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Perrone U, Ferrero S, Gazzo I, Izzotti A, Leone Roberti Maggiore U, Gustavino C, Ceccaroni M, Bogliolo S, Barra F. Endometrioma surgery: Hit with your best shot (But know when to stop). Best Pract Res Clin Obstet Gynaecol 2024:102528. [PMID: 38977389 DOI: 10.1016/j.bpobgyn.2024.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/08/2024] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.
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Affiliation(s)
- Umberto Perrone
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.
| | - Irene Gazzo
- Department of Reproductive Medicine, Ospedale Evangelico Internazionale, Genoa, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | | | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Stefano Bogliolo
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
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Urman B, Ata B, Gomel V. Reproductive surgery remains an essential element of reproductive medicine. Facts Views Vis Obgyn 2024; 16:145-162. [PMID: 38950529 DOI: 10.52054/fvvo.16.2.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Background Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns. Objectives To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management. Materials and Methods Narrative review based on literature and the cumulative experience of the authors. Main outcome measures The paper does not address specific research questions. Conclusions Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology. What is new? A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.
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Miquel L, Liotta J, Pivano A, Gnisci A, Netter A, Courbiere B, Agostini A. Ethanol endometrioma sclerotherapy: safety through 8 years of experience. Hum Reprod 2024; 39:733-741. [PMID: 38327007 DOI: 10.1093/humrep/deae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
STUDY QUESTION What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas? SUMMARY ANSWER Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented. WHAT IS KNOWN ALREADY There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications. STUDY DESIGN, SIZE, DURATION A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women. PARTICIPANTS/MATERIALS, SETTING, METHODS The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity. MAIN RESULTS AND THE ROLE OF CHANCE We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications. LIMITATIONS, REASONS FOR CAUTION This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated. WIDER IMPLICATIONS OF THE FINDINGS Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER Aix Marseille University's ethics committee registration number 2021-06-03-01.
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Affiliation(s)
- L Miquel
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - J Liotta
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Pivano
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Gnisci
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Netter
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
- Department of Mediterranean Institute of marine and terrestrial Biodiversity and Ecology, Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - B Courbiere
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
- Department of Mediterranean Institute of marine and terrestrial Biodiversity and Ecology, Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - A Agostini
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
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Mohtashami S, Jabarpour M, Aleyasin A, Aghahosseini M, Najafian A. Efficacy of Ethanol Sclerotherapy Versus Laparoscopic Excision in the Treatment of Ovarian Endometrioma. J Obstet Gynaecol India 2024; 74:60-66. [PMID: 38434126 PMCID: PMC10902231 DOI: 10.1007/s13224-023-01840-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 02/26/2023] [Indexed: 03/05/2024] Open
Abstract
Objective The purpose of this study was to examine the recurrence rates of ovarian endometrioma, dysmenorrhea, dyspareunia, and related complications between sclerotherapy and laparoscopic ovarian cystectomy in individuals aged 25 to 38. Methods Eighty-eight women participated in this retrospective, single-center study between January 2020 and February 2022. Patients received either laparoscopy or sclerotherapy, depending on the opinion of the pertinent physician. In this study, the following parameters were retrospectively analyzed in follow-up visits 2, 6 and 12 months after sclerotherapy and laparoscopy: dysmenorrhea and dyspareunia by visual analog scale, complications following the intervention, and serial pelvic sonograms for endometrioma cyst recurrence. Moreover, serum Anti-Müllerian hormone (AMH) level before and 6 months after sclerotherapy/surgery were analyzed. The collected data were then analyzed using R software. Results The results demonstrate the efficiency of both sclerotherapy and laparoscopic techniques in reducing endometrioma-related dysmenorrhea and dyspareunia over a 12-month period. There was no statistically significant difference in the occurrence of complications and recurrence rate between these two therapies, and both are equally beneficial. Also, the rate of AMH decline after laparoscopy was higher than sclerotherapy; however there was not a statistically significant change in serum level of AMH in laparoscopy compared to the sclerotherapy after 6 months. Conclusion Considering all the data, it appears that sclerotherapy, with its lower cost, shorter hospital stay, and quicker return to activities, can be a laparoscopic alternative to endometrioma cyst removal. More studies are required.
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Affiliation(s)
- Samaneh Mohtashami
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Jalal-E-Al-E-Ahmad Hwy, Tehran, 1411713135 Iran
| | - Masoome Jabarpour
- Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashraf Aleyasin
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Jalal-E-Al-E-Ahmad Hwy, Tehran, 1411713135 Iran
- Department of Infertility, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Aghahosseini
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Jalal-E-Al-E-Ahmad Hwy, Tehran, 1411713135 Iran
- Department of Infertility, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ayda Najafian
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Jalal-E-Al-E-Ahmad Hwy, Tehran, 1411713135 Iran
- Department of Infertility, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Daniilidis A, Grigoriadis G, Kalaitzopoulos DR, Angioni S, Kalkan Ü, Crestani A, Merlot B, Roman H. Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes. J Clin Med 2023; 12:5324. [PMID: 37629367 PMCID: PMC10455819 DOI: 10.3390/jcm12165324] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.
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Affiliation(s)
- Angelos Daniilidis
- 1st Department in Obstetrics and Gynaecology, Papageorgiou General Hospital, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece;
| | - Georgios Grigoriadis
- 2nd Department in Obstetrics and Gynecology, Hippokratio General Hospital, School of Medicine, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece;
| | | | - Stefano Angioni
- Department of Obstetrics and Gynecology, University of Cagliari, Monserrato, 09042 Cagliari, Italy;
| | - Üzeyir Kalkan
- Department of Obstetrics and Gynecology, Koç University, 34010 Istanbul, Turkey;
| | - Adrien Crestani
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
| | - Benjamin Merlot
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi 7400, United Arab Emirates
| | - Horace Roman
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi 7400, United Arab Emirates
- Aarhus University, 8000 Aarhus, Denmark
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Crestani A, Merlot B, Dennis T, Chanavaz-Lacheray I, Roman H. Impact of Laparoscopic Sclerotherapy for Ovarian Endometriomas on Ovarian Reserve. J Minim Invasive Gynecol 2023; 30:32-38. [PMID: 36228863 DOI: 10.1016/j.jmig.2022.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/28/2022] [Accepted: 10/03/2022] [Indexed: 11/08/2022]
Abstract
STUDY Objective: To evaluate the impact of laparoscopic sclerotherapy on the management of endometrioma during surgery for deep infiltrative endometriosis (DIE). DESIGN Observational study. SETTING Tivoli-Ducos Clinic, Bordeaux. PATIENTS Sixty-nine patients underwent laparoscopic sclerotherapy for endometrioma during surgery for DIE. INTERVENTIONS Laparoscopic sclerotherapy with 95% ethanol solution and DIE surgery. MEASUREMENTS AND MAIN RESULTS Antimüllerian hormone (AMH) levels before and at least 6 months after surgery, recurrences, and pregnancies. Mean AMH (ng/mL) levels were 3.4 (2.3) before surgery and 2 (1.7) after surgery (p <.001). Mean difference was 1.29 ng/mL. Preoperative AMH level was the only variable independently associated with an additive decrease in AMH. Mean (standard deviation) follow-up period was 17.5 months (4.6) (range 9-26 months); 18 of 44 patients (40.1%) with pregnancy intent conceived. Of 51 patients who underwent postoperative pelvic ultrasound, 6 (6 of 51, 11.8%) had a recurrence of endometrioma. CONCLUSION Laparoscopic sclerotherapy for endometrioma >40 mm during surgery for DIE sclerotherapy has a low impact on AMH, preserves fertility, and prevents recurrence.
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Affiliation(s)
- Adrien Crestani
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman); and Sorbonne Université, Paris (Dr. Crestani), France.
| | - Benjamin Merlot
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman)
| | - Thomas Dennis
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman)
| | - Isabella Chanavaz-Lacheray
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman)
| | - Horace Roman
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman); Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman)
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Crestani A, Merlot B, Dennis T, Roman H. Laparoscopic sclerotherapy for an endometrioma in 10 steps. Fertil Steril 2022; 117:1102-1103. [DOI: 10.1016/j.fertnstert.2022.01.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 11/25/2022]
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Kim GH, Kim PH, Shin JH, Nam IC, Chu HH, Ko HK. Ultrasound-guided sclerotherapy for the treatment of ovarian endometrioma: an updated systematic review and meta-analysis. Eur Radiol 2021; 32:1726-1737. [PMID: 34580747 DOI: 10.1007/s00330-021-08270-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/24/2021] [Accepted: 08/12/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of ultrasound (US)-guided sclerotherapy for the treatment of ovarian endometrioma through a systematic review and meta-analysis. METHODS MEDLINE and EMBASE databases were searched for studies reporting outcomes in patients with endometrioma who were treated with US-guided sclerotherapy. Meta-analyses of recurrence, pain resolution, pregnancy, technical success, and complication rates were analyzed. Subgroup analyses were conducted regarding the indwelling time of sclerotherapy (≤ 10 min vs > 10 min). RESULTS Twenty-eight studies (1301 patients) were included. The pooled technical efficacy was 98.3%. The pooled estimates of recurrence, pain resolution, and pregnancy rate were 13.8%, 85.9%, and 37.6%, respectively. The pooled major complication rate was 1.7%. A sclerotherapy time > 10 min had a lower pooled recurrence rate than a time ≤ 10 min (11.2% vs 20.9%; p = 0.106). Direct comparisons showed that the recurrence rate was significantly lower with sclerotherapy > 10 min than with sclerotherapy ≤ 10 min (OR, 0.2; p = 0.015). Regarding pregnancy rates, sclerotherapy of > 10 min showed no significant difference compared with sclerotherapy of ≤ 10 min (35.9% vs 38.8%; p = 0.664). Direct comparisons with surgery showed that sclerotherapy increased the pregnancy rate compared with surgery (OR, 2.0; p = 0.042). There was no significant difference in AMH level before and after sclerotherapy (p = 0.951). There was no significant difference in major complication rates between sclerotherapy > 10 min and ≤ 10 min (p = 0.837). CONCLUSION US-guided sclerotherapy seems to be an effective and safe therapeutic option regarding recurrence, pain resolution, and pregnancy for patients with ovarian endometrioma. KEY POINTS • US-guided sclerotherapy seems to be an effective and safe therapeutic option regarding recurrence, pain resolution, and pregnancy for patients with ovarian endometrioma. • Sclerotherapy of more than 10 min had a lower recurrence rate than sclerotherapy less than or equal to 10 min. There was no significant difference in major complication rates between sclerotherapy of > 10 min and ≤ 10 min. • Future randomized controlled trials are warranted to compare the outcomes of US-guided sclerotherapy with surgery.
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Affiliation(s)
- Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Pyeong Hwa Kim
- Department of Radiology and Research Institute of Radiology, College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea.
| | - In Chul Nam
- Department of Radiology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Changwon, Korea
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, College of Medicine, Asan Medical Center, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
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Koninckx PR, Ussia A, Porpora MG, Malzoni M, Adamyan L, Wattiez A. Surgical management of endometriosis-associated pain. Minerva Obstet Gynecol 2021; 73:588-605. [PMID: 33978353 DOI: 10.23736/s2724-606x.21.04864-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis and pelvic pain are associated. However, only half of the subtle and typical, and not all cystic and deep lesions are painful. The mechanism of the pain is explained by cyclical trauma and repair, an inflammatory reaction, activation of nociceptors up to 2.7 cm distance, painful adhesions and neural infiltration. The relationship between the severity of lesions and pain is variable. Diagnosis of the many causes requires laparoscopy and expertise. Imaging cannot exclude endometriosis. Surgical removal is the treatment of choice. Medical therapy without a diagnosis risks missing pathology and chronification of pain if not 100% effective. Indications and techniques of surgery are described as expert opinion since randomised controlled trials were not performed for ethical reasons, since not suited for multimorbidity while a control group is poorly accepted. Subtle endometriosis needs destruction since some cause pain or progress to more severe disease. Typical lesions need excision or vaporisation since depth can be misjudged by inspection. Painful cystic ovarian endometriosis needs adhesiolysis and either destruction of the lining or excision of the cyst wall, taking care to avoid ovarian damage. Cysts larger than 6cm need a 2 step technique or an ovariectomy. Excision of deep endometriosis is difficult and complication prone surgery involving bladder, ureter, and bowel surgery varying from excision and suturing, disc excision with a circular stapler and resection anastomosis. Completeness of excision, prevention of postoperative adhesions and recurrences of endometriosis, and the indication to explore large somatic nerves will be discussed.
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Affiliation(s)
- Philippe R Koninckx
- Latifa Hospital, Dubai, Unated Arab Emirates - .,Obstetrics and Gynecology, KULeuven, Leuven, Belgium -
| | - Anastasia Ussia
- Università Cattolica del Sacro Cuore, Rome, Italy.,Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
| | - Maria G Porpora
- Department of Maternal and Child Health and Urology, Sapienza University of Rome, Rome, Italy
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Pelvic Surgery, Avellino, Italy
| | - Leila Adamyan
- Department of Operative Gynecology, FSBI National Medical Research Center For Obstetrics, Gynecology And Perinatology Named After Academician V.I.Kulakov, Ministry of Healthcare of The Russian Federation, Moscow, Russia.,Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Arnaud Wattiez
- Latifa Hospital, Dubai, Unated Arab Emirates.,Department of Obstetrics and Gynaecology, University of Strasbourg, Strasbourg, France
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Koninckx PR, Fernandes R, Ussia A, Schindler L, Wattiez A, Al-Suwaidi S, Amro B, Al-Maamari B, Hakim Z, Tahlak M. Pathogenesis Based Diagnosis and Treatment of Endometriosis. Front Endocrinol (Lausanne) 2021; 12:745548. [PMID: 34899597 PMCID: PMC8656967 DOI: 10.3389/fendo.2021.745548] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022] Open
Abstract
Understanding the pathophysiology of endometriosis is changing our diagnosis and treatment. Endometriosis lesions are clones of specific cells, with variable characteristics as aromatase activity and progesterone resistance. Therefore the GE theory postulates GE incidents to start endometriosis, which thus is different from implanted endometrium. The subsequent growth in the specific environment of the peritoneal cavity is associated with angiogenesis, inflammation, immunologic changes and bleeding in the lesions causing fibrosis. Fibrosis will stop the growth and lesions look burnt out. The pain caused by endometriosis lesions is variable: some lesions are not painful while other lesions cause neuroinflammation at distance up to 28 mm. Diagnosis of endometriosis is made by laparoscopy, following an experience guided clinical decision, based on history, symptoms, clinical exam and imaging. Biochemical markers are not useful. For deep endometriosis, imaging is important before surgery, notwithstanding rather poor predictive values when confidence limits, the prevalence of the disease and the absence of stratification of lesions by size, localization and depth of infiltration, are considered. Surgery of endometriosis is based on recognition and excision. Since the surrounding fibrosis belongs to the body with limited infiltration by endometriosis, a rim of fibrosis can be left without safety margins. For deep endometriosis, this results in a conservative excision eventually with discoid excision or short bowel resections. For cystic ovarian endometriosis superficial destruction, if complete, should be sufficient. Understanding pathophysiology is important for the discussion of early intervention during adolescence. Considering neuroinflammation at distance, the indication to explore large somatic nerves should be reconsidered. Also, medical therapy of endometriosis has to be reconsidered since the variability of lesions results in a variable response, some lesions not requiring estrogens for growth and some being progesterone resistant. If the onset of endometriosis is driven by oxidative stress from retrograde menstruation and the peritoneal microbiome, medical therapy could prevent new lesions and becomes indicated after surgery.
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Affiliation(s)
- Philippe R. Koninckx
- Latifa Hospital, Dubai, United Arab Emirates
- Prof Emeritus Obstet Gynecol (OBGYN), Catholic University Leuven (KU), Leuven, Belgium
- University of Oxford-Hon Consultant, Oxford, United Kingdom
- University Cattolica, Roma, Italy
- Moscow State University, Moscow, Russia
- Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
- *Correspondence: Philippe R. Koninckx,
| | - Rodrigo Fernandes
- Instituto do Cancer do Estado de São Paulo, University of São Paulo, São Paulo, Brazil
| | - Anastasia Ussia
- University Cattolica, Roma, Italy
- Gruppo Italo Belga, Villa Del Rosario, Rome, Italy
| | - Larissa Schindler
- Dubai Fertility Centre of the Dubai Health Authority, Dubai, United Arab Emirates
| | - Arnaud Wattiez
- Latifa Hospital, Dubai, United Arab Emirates
- Prof Department of Obstetrics and Gynaecology, University of Strasbourg, Strasbourg, France
| | | | | | | | | | - Muna Tahlak
- Latifa Hospital, Dubai, United Arab Emirates
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Darwish B, Roman H. When Opportunity Knocks, Grab Your Chance: Shall Ablation Be Rehabilitated in the Treatment of Endometrioma? J Minim Invasive Gynecol 2020; 28:1-2. [PMID: 32828900 DOI: 10.1016/j.jmig.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Basma Darwish
- Department of Obstetrics and Gynecology, Bahrain Defense Force, Royal Medical Services, Riffa, Bahrain (Dr. Darwish); Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France (Dr. Roman); Department of Gynecology and Obstetrics, Aarhus Medical University, Aarhus, Denmark (Dr. Roman)
| | - Horace Roman
- Department of Obstetrics and Gynecology, Bahrain Defense Force, Royal Medical Services, Riffa, Bahrain (Dr. Darwish); Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France (Dr. Roman); Department of Gynecology and Obstetrics, Aarhus Medical University, Aarhus, Denmark (Dr. Roman).
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