of and risk factors for recurrence in women with ovarian endometriomas. Obstet Gynecol. 2007;109(6):1411-1120.

22. Seracchioli R, Mabrouk M, Frasca C, et al. Long-term cyclic and continuous oral contraceptive therapy and endometriomas recurrence: a randomized controlled trial. Fertil Steril. 2010;93(1):52-56.

23. Vercellini P, Somigliana E, Daguati R, Vigano P, Meroni F, Crosignani PG. Postoperative oral contraceptive exposure and risk of endometrioma recurrence. Am J Obstet Gynecol. 2008;198(5):504.e1-5.

24. Bulletti C, DeZiegler D, Stefanetti M, Cicinelli E, Pelosi E, Flamigni C. Endometriosis: absence of recurrence in patients after endometrial ablation. Hum Reprod. 2001;16(12):2676-2679.

25. Vercellini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Crosignani PG. Comparison of levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study. Fertil Steril. 2003;80(2):305-309.

26. Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol. 2008;111(6):1285-1292.

27. Surrey ES, Hornstein MD. Prolonged GnRH agonist and add-back therapy for symptomatic endometriosis: a long-term follow-up Obstet Gynecol. 2002;99(5 Pt 1):709-719.

FIGURE 3 Endometrioma
Endometrioma on ultrasonography (A), with its characteristic homogeneous, echogenic appearance and “ground glass” pattern, and through the laparoscope (B). These images are from the patient whose case is described in the text.

Focal point: Ovary

The ovary is the most common organ affected by endometriosis. The presence of ovarian endometriomas, in 17% to 44% of patients who have this disease,⁴ is often associated with an advanced stage of disease.

In a population of 1,785 patients who were surgically treated for ovarian endometriosis, Redwine reported that only 1% had exclusively ovarian involvement; 99% also had diffuse pelvic disease,⁵ suggesting that ovarian endometrioma is a marker of extensive disease, which often requires a gynecologic surgeon who has advanced skills and experience in the surgical management of severe endometriosis.

Simple drainage is inadequate

Surgical management of ovarian endometrioma must go beyond simple drainage, which has little therapeutic value because symptoms recur and endometriomas re-form quickly after simple drainage in almost all patients.⁶ The currently accepted surgical management of endometrioma involves either 1) coagulation and ablation of the wall of the cyst with electrosurgery or laser or 2) removal of the cyst wall from the ovary with blunt and sharp dissection.

Several studies have compared these two techniques, but only two^7,8 were prospectively randomized.

Study #1. Beretta and co-workers⁷ studied 64 patients who had ovarian endometriomas larger than 3 cm and randomized them to cystectomy by complete stripping of the cyst wall or to drainage of fluid followed by electrocoagulation to ablate the endometriosis lesions within the cyst wall. The two groups were followed for 2 years to assess the recurrence of symptoms and the pregnancy rate in the patients who were infertile.

Recurrence of symptoms and the need for medical or surgical intervention occurred with less frequency and much later in the resection group than in the ablation group: 19 months, compared to 9.5 months, postoperatively. The cumulative pregnancy rate 24 months postoperatively was also much higher in the resection group (66.7%) than in the ablative group (23.5%).

Study #2. In a later study,⁸ Alborzi and colleagues randomized 100 patients who had endometrioma to cystectomy or to drainage and coagulation of the cyst wall. The mean recurrence rate, 2 years postoperatively, was much lower in the excision group (15.8%) than in the ablative group (56.7%). The cumulative pregnancy rate at 12 months was higher in the excision group (54.9%, compared to 23.3%). Furthermore, the reoperation rate at 24 months was much lower in the excision group (5.8%) than in the ablative group (22.9%).

These favorable results for cystectomy over ablation were validated by a Cochrane Review, which concluded that excision of endometriomas is the preferred approach because it provides 1) a more favorable outcome than drainage and ablation, 2) lower rates of recurrence of endometriomas and symptoms, and 3) a much higher spontaneous pregnancy rate in infertile women.⁹

Although resection of the cyst wall is technically more challenging and takes longer to perform than drainage and ablation, we exclusively perform resection rather than ablation of endometriomas because we believe that more lasting therapeutic effects and reduced recurrence of symptoms and disease justify the extra effort and a longer procedure.

Drawback of cystectomy

A potential risk of cystectomy is that it can diminish ovarian reserve and, in rare cases, induce premature menopause, which can be devastating for women whose main purpose for having surgery is to restore or improve their fertility.

The impact of laparoscopic ovarian cystectomy on ovarian reserve was prospectively studied by Chang and co-workers,¹⁰ who measured preoperative and postoperative levels of anti-müllerian hormone (AMH) in 13 women who had endometrioma, 6 who had mature teratoma, and 1 who had mucinous cystadenoma. One week postoperatively, the AMH level decreased significantly overall in all groups. At 4 and 12 weeks postoperatively, however, the AMH level returned to preoperative levels among subjects in the non-endometrioma group but not among subjects who had endometrioma; rather, their level remained statistically lower than the preoperative level during the entire 3 months of follow-up.

Stripping the wall of an endometrioma cyst is more difficult than it is for other benign cysts, such as cystic teratoma or cystadenoma, in which there usually is a well-defined dissection plane between the wall of the cyst and surrounding stromal tissue—allowing for easy and clean separation of the wall. The cyst wall of an endometrioma, on the other hand, is intimately attached to underlying ovarian stroma; lack of a clear cleavage plane between cyst and ovarian stroma often results in unintentional removal of layers of ovarian cortex with underlying follicles, which, in turn, may lead to a reduction in ovarian reserve.