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Endometriosis: The Case for Surgical Excision

Todd R. Jenkins, MD

For women with endometriosis who reject or are not candidates for hormone therapy—particularly those hoping to improve fertility—excision may be the surgical option of choice.

Endometriosis remains one of the most challenging conditions confronted by the ObGyn, posing problems with regard to both diagnosis and treatment. It is estimated to occur in 10% to 15% of reproductive-aged women, including 20% to 50% of infertile patients and up to 87% of women with chronic pelvic pain.1,2 The cost of hospital treatment for endometriosis in the United States has risen 2.7 times faster than that of overall medical care costs; in 2002, inpatient costs were approximately $1.1 billion.1

Current treatment options include medical and surgical approaches. Except in women with gross abnormalities on pelvic examination, initial therapy usually consists of pharmacologic suppression of endometriosis. If these medications fail or produce intolerable side effects, many physicians will proceed to surgical therapy. For patients who desire future fertility, conservative surgery is indicated. Currently, surgeons use 2 techniques for the surgical treatment of endometriosis: ablation with laser or electrodessication, or excision.

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THE ROLE OF EXCISION

Excision of endometriosis was first described in 1991 in a 5-year follow-up of more than 350 women.3 In this cohort, fewer than 20% of women experienced subsequent recurrent symptoms or disease. Today, excision is the standard of care for the treatment of endometriomas and bulky disease in the cul-de-sac. Indeed, excision of endometriomata appears to produce a more favorable outcome than drainage or ablation.3 Furthermore, it has demonstrated efficacy in the treatment of deep infiltrating lesions of the cul-de-sac and rectovaginal septum.4,5 The European Society for Human Reproductive Endocrinology guidelines encourage excision, stating that pain due to endometriosis can be reduced by surgical removal of the entire lesion in severe and in deep, infiltrating endometriosis. The guidelines also state that the best approach is to diagnose and remove endometriosis surgically.6

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EXCISION VERSUS ABLATION

Despite these recommendations, most surgeons do not excise endometriosis during diagnostic procedures. A recent survey of British gynecologic consultants and surgeons found that only 30% performed surgical removal. In the survey, 95% favored ablative techniques, and 25% used both ablation and excision.7 This reluctance to adopt excision of endometriosis has been judged appropriate by some, due to the lack of good long-term data regarding its effects and the increased potential for surgical complications.

A review of the literature yields 2 randomized controlled trials (RCTs) and 5 cohort studies addressing the effectiveness of laparoscopic excision for the treatment of endometriosis.8-14 A 2003 study involving 39 subjects with histologically confirmed endometriosis randomized patients to either immediate excisional surgery or diagnostic surgery only.8 All patients underwent second-look laparoscopy, with 80% of women in the excision group reporting improvements in pain symptoms versus 32% in the control group. Women with more advanced disease experienced a greater response to laparoscopic excision. Furthermore, responses on quality-of-life instruments showed significant improvements in both mental and physical scores.8 In the second RCT, 24 women with mild endometriosis (stage 1 or 2) were randomized to either laparoscopic excision or ablation of endometriotic lesions.9 There was no significant difference between groups with respect to pain relief and pelvic tenderness, but there was a significant improvement in the signs of endometriosis (eg, back pain, fatigue, tenderness, adnexal pain) in the excision group. As in the first RCT, severity of symptoms was the strongest indicator of the success of treatment.8,9 The latter study identified no additional morbidity associated with excision, but both trials were limited by small size and short follow-up.8,9

There were 5 cohort studies involving laparoscopic excision of endometriosis, 4 of which directly assessed the effects of excisional surgery on pelvic pain (Table).11,12,14-16 A 1996 investigation reported on a 2-year follow-up of women undergoing excision versus laser vaporization. At 12 months, 96% of excision patients and 69% of vaporization patients were pain-free, falling to 69% and 23%, respectively, at 24 months.10 Findings from a study of 135 patients with a mean follow-up of 3.2 years revealed reductions in pain scores related to dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia.11 As expressed by survival curves, the likelihood of avoiding further surgery over the subsequent 5 years was 64%, with the strongest predictive factor for reoperation being a revised American Fertility Score of 70 or higher. Interestingly, endometriosis was not identified at the time of subsequent surgery in 32% of subjects.11 A study that followed 62 women for an average of 13 months reported a 71% satisfaction rate with excision, but 40% of subjects still required regular medication and 11% underwent further surgery.12 Finally, among 107 women treated by laparoscopic excision and followed for a mean of 7.65 years, the 2-, 5-, and 7-year surgery-free rates were 79.2%, 51%, and 41.4%, respectively.14 All of these studies were limited by the lack of a control group, but they consistently showed a 2-year surgery-free rate of more than 70%.

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Table. Comparison of Cohort Studies on the Treatment of Endometriosis

Three studies presented data regarding quality of life before and after excision.11,12,17 A 4-month follow-up of 57 consecutive patients undergoing laparoscopic excision of endometriosis reported significant improvement in the physical components of quality-of-life scores, but showed no improvement in the mental components.17 The aforementioned study of 135 patients noted improvement in a quality-of-life scale that persisted through 5 years of follow-up, but these improvements did not reach the quality of life of healthy subjects.17 Finally, the study that involved 62 patients noted only limited increases in quality-of-life scores, with improvement in social life reported by 32%, in relationships by 24%, and in anxiety levels by 39%.12

Deep dyspareunia is a common complaint among women with endometriosis, affecting 60% to 79% of patients undergoing surgery.13 An observational prospective cohort study addressed the effects of laparoscopic excision on deep dyspareunia and overall sexual function. The study enrolled 68 women, of whom 87% had stage 3 or 4 disease. At 6 and 12 months’ follow-up, patients demonstrated both significant reductions in the intensity of deep dyspareunia and improvements in the quality of sexual function.13 Two of these studies reported significant improvements in pleasure and comfort.11,13

One RCT comparing laparoscopic endometriosis ablation with diagnostic laparoscopy reported a 62.5% improvement in symptoms at 6 months versus 22% in the control group.15 At a mean follow-up of 73 months, there was a symptom recurrence rate of 74%, but a 55% rate of satisfactory symptom relief. Whereas the cohort study of 107 patients noted a 2-year reoperation rate of 21.2%, this RCT yielded a median time to symptom recurrence of 19.7 months and a 2-year reoperation of 37%.14,16

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DISCUSSION

Overall, these data have several limitations. All of the studies were conducted by expert laparoscopic surgeons, whose results are unlikely to be reproduced by the generalist surgeon. Also, the absence of a control group in the cohort studies limits the significance of their findings. Finally, variations in designs, endpoints, and surgical techniques make it difficult to generalize. There is no definitive study as of yet, and a large, well-designed RCT of laparoscopic excision versus ablation of endometriosis remains to be performed.

Based on the studies performed to date, it is the author’s opinion that laparoscopic excision of endometriosis, when technically feasible, should be the standard of care. First, whereas visual diagnosis of endometriosis is correct in only 57% to 72% of cases, excisional surgery yields specimens for histologic confirmation—and identifies endometriosis in 25% of “atypical” pelvic lesions as well.18 The availability of such specimens would prevent unnecessary treatment and ensure more reproducible research findings. Excision should also reduce the incidence of persistent disease secondary to inadequate “tip of the iceberg” destruction, removing both invasive and microscopic endometriosis to provide the best possible symptom relief. Finally, the results of excision are comparable to or better than those of ablation. Endometriosis usually recurs, but excision both prolongs the time to reoperation and reduces the severity at second surgery. Excision provides the greatest benefit for patients with extensive disease without increasing complication rates or morbidity.

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CONCLUSION

Surgical treatment of endometriosis can be difficult due to its tendency to target the uterosacral ligaments adjacent to the ureter and to cause fibrosis and adhesions. However, these complexities need not result in suboptimal debulking of lesions. These studies suggest that converting from ablative to excisional therapy will refine diagnosis, reduce disease burden and morbidity, lengthen the time to recurrence, and improve outcomes overall.

The author reports no actual or potential conflicts of interest in relation to this article.

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Todd R. Jenkins, MD, is Associate Professor and Director, Division of Women’s Reproductive Healthcare, Department of Obstetrics and Gynecology, University of Alabama-Birmingham, Birmingham.

References

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