Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease

Post-operative GnRH analogue treatment after conservative surgery for symptomatic endometriosis stage III-IV: a randomized controlled trial

BACKGROUND

In order to decrease endometriosis recurrence after surgical therapy, it has been proposed to use a post-surgical oestrogen-lowering medical treatment. Results from previous trials on this topic are contradictory.

METHODS

A total of 89 women were randomized, by computer-generated list, after laparoscopic conservative surgery for symptomatic endometriosis stage III-IV to receive monthly i.m. injections of gonadotrophin-releasing hormone (GnRH) analogue, leuprolide acetate depot (3.75 mg) for 3 months (n = 44) or to an expectant management (n = 45). All patients were followed up every 6 months for evaluation of pain symptoms, fertility and objective disease recurrence.

RESULTS

During the follow-up, which ranged from 6-36 months, five (33%) of the 15 women who wanted children and who were allocated the GnRH analogue and six (40%) of the 15 given no treatment became pregnant (not significant). Moderate/severe pelvic pain recurred during the follow-up in 10 (23%) of the women allocated the GnRH analogue and 11 (24%) of those allocated no treatment; the cumulative pain recurrence rates at 18 months were 23 and 29% respectively (not significant). Four women (9%) treated with GnRH analogue and four women (9%) who received no treatment had objective disease recurrence as demonstrated by gynaecological examination and/or pelvic ultrasonography.

CONCLUSIONS

This study does not support the routine post-operative use of a 3 month course of GnRH analogue in women with symptomatic endometriosis stage III-IV.

Management of deep endometriosis

Deep endometriosis is defined as an endometriotic lesion that penetrates the retroperitoneal space for a distance of > or =5 mm. Deep endometriosis is extremely active, occurs in phase with eutopic endometrium, evolves progressively with age, and is most often located in the pouch of Douglas, the rectovaginal septum, the uterosacral ligaments, and occasionally in the uterovesical fold. These lesions are associated with pelvic pain, the intensity of which is proportional to the depth of penetration. It is clear that choice of treatment depends on the location of the endometriotic lesion. In this paper we describe our methods for the initial diagnosis and subsequent treatment of deep endometriosis. These include consultation and clinical examination protocols, use of rectal endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and transvaginal ultrasonography techniques in diagnosis and surgical treatment approaches.

Adhesion formation after laparoscopic resection of uterosacral ligaments in women with endometriosis

STUDY OBJECTIVE

To analyze the risk of postoperative adhesions in women who undergo laparoscopic surgical management of deep endometriosis infiltrating the uterosacral ligaments (USL).

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Forty-six women with deep endometriosis infiltrating the USL.

INTERVENTION

Laparoscopic resection of all USL with deep endometriotic lesions and excision of all other endometriotic lesions, followed by second-look laparoscopy.

MEASUREMENTS AND MAIN RESULTS

At second-look laparoscopy, 15 patients (32.6%) had no adhesions at the site where the USL had been resected, 24 (52.2%) had filmy avascular adhesions, and 7 (15.2%) had dense or vascular adhesions. No patient had adhesions of the binding type. Only two factors, the revised American Fertility Association (rAFS) score at initial laparoscopy and surgical modality (unilateral resection of the right USL, unilateral resection of the left USL, bilateral resection of USL) had a statistically significant influence on the risk of postoperative adhesions occurring. After adjustment, the relation with initial rAFS stage and surgical modality remained significant in the stepwise logistic regression model.

CONCLUSION

These encouraging results are particularly interesting for patients with infertility due to pelvic pain syndrome. Second-look laparoscopy should not be performed routinely after laparoscopic management of deep endometriosis infiltrating the USL. We propose that it be reserved for women with rAFS stages III and IV endometriosis, especially when lesions are located on the left side.

Use of the CEEA stapler to avoid ultra-low segmental resection of a full-thickness rectal endometriotic nodule

A woman with a history of numerous surgical episodes for treatment of aggressive endometriosis experienced rectal symptoms. She was prepared for the possibility of laparotomy with or without colostomy to relieve her symptoms. After extensive laparoscopic dissection of the rectovaginal septum, a circular stapling device (Premium Plus CEEA; Autosuture, Melbourne, Victoria, Australia) was used to excise completely an anterior rectal lesion that otherwise would have resulted in ultra-low rectal resection and anastomosis. Morbidity associated with the latter procedure was avoided; the patient was discharged within 72 hours and experienced no early or late complications. Postoperative barium enema was obviated by rapid return to normal bowel habits and complete resolution of dyschezia and dyspareunia.

Deeply infiltrating endometriosis: implications, diagnosis, and management

Deeply infiltrating endometriosis was described in the early part of the last century. Only recently, has there become a greater awareness and understanding of this form of endometriosis aided in part by advances in laparoscopic surgical technology in techniques. The clinical implications of the disease as well as diagnosis and current management are reviewed.

Medical and surgical therapies for pain associated with endometriosis

Endometriosis is a common condition for which a number of treatments have been proposed. Medical treatments are based on the hormonal responsiveness of endometriosis implants. These therapies include progestins (with or without estrogens), androgens, and gonadotropin-releasing hormone (GnRH) analogs. Surgical treatments may include hysterectomy with oophorectomy or organ-sparing surgery involving ablation or resection of visible lesions of endometriosis and restoration of pelvic anatomy. There are no studies that directly compare the effectiveness or adverse effects of medical therapy and surgical therapy. Studies on medical therapy compare different treatments with placebo or with other active treatments. Hormone-based therapies for endometriosis show 80%-100% effectiveness in relief of pelvic pain over a 6-month course of therapy. Serious adverse outcomes after medical therapy are unusual. Studies on surgical therapy are largely anecdotal, with noncomparative reports on a variety of surgical methods. A few comparative surgical studies have been reported. Because of the noncomparative nature of many of the surgical studies, the use of combinations of surgical procedures and techniques in the reported studies, and the reporting of results from surgeons with an unusually high level of technical skill, the gynecological practitioner has little basis in the literature for assessing the optimum surgical approach. Surgical complications are believed to be underreported and may be related to how aggressive a surgical procedure is undertaken.

Impact of surgical resection of rectovaginal pouch of douglas endometriotic nodules on pelvic pain and some elements of patients' sex life

STUDY OBJECTIVE

To assess the impact of laparoscopic resection of endometriotic nodules in the rectovaginal pouch of Douglas on women's pain symptoms, analgesic intake, work absenteeism, work difficulties, and some elements of sex life.

DESIGN

Observational study (Canadian Task Force classification II-2).

SETTING

Gynecology department at a university hospital.

PATIENTS

Twenty-six women with rectovaginal pouch of Douglas endometriotic nodules and no evidence of other potential cause of pain at physical examination, laparoscopy, and transvaginal ultrasonography.

INTERVENTION

Laparoscopic resection of endometriotic nodules with the CO2 laser until no residual induration was felt in surrounding tissues.

MEASUREMENTS AND MAIN RESULTS

Significant statistical differences were found between preoperative and postoperative pain scores, percentages of women absent from work, percentages taking analgesics or nonsteroidal antiinflammatory drugs, and percentages having work difficulties due to pain. A significant difference also was found in frequencies of sexual desire and coitus.

CONCLUSION

Endometriotic nodules in the rectovaginal pouch of Douglas may be responsible for major pelvic pain and also for sexual dysfunction (lack of sexual desire, dyspareunia). Laparoscopic resection of the nodules significantly improves these conditions. (J Am Assoc Gynecol Laparosc 8(1):55-60, 2001)

Laparoscopic surgery for pelvic pain associated with endometriosis

OBJECTIVES

To assess the efficacy of laparoscopic surgery in the treatment of pelvic pain associated with endometriosis. The review aims to compare the effectiveness of any laparoscopic procedure versus any other treatment modality, including expectant management.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility Review Group was used to identify all publications that described or might have described randomised trials of laparoscopic surgery in the treatment of symptomatic endometriosis. For a full description of the Review Group strategy see the Review Group details.

SELECTION CRITERIA

Trials were selected if they were randomised and compared the effectiveness of laparoscopic surgery in the treatment of pelvic pain associated with endometriosis, with other treatment modalities or placebo.

DATA COLLECTION AND ANALYSIS

One study had data appropriate for inclusion within the review. This study compared laparoscopic laser surgery with diagnostic laparoscopy. Pain relief was the primary outcome measure. The data was extracted independently by two reviewers.

MAIN RESULTS

In comparison to expectant treatment there is a significant degree of pain relief at six months after surgery with laser laparoscopic surgery for minimal, mild and moderate endometriosis. Odds Ratio (OR) 4.97, 95% Confidence Interval (CI) 1.85,13.39

REVIEWER'S CONCLUSIONS

The combined surgical approach of laparoscopic laser ablation, adhesiolysis and uterine nerve ablation is likely to be a beneficial treatment for pelvic pain associated with minimal, mild and moderate endometriosis. As only one trial is included in the analysis, this conclusion should be interpreted with caution.

Oophorectomy at the time of surgery for moderate endometriosis: a survey of Australian gynaecologists

The decision to perform bilateral oophorectomy at the time of surgery for endometriosis is dependent upon many factors, one of which is the opinion of the surgeon concerned. At present there is no consensus on this subject, and in an attempt to document current opinion, we performed a postal survey of all Fellows of RANZCOG living within Australia. The questionnaire presented the Fellow with a clinical scenario describing moderate endometriosis, and then asked him/her to select their preferred option for each of a number of anatomical areas. Out of 1,050 questionnaires, 688 (65.5%) were returned. Analysis of these replies suggests that current opinion supports a conservative approach to surgery, with only 27.5% of Fellows electing to perform a hysterectomy in conjunction with bilateral oophorectomy.

The effect of endometriosis and its radical laparoscopic excision on quality of life indicators

OBJECTIVE

To assess the effect of endometriosis and radical laparoscopic excision on the quality of life of women with this condition.

DESIGN

A prospective study.

SETTING

The Northern Endometriosis Centre at South Cleveland Hospital, Middlesbrough and St. James's University Hospital, Leeds.

POPULATION

Fifty-seven consecutive patients undergoing laparoscopic excision of invasive endometriosis.

METHODS

Questionnaires, both pre-operatively and four-month post-operatively, for a number of different symptoms associated with endometriosis were completed by patients. Details of fertility, previous treatments and quality of life as measured by SF12 and EuroQOL (EQ-5D) and sexual activity questionnaire, as well as linear pain scores for several symptoms, were recorded. Details of intra-operative findings was also collected.

MAIN OUTCOME MEASURES

Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery and incidence of intra- and post-operative complications.

RESULTS

Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-5D (0 x 595:0 x 729, P = 0 x 002) and EQ thermometer (68 x 9:77 x 7, P = 0 x 008); SF12 physical score (44 x 8:51 x 9, P = 0 x 015); sexual activity (habit P = 0 x 002, pleasure P = 0 x 002 and discomfort P < or = 0 x 001). Only the mental health score of SF12 failed to show any statistical improvement (47 x 1:48 x 4, P = 0 x 84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8 x 0:4 x 0, P < or = 0 x 001), pelvic pain (median 7 x 0:2 x 0, P < or = 0 x 001), dyspareunia (median 6 x 0:0 x 0, P < 0 x 001) and rectal pain scores (median 4 x 0:0 x 0, P < 0 x 001). Complications were noted, but were deemed to be acceptable for the extent of the surgery.

CONCLUSIONS

This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further follow up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomised trial.

Endometriosis and pain

Endometriosis generally causes pain that is cyclic and generally responds to medication and/or surgery. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. In other women, the biologic behavior is much more unpredictable. Severe dysmenorrhea, focal pelvic tenderness, and deep dyspareunia are suggestive of endometriosis. Diagnosis at laparoscopy includes concerns about subtle appearance, endometriosis hidden within adhesions, retroperitoneal disease, and intra-ovarian lesions. Negative laparoscopy results do not mean that patients have no endometriosis. In contrast, a response to GnRH agonists can occur in patients with no endometriosis because conditions other than endometriosis are estrogen sensitive. Coexistent disease can confuse the picture at the time of surgery. Some coexistent diseases also can cause pain that is similar to that of endometriosis. Distinguishing those patients who need no treatment from those who need intermediate or extensive treatment can be very difficult. Care is needed to ensure that patients are neither overtreated or undertreated. An integrated approach involving a multidisciplinary team is needed in some. Other patients respond to primary care techniques.

Diaphragmatic endometriosis

Endometriosis is a relatively common condition usually found in the pelvis. However, lesions do occur outside the pelvis and, more rarely, in the upper abdomen. In the case reported here, the patient presented with chronic right shoulder tip pain. The diagnosis of extrapelvic endometriosis is often not considered in such circumstances. This patient's symptoms were relieved by surgical excision of the diaphragmatic lesion.

A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis

OBJECTIVE

To ascertain whether the frequency of pelvic pain recurrence is reduced and time to symptoms recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery and post-operative hormonal therapy compared with women treated with surgery only. Pregnancy rates and time to conception in women wanting children were also evaluated.

DESIGN

A multicentre, prospective, randomised controlled study.

SETTING

Nineteen Italian academic departments and teaching hospitals specialising in reparative and reconstructive surgery.

POPULATION

A total of 269 women undergoing conservative surgery for mild to severe symptomatic endometriosis.

METHODS

After surgery the women were assigned to treatment with subcutaneous goserelin depot injections for six months or to expectant management. Dysmenorrhoea, deep dyspareunia, nonmenstrual pain and general discomfort were graded according to a verbal rating scale from 0 (absent) to 3 (severe) and the scores summed to give a total symptoms score. Only patients with at least one preoperative moderate or severe symptom were enrolled. The women were evaluated regularly for two years.

MAIN OUTCOME MEASURES

Post-operative pain recurrences (total symptoms scores > or = 5), time to recurrence, pregnancy rates and time to conception in the two study groups.

RESULTS

At one- and two-year follow up visits, 14/107 (13.1%) and 19/81 (23.5%) patients had moderate or severe symptoms recurrence in the goserelin group compared with, respectively, 22/103 (21.4%) and 27/74 (36.5%) in the expectant management group (P = 0.143 at 1 year and 0.082 at 2 years). Time to symptoms recurrence was significantly longer in the goserelin group according to survival analysis (Wilcoxon test, P = 0.041). Among women wanting children, few conceptions occurred in both the goserelin (8/69, 11.6%) and the expectant management group (14/76, 18.4%). There was no significant difference at survival analysis (Wilcoxon test, P = 0.427).

CONCLUSION

Post-operative treatment with goserelin significantly prolonged the pain-free interval after conservative surgery for symptomatic endometriosis and did not influence reproductive prognosis.

Recurrence of ovarian endometrioma after laparoscopic excision

OBJECTIVE

Our purpose was to evaluate the recurrence rate after laparoscopic excision of ovarian endometrioma.

STUDY DESIGN

An unrandomized prospective clinical study was performed at 2 tertiary-care centers of 366 patients who had a minimum of 6 months of postoperative follow-up or 6 months after the suspension of medical therapy after laparoscopic ovarian endometrioma excision. Patients underwent clinical examination and vaginal ultrasonography 3, 6, and 12 months after surgery and subsequently at least once a year. We evaluated the cumulative recurrence rate of pain and clinical findings of ovarian endometrioma, the rate of repeated surgery, and the recovery of fertility.

RESULTS

During follow-up we observed ultrasonographic recurrence in 26 (7.1%) cases; surgery was repeated in 12 (3.3%) cases. The cumulative rate of ultrasonographic recurrence over 48 months was 11.7%, whereas the cumulative rate of a second surgery was 8.2%. Ultrasonographic cyst recurrence was associated with pain recurrence in 73% of cases, whereas in the remaining 27% the recurrence was asymptomatic. Significant factors related to recurrence of endometriomas would appear to be the stage of disease (P =.03) and previous surgery for endometriosis (P =.003). Eighty-five (23.2%) women conceived during follow-up.

CONCLUSIONS

Laparoscopic treatment of endometriomas seems to be both effective and reliable. The rate of recurrence appears to be correlated to the duration of follow-up. Stage IV disease and previous surgery for endometriosis are unfavorable prognostic factors.

Endoscopic treatment for endometriosis

Endometriosis is best regarded as a chronic disease that can vary in symptomatology over time. Endoscopic therapy for relief of pelvic pain as well as infertility is a therapeutic option. The formation of a rational treatment plan before surgery will ensure a minimum number of reproductive surgeries over the patient's lifetime.

Follow-up of laparoscopic treatment of stage III-IV endometriosis

STUDY OBJECTIVE

To evaluate the efficacy of conservative laparoscopic surgery in a series of patients with stage III-IV endometriosis.

DESIGN

Prospective study (Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

All 141 women who underwent conservative operative laparoscopy for stage III-IV endometriosis between January 1993 and December 1996 and were followed for a minimum of 6 months.

INTERVENTIONS

Laparoscopic procedures performed with scissors, bipolar coagulation, and hydrodissection.

MEASUREMENTS AND MAIN RESULTS

Clinical examination, transvaginal ultrasonography, and pain questionnaire were scheduled every 6 months postoperatively. The cumulative proportion of pregnant patients and cumulative recurrence rate were calculated by Kaplan-Meier method. Twenty-five women (44%) with infertility became pregnant. Twenty-three (51%) had stage III and two (16.7%, p <0.05) had stage IV endometriosis. The 24-month cumulative pregnancy rate was 57.5%. Thirty-one women (22%) reported pain recurrence during follow-up. Five (3.5%) recurrences were confirmed by histologic examination and eight (5.7%) were documented only by clinical and ultrasonographic findings. No recurrence occurred in the first 6 months of follow-up.

CONCLUSION

Operative laparoscopy seems to be effective treatment for stage III endometriosis. A larger series with longer follow-up is necessary to clarify its role in the management of stage IV disease. (J Am Assoc Gynecol Laparosc 6(1):55-58, 1999)

Operative management of deep endometriosis infiltrating the uterosacral ligaments

STUDY OBJECTIVE

To describe and assess the efficacy of laparoscopic surgical treatment for patients with pain and deep endometriosis located on the uterosacral ligaments.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

One hundred ten consecutive women with deep endometriosis infiltrating uterosacral ligaments.

INTERVENTION

Operative laparoscopic management of endometriosis.

MEASUREMENTS AND MAIN RESULTS

Improvement was reported in 82.3% (70/85) of patients with severe dysmenorrhea and was considered satisfactory in 82.8% (58/70). Improvement also occurred in 88.2% (75/85) of women with deep dyspareunia, and was considered satisfactory in 88.0% (66/75).

CONCLUSION

Provided the surgeon is highly skilled in laparoscopy, operative laparoscopy is efficient for the treatment of painful symptoms related to deep endometriosis infiltrating uterosacral ligaments. (J Am Assoc Gynecol Laparosc 6(1):31-37, 1999)

Biases in the endometriosis literature. Illustrated by 20 years of endometriosis research in Leuven

AIM

To review the Leuven data on endometriosis to demonstrate the shifts that occurred over the years in diagnosis of endometriosis, classification of women with endometriosis and thus in interpretation of results.

RESULTS

The contributions to the LUF syndrome, to non-pigmented endometriosis, to cystic ovarian endometriosis, to deep endometriosis, to endometriosis as an immunologic disease and to the development of an animal model of endometriosis, illustrate the persistent interest in endometriosis over 20 years. Using these data it can be shown how progressively the recognition of endometriosis caused important shifts from women who in the beginning of this period were classified as normal, to women who later became classified as having minimal or mild endometriosis. This was caused initially by the active search for small typical lesions and later by the recognition of non-pigmented lesions as endometriosis. The second important shift was caused by the recognition that deep endometriosis is not only a frequent disease, but that these women are predominantly classified as having mild to moderate endometriosis and even as women without endometriosis. The third shift is still ongoing, since the deep lesions reported become progressively smaller, by the "enthusiasm" of the surgeons, and by the introduction of a menstrual clinical exam. A fourth bias in the literature concerns the diagnosis and treatment of cystic ovarian endometriosis. Together with these shifts in recognition and treatment of endometriosis, our understanding of the physiopathology of endometriosis has changed. This is illustrated by the new concepts which have emerged over this period. These are, the focal treatment of cystic ovarian endometriosis, the concept that mild endometriosis could be a normal physiological condition and the endometriotic disease theory.

CONCLUSION

To interpret the data of the literature we should be aware of the shifts that have occurred in the classification of endometriosis over the past 20 years, and which still can hamper the comparison of results between research groups.

The evidence for the management of endometriosis

This review article has focussed on identifying the evidence from randomized controlled trials for the medical and surgical management of endometriosis. A critical summary of the medical management has shown that there is little difference in effectiveness of various medical treatments, but there are differences in the side-effect profiles. Few randomized controlled trials have been undertaken in surgery, but these have shown that surgical management is effective in the management of both painful symptoms and subfertility.

Reproductive outcome after treatment of mild endometriosis with laparoscopic excision and electrocoagulation

OBJECTIVE

To compare the pregnancy rates (PRs) of infertile women with mild endometriosis treated laparoscopically by surgical excision and by electrocoagulation. Laparoscopic treatment of minimal and mild endometriosis usually is done by laser or electrocoagulation. Whether surgical excision is associated with similar results is unknown.

DESIGN

Retrospective study with a historical control.

SETTING

University teaching hospitals.

PATIENT(S)

One hundred one infertile women undergoing laparoscopic treatment of mild endometriosis.

INTERVENTION(S)

Forty-eight women were treated with electrosurgery (historical control) and 53 women were treated with excision.

MAIN OUTCOME MEASURE(S)

The PRs of the two groups of women were evaluated using life-table calculations and the Mantel-Cox test.

RESULT(S)

Of the total 24 pregnancies (PR: 57.1%) in the electrosurgery group, there were 3 spontaneous abortions (12.5%) and 1 ectopic pregnancy (4.2%). The total PR in the excision group was 53.5%, the abortion rate was 17.4% (4 of 23), and the ectopic PR was 8.7% (2 of 23). The median interval between surgery and conception was 10.7 months in the electrosurgery group and 13.3 months in the excision group. There was no statistically significant difference in the probability of conception between the two groups of women (Mantel-Cox test: z = 0.24). Using the Cox proportional-hazards model, the effects of age and duration of infertility were evaluated and were found not to be associated with a decreased PR.

CONCLUSION(S)

There is no difference in the PRs of infertile women with mild endometriosis treated laparoscopically by surgical excision and by electrocoagulation. The difference between these two modalities in women with endometriosis-related pelvic pain remains to be determined.

Reproductive disorders associated with pelvic pain

Pelvic pain is common in adolescents and can result from a number of physiological and pathological etiologies, both gynecologic and nongynecologic in origin. The evaluation, diagnosis, and management of these conditions involve both medical and surgical approaches. In this review, the authors present a comprehensive approach to the care of adolescents with pelvic pain associated with dysmenorrhea, endometriosis, and obstruction of the genital tract.

Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

OBJECTIVE

To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group.

DESIGN

One-year follow-up of a prospective, randomized, double-blind controlled trial.

SETTING

A referral center for the laparoscopic laser treatment of endometriosis.

PATIENT(S)

Sixty-three patients with pelvic pain and minimal to moderate endometriosis.

INTERVENTION(S)

After the 6-month follow-up visit, the randomization code was broken, and follow-up was continued to 1 year. Symptomatic patients were offered second-look laser laparoscopy.

MAIN OUTCOME MEASURE(S)

Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls.

RESULT(S)

Symptom relief continued at 1 year in 90% of those who initially responded. All symptomatic controls had a second-look procedure, with 7 (29%) showing disease progression, 7 (29%) showing disease regression, and 10 (42%) having static disease.

CONCLUSION(S)

The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year. Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others.

Use of nafarelin versus placebo after reductive laparoscopic surgery for endometriosis

OBJECTIVE

To evaluate the efficacy of the GnRH agonist (GnRH-a) nafarelin compared with placebo administered for 6 months after reductive laparoscopic surgery for symptomatic endometriosis.

DESIGN

Randomized, prospective, placebo-controlled, multicenter clinical trial.

SETTING

Thirteen clinics including private practice and university centers.

PATIENT(S)

One hundred nine women aged 18-47 with laparoscopically proven endometriosis and pelvic pain who had undergone reductive laparoscopic surgery for endometriosis.

INTERVENTION(S)

Patients were randomized to receive either the GnRH-a nafarelin (200 micrograms twice daily) or placebo for 6 months.

MAIN OUTCOME MEASURE(S)

Time to initiation of alternative treatment (the length of time from beginning study medication to receiving alternative therapy or to deeming that the study drug was ineffective) and patient-reported and physician-assessed pelvic pain scores.

RESULT(S)

The median time to initiation of alternative treatment was > 24 months in the nafarelin group versus 11.7 months in the placebo group. Fifteen (31%) of 49 nafarelin-treated patients required alternative therapy, compared with 25 (57%) of 44 placebo-treated patients. The patients' pelvic pain scores dropped significantly in the nafarelin and placebo groups after 6 months of treatment. Physician summary ratings showed significant improvement in the nafarelin group and no significant changes in the placebo group after 6 months of treatment.

CONCLUSION(S)

Compared with placebo, nafarelin administered after reductive laparoscopic surgery for endometriosis significantly delays the return of endometriosis symptoms requiring further treatment.

Surgical treatment of endometriosis

Surgical resection of endometriosis, previously possible only by means of laparotomy, can now be accomplished through laparoscopic techniques. The requirements for surgery, surgical principles, operative techniques, and results are summarized in this article, with emphasis on the laparoscopic approach.

Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis

OBJECTIVE

To determine the outcome of laparoscopy compared with laparotomy in conservative surgical treatment for severe endometriosis.

DESIGN

Comparison of nonrandomized historical surgical series.

SETTING

Two teaching hospitals and referral centers specializing in reparative and reconstructive surgery.

PATIENT(S)

A total of 216 patients operated for severe endometriosis during a 5-year period.

INTERVENTION(S)

Conservative surgical treatment at laparoscopy (n = 67) or laparotomy (n = 149) with median follow-up of 24 months.

MAIN OUTCOME MEASURE(S)

Cumulative probability of pregnancy in previously infertile patients (22 in the laparoscopy group and 70 in the laparotomy group) and cumulative probability of pain recurrence in subjects with moderate or severe symptoms before surgery (47 in the laparoscopy group and 108 in the laparotomy group).

RESULT(S)

The 24-month cumulative probability of pregnancy according to the Kaplan-Meier method was 44.9% after laparoscopy and 62.7% after laparotomy. The 24-month cumulative probability of symptoms recurrence evaluated with a 0 to 3 point verbal rating scale was, respectively, 16.4% versus 20.3% for dysmenorrhea, 33.3% versus 15.4% for deep dyspareunia, and 25.0% versus 15.9% for nonmenstrual pain. The corresponding figures obtained with a 10-point linear analogue scale were 20.3% versus 24.7%, 28.6% versus 10.4%, and 17.5% versus 20.1%. No difference is statistically significant.

CONCLUSION(S)

Laparoscopy and laparotomy seem equally effective in the treatment of infertility and chronic pelvic pain associated with severe endometriosis. However, a trend was observed toward a higher pregnancy rate and lower dyspareunia recurrence rate after surgery for severe endometriosis performed at laparotomy compared with laparoscopy.

Peritoneal surgery in the treatment of endometriosis--excision or thermal ablation?

Twenty patients with Stage 2 to 4 endometriosis were referred to an Endometriosis Clinic with an average of 3.4 previous medical and surgical treatments. All were treated by peritoneal excision. Follow-up was for 9-36 months and 14 had a further laparoscopy. Seventeen of 20 patients are free of symptoms. In 1 patient recurrence occurred in a separate site and in 2 there were lesions close to the original lesion in the pouch of Douglas and bladder wall. In addition, 1 of the 14 patients having further laparoscopy had mild adhesions. The satisfactory results of the study suggest that a controlled trial comparing peritoneal excision and thermal ablation is worthwhile. There are considerable theoretical advantages in using peritoneal excision rather than peritoneal thermal ablation.

Advanced laparoscopic procedures for pelvic pain and dysmenorrhoea

The effective removal of endometriosis is the major aim of physicians treating patients with pelvic pain. This can now be accomplished long-term as effectively at laparoscopy as at laparotomy (Wheeler and Malinak, 1987; Redwine, 1991; Martin, 1994). All successful operative laparoscopists dealing with endometriosis-associated pain should be familiar with and consider offering their patients the operative procedures discussed in this chapter. Adhesiolysis is a well-accepted therapy but uterine suspension and the nerve separating techniques of LUNA and PSN are much more controversial. Pain, being subjective, is difficult to quantify and a poor end point to monitor scientifically. However, there is a significant body of published work to suggest that uterine suspension, LUNA and PSN, which have all been performed for decades, seem effective laparoscopically in reducing pelvic pain associated with endometriosis. Much more data are obviously needed to determine if endometriosis-associated pain can be effectively treated with laparoscopic procedures. Properly designed scientific prospective randomized studies to evaluate some of the laparoscopic operations discussed to treat endometriosis-associated pain have recently been reported (Sutton, 1994). Thoughtful gynaecologists dealing daily with patients with endometriosis should consider discussing with them the advantages and disadvantages of the techniques reviewed in this chapter. From our experience and that of others, it appears that adhesiolysis, uterine suspension, LUNA and PSN can all be safely and effectively accomplished by skilled laparoscopists and result in good patient outcomes. All gynaecologists involved in the care of patients with endometriosis and pain should consider learning and offering these operations to their patients with appropriate discussion of the potential risks and benefits.

Recurrent endometriosis: a review of biological and clinical aspects

The recurrence of pelvic endometriosis some time after the initial treatment is a common finding in clinical practice. When symptoms of endometriosis reappear several months after treatment, it is difficult to distinguish between recurrence and persistence of the disease. In this review, the current hypotheses about the biological basis of endometriosis recurrence/persistence are discussed. The results of several clinical trials estimating the recurrence rate of endometriosis after medical, surgical, and combined treatments are presented. In addition, a critical analysis of the tools available for the diagnosis of recurrent endometriosis is made, and some therapeutic options to treat recurrent endometriosis are discussed with recommendations for their use.

Pain and infertility--a rationale for different treatment approaches

Endometriosis may result in pain and/or infertility in some patients, while others may remain asymptomatic. The disease appears to progress and regress somewhat unpredictably, making it difficult to determine the appropriate treatment. Progression of the disease can be altered by medical and surgical treatments used according to general guidelines but selected for the individual. Coagulation, medical suppression and observation are frequently the first approaches to infertility or pain resulting from endometriosis. Deep dissection and excision may be indicated with deep disease, persistent pain or persistent tenderness.

Pain recurrence: a quality of life issue in endometriosis

Studies reveal endometriosis to be present in 38-51% of women undergoing laparoscopy for chronic pelvic pain. Symptoms attributable to endometriosis include dysmenorrhea, dyspareunia, generalized pelvic pain, dyschezia, and radiation of pain to the back or leg. Psychological factors may also contribute to a more intense pain experience. Medical therapy provides symptom relief in 72-93% of patients, although recurrence is common following treatment discontinuation. Surgical therapy has had varying results for long-term pain relief; adequacy of the initial surgical treatment appears to be a critical factor. Important adjunctive measures include presacral neurectomy and excisional techniques to remove deep, fibrotic, retroperitoneal lesions. The quality of life of women with endometriosis will improve with greater focus on achieving the long-term relief of pelvic pain. Limitation of pain recurrence would benefit the patient greatly, by providing symptom relief and preventing the cycle of its probably adverse effects on physical activity, work productivity, sexual fulfilment, and mood.

Laparoscopic treatment of chronic pelvic pain in 100 adult women

STUDY OBJECTIVE

To evaluate the effectiveness of laparoscopic surgical treatment for women with chronic pelvic pain.

DESIGN

Prospective evaluation of women treated consecutively between January 1, 1989, and December 31, 1992.

SETTING

A private practice.

PATIENTS

One hundred women with chronic pelvic pain.

INTERVENTIONS

Laparoscopic treatment was performed in all patients. Pain level was rated on a scale of 1 to 10 (1 = no pain, 10 = severe, disabling pain). Patients recorded their pain levels before and 1 month, 3 months, and 6 months after surgery, as well as at intervals of 1, 2, and 3 years after surgery.

MEASUREMENTS AND MAIN RESULTS

Preoperatively, the average pain level reported by the patients was 8.2. At 1 month after laparoscopic surgical therapy, it had dropped to 3.6, at 6 months to 1.9, and at 3 years to 2.2. Twenty patients reported pain levels of 5 or greater at the 6-month interval. Six of them proceeded to hysterectomy, and four of these six were found to have adenomyosis. Eleven of the 100 who had pain levels greater than 5 after initial procedure had no further therapy, and 3 underwent repeat laparoscopy.

CONCLUSION

Extensive laparoscopic surgery to restore normal pelvic anatomy and remove all diseased tissue, including treatment of all endometriosis, resection of ovarian cysts, resection of adhesions, removal of the appendix, and treatment of hernias when indicated, together with laparoscopic uterosacral nerve vaporization or presacral neurectomy, results in significant improvement in reported pain levels.

Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis

OBJECTIVE

To assess the efficacy of laser laparoscopic surgery in the treatment of pain associated with minimal, mild, and moderate endometriosis.

DESIGN

A prospective, randomized, double-blind, and controlled clinical study.

SETTING

Royal Surrey County Hospital, Guildford, United Kingdom, a referral center for the laser laparoscopic treatment of endometriosis.

PATIENTS

Sixty-three patients with pain (dysmenorrhoea, pelvic pain, or dyspareunia) and minimal to moderate endometriosis.

INTERVENTIONS

The patients were randomized at the time of laparoscopy to laser ablation of endometriotic deposits and laparoscopic uterine nerve ablation or expectant management. Pain symptoms were recorded subjectively and by visual analogue scale. The women were unaware of the treatment allocated as was the nurse who assessed them at 3 and 6 months after surgery.

MAIN OUTCOME MEASURE

Improvement or resolution of pain symptoms assessed subjectively and by visual analogue score.

RESULTS

Laser laparoscopy results in statistically significant pain relief compared with expectant management at 6 months after surgery. Sixty-two and a half percent of the lasered patients reported improvement or resolution of symptoms compared with 22.6% in the expectant group. Results were poorest for minimal disease and, if patients with mild and moderate disease only are included, 73.7% of patients achieved pain relief. There were no operative or laser complications.

CONCLUSIONS

Laser laparoscopy is a safe, simple, and effective treatment in alleviating pain symptoms in women with stages I, II, and III endometriosis.

Prevention of adhesions

A survey is given on the literature of the prevention of adhesions. Various methods of adhesion prevention are discussed: limitation of peritoneal injury, inhibition of the inflammatory response, prevention of coagulation of fibrinogen, removal of fibrin and mechanical separation of injured mesothelial surfaces.

Remote recollection of preoperative pain in patients undergoing excision of endometriosis

To determine the accuracy of postoperative recall of preoperative pain, this prospective, longitudinal study was conducted by a general gynecologist in private practice at a referral center. Before excision of endometriosis at laparoscopy or laparotomy and again at 6 to 18 months after surgery, 168 patients completed a 5-point scale assessing 11 symptoms that may be related to endometriosis. For 6 of the 11 symptoms, over 50% of patients had exact recall of pain level. For 10 symptoms, over 80% recalled their preoperative pain level within +/-1 point. Patients requiring reoperation were most likely to recall preoperative pain levels accurately. Those not requiring reoperation tended to inflate slightly their remote assessment of preoperative pain, indicating that successfully treated patients tend to forget how much they formerly hurt.

Endometriosis: radical surgery

Radical ablative surgery for endometriosis is indicated chiefly for symptoms of pain that fail to respond to conservative treatment. The sites of involvement must be carefully assessed and surgery planned taking account of the wishes of the patient concerning her fertility. Procedures include oophorectomy, salpingo-oophorectomy, hysterectomy, appendicectomy, and the excision of deeply infiltrating endometriosis possibly involving bowel resection. The most important arbiter of therapeutic success is the removal of the ovaries, hysterectomy and bilateral salpingo-oophorectomy offering the ultimate cure for this chronic condition. Whereas laparotomy has been the traditional approach for most of these procedures, vaginal and laparoscopic surgery are modern alternatives for many of these cases offering important advantages in terms of reduced postoperative discomfort, shorter hospitalization, faster recovery and a superior cosmetic result. Preoperative and postoperative medical therapy has a limited role in surgery, whereas postoperative hormone replacement therapy after bilateral oophorectomy is generally recommended.

Laparoscopic excision of endometriosis with 3-mm scissors: comparison of operating times between sharp excision and electro-excision

To determine if laparoscopic excision of endometriosis by electrosurgery is more rapid than by sharp dissection, a retrospective comparative study was made of operative times for the two procedures. Median operating times for laparoscopic electro-excision of endometriosis were 26% to 49% faster than excision by sharp dissection. A chi2 analysis of the frequency counts of surgical intervals, and disease stage revealed this difference to be statistically significant and not due to acquired experience or differences in extent of disease in the two groups. The reduction in operating time achieved with monopolar electro-excision seems primarily associated with a more rapid cutting action with simultaneous coagulation of bleeders.

Laparoscopic removal of endometriosis in the pouch of Douglas

Twenty-six patients with endometriosis in the pouch of Douglas were treated by laparoscopic excisional surgery; previous medical and surgical therapy had failed in 24 of them. Endometriosis in the pouch of Douglas occurred infrequently in association with bladder or ovarian endometriosis. Coital and rectal pain were markedly reduced or cured 6 months after surgery in all except 2 patients. Laparoscopic surgical excision of endometriosis is indicated when drug or other surgical treatments fail and may avoid the need for hysterectomy in some patients.