Laparoscopic CO2 laser vaporization of endometriosis compared with traditional treatments

Safety of the Helica Thermal Coagulator in treatment of early stage endometriosis

The objective of this prospective study was to assess the safety and short-term outcome of the Helica Thermal Coagulator in the laparoscopic treatment of early stage endometriosis. Two hundred and fifty consecutive women with chronic pelvic pain and stage I and II endometriosis (r-AFS classification) were treated laparoscopically with the Helica Thermal Coagulator. No bladder, ureteric or bowel injuries occurred. None of the procedures was converted to laparotomy and there were no major peri-operative complications. The only complication was a vaginal perforation during dissection of the cul-de-sac in a patient with a vaginal vault endometriotic nodule. We conclude that the Helica Thermal Coagulator is a safe alternative for the treatment of mild to moderate endometriosis. Long-term efficacy studies are required to better assess the role of the device in laparoscopic management of endometriosis.

Surgical management of endometriosis-associated pain

General surgical guidelines are reasonable, but treatment frequently must be individualized. Laparoscopic coagulation can be used for many cases of superficial endometriosis. Resection seems to be associated with an increased resolution of endometriosis. Resection increases the difficulty of the procedure, the time of the operation, and the cost, however. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. Distinguishing patients who need no treatment from patients who need intermediate or extensive treatment can be difficult. Care is needed to attempt to ensure that patients are neither overtreated nor undertreated.

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.

Life table analysis of pregnancy rates in women with moderate or severe endometriosis comparing danazol therapy after carbon dioxide laser laparoscopy plus electrocoagulation or laparotomy plus electrocoagulation versus danazol therapy only

STUDY OBJECTIVE

To assess the effectiveness, in terms of pregnancy rates, of isotopic 13CO2 laser laparoscopy versus traditional laparoscopy or laparotomy in the treatment of infertile women with moderate or severe endometriosis.

DESIGN

Prospective 5-year study.

SETTING

Medical school-affiliated hospital.

PATIENTS

Three hundred nine infertile women with moderate to severe endometriosis.

INTERVENTIONS

The patients were treated with one of four options: operative laparoscopy with the 13carbon dioxide (13CO2) laser vaporization and/or resection, operative laparoscopy with simple electrocoagulation and sharp dissection, laparotomy with electrocoagulation and sharp dissection, and medical treatment with danazol. Estimated cumulative pregnancy rates using life table analyses were indicators of treatment of success and compared among treatments. A subgroup of 192 women considered to have endometriosis as the only infertility factor was also evaluated.

MEASUREMENTS AND MAIN RESULTS

Pregnancy rates in the laparoscopy group were equal to or higher than those of the laparotomy group, for both the entire population and the endometriosis-only subset. When the CO2 laser was used as an adjuvant option, the rates were better, especially in patients with advanced disease and with endometriosis as the only infertility factor.

CONCLUSION

In women with endometriosis as the only infertility factor, laparoscopic surgery with the 13CO2 laser was more effective than nonlaser treatment.

Efficacy of isotopic 13CO2 laser laparoscopic evaporation in the treatment of infertile patients with minimal and mild endometriosis: a life table cumulative pregnancy rates study

STUDY OBJECTIVE

To assess the efficacy of 13CO2 laser laparoscopy in treating infertile women with minimal to mild endometriosis according the American Fertility Society classification in terms of pregnancy rates.

DESIGN

Prospective study.

SETTING

Medical school-affiliated hospital.

PATIENTS

One hundred seventy-six women whose infertility was associated with minimal or mild endometriosis diagnosed by laparoscopy.

INTERVENTIONS

The patients were treated with one of four methods: 49 underwent operative laparoscopy with newly developed 13CO2 laser vaporization and/or resection; 45 were treated by operative laparoscopy with simple monopolar electrocoagulation; 43 who had undergone only diagnostic laparoscopy did not receive any treatment; and 39 received danazol 800 mg/day for 3 months after diagnostic laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Estimated cumulative pregnancy rates using life table analyses were indicators of treatment of success and compared among the treatments. A subgroup of 111 patients considered to have endometriosis as the only major infertility factor were also evaluated and compared among treatment options. Pregnancy rates in the CO2 laser laparoscopy group were significantly higher than in the other three groups and in endometriosis-only subset.

CONCLUSIONS

Advanced laparoscopic surgery with the CO2 laser can be more efficient than other modalities in treating infertile women with minimal to mild endometriosis in terms of pregnancy rates. It appears that in experienced hands, laser laparoscopy has more favorable results than the other treatments.

Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate or severe endometriosis

STUDY OBJECTIVE

To compare the efficacy of laparoscopy versus microsurgery by laparotomy in the treatment of ovarian endometriomas.

DESIGN

Retrospective study with historical controls.

SETTING

A tertiary university hospital.

PATIENTS

One hundred thirty-two women under 40 years of age with ovarian endometriotic cysts at least 3 cm in diameter (stage III and IV endometriosis, R-AFS classification). Interventions. A single surgeon (RM) treated 83 patients by laparoscopy for excision of ovarian endometriomas by the stripping technique and 49 by microsurgery at laparotomy.

MEASUREMENTS AND MAIN RESULTS

Data regarding recurrence of ovarian cysts, symptomatic improvement, and reproductive outcome were comparable for the two groups. Postoperative febrile morbidity and length of hospitalization were significantly less for the laparoscopy group than for the laparotomy group (p <0.0005).

CONCLUSIONS

Operative laparoscopy for excision of ovarian endometrial cysts by the stripping technique is as effective as microsurgery by laparotomy. It is associated with less febrile morbidity and a shorter hospitalization.

Operative laparoscopy: surgical modalities

OBJECTIVE

To review basic physics of different surgical modalities and their clinical applications and outcomes.

DESIGN

The relevant literature and personal experience were used to prepare the manuscript.

RESULTS

Operative laparoscopy is safe and effective whether using sharp dissection, electrosurgical, or laser energy. The newer surgical modalities, including the vibrating ultrasound scalpel and argon beam coagulator, need further evaluation.

CONCLUSIONS

The results of laparoscopic surgery are independent of the surgical modality used. The surgeon's skill and experience, his or her preference of the technique, and proper patient selection play a more important role.

Surgical treatment of endometriosis-associated infertility: meta-analysis compared with survival analysis

OBJECTIVE

Our purpose was to evaluate the role of surgery in the treatment of endometriosis associated with infertility.

STUDY DESIGN

We used a prospective cohort analysis of pregnancy rates and variables affecting pregnancy rates for surgical, medical, and no treatment. Our studies were combined with those reported by Hughes et al. (Fertil Steril 1993; 59:963-70), and the meta-analysis was expanded to include additional comparisons. Treatment was performed by a single surgeon in a referral reproductive endocrinology and surgery private practice. Results from 579 women with endometriosis and infertility in our study and the meta-analysis of 25 studies by Hughes et al. were examined. Interventions consisted of no treatment, medical treatment, or surgical treatment by laparoscopy or laparotomy. The main outcome measure was pregnancy rates.

RESULTS

For minimal and mild disease, no treatment, laparoscopy, and laparotomy had equivalent 3-year estimated cumulative life-table pregnancy rates (67% +/- 12%, 68% +/- 4%, and 74% +/- 8%, respectively) that were higher than medical treatment pregnancy rates (Breslow p = 0.003). For moderate and severe disease, all but 11 patients were treated surgically. The 3-year estimated cumulative life-table pregnancy rates were 62% + 6% [corrected] for 120 laparoscopy cases and 44% + 6% [corrected] for 102 laparotomy cases (Breslow p = 0.054). For endometriomas, 48 laparoscopy patients had a 3-year estimated cumulative life-table pregnancy rate of 52% +/- 9% and 52 laparotomy patients had a 3-year estimated cumulative life-table pregnancy rate of 46% +/- 9% (Breslow p = 0.48). For 28 patients with complete cul-de-sac obliteration, the 3-year estimated cumulative life-table pregnancy rates were 30% +/- 14% after laparoscopy and 24% +/- 12% after laparotomy (Breslow p = 0.084). Comparison of our results with the expanded meta-analysis revealed deficiencies in the design of meta-analysis studies and the impact of our using life-table pregnancy rates controlled for factors influencing outcome (survival analysis with fixed covariates) rather than the simple pregnancy rates used in the meta-analysis. Benefits of sophisticated statistical techniques, including propensity scores, to adjust for noncomparability of groups in prospective cohort studies were identified.

CONCLUSION

Both our study and the meta-analysis show that either no treatment or surgery is superior to medical treatment for minimal and mild endometriosis associated with infertility. For moderate and severe disease, surgery is usually used. In these patients experienced surgeons utilizing good clinical judgment can achieve results at operative laparoscopy at least equivalent to those at laparotomy, even in cases involving endometriomas and complete cul-de-sac obliteration. Prospective randomized trials should be performed to confirm these findings.

Management of stage III and IV endometriosis: a 10-year experience

A retrospective analysis is reported of the management of 117 cases of infertility associated with Stage III and IV endometriosis. Combined medico-microsurgical treatment was selected in 75.3% of Stage III cases and in 83.3% of those on Stage IV. Medication consisted of medroxyprogesterone acetate in 26 patients and danazol in the remaining 64. Microsurgery alone was utilized in 24.7% of Stage III patients and in 16.6% of those on Stage IV. Both surgery alone and the combined therapy had a profound positive effect on subjective symptoms: dysmenorrhea, dyspareunia and pelvic pain. Following combined therapy, pregnancy was achieved in 34.4% of all women. Respective figures are 30.7% for medroxyprogesterone acetate (29.4% Stage III and 33.3% Stage IV) and 35.9% for danazol (37.7% Stage III and 27.2% Stage IV). In the group of patients treated by surgery alone, pregnancy occurred in 25.9%. Of the pregnancies in women with Stage III endometriosis, 25 were carried to term and 6 ended with a spontaneous abortion; figures for Stage IV women are 5 and 2, respectively. Second-look laparoscopy was performed in 49 of the 79 patients who failed to conceive, at 12-36 months after treatment; persistent genital pathology, to which infertility could be attributed, was found in 77.5% of them.

Laser use in laparoscopic surgery

Gynecologists have found the argon and CO2 lasers very valuable for performance of pelviscopic surgery. Their interest was born from the complications initially seen with electrosurgical pelviscopic procedures and from the unique features of the laser for treatment of endometriosis. Laser technology was applied to laparoscopic cholecystectomy from its inception. This article reviews the arguments for laser and electrosurgical use in the many laparoscopic procedures--established and in evolution.

Present day endoscopic surgery in gynecology

The last ten years have been characterized by a tremendous change in laparoscopy. Initially used exclusively for diagnosis, laparoscopy is now a surgical method in its own right and plays a strategic role. Long-term evaluation of results for various pathologies (such as ectopic pregnancy and tubo-peritoneal sterility) means that just one laparoscopic procedure can be used for diagnosis, selection of the best therapeutic approach and also for treatment in those cases where laparoscopy is the optimum choice. Other more recent indications (including hysterectomy, lymphadenectomy etc.) which are now possible thanks to recent technological developments (such as clips and mechanical sutures) need long-term analysis of their results.